bluuebunny/crossref_metadata_2025 huggingface dataset:
Subcutaneous blood flow in man during sleep with continuous epidural anaesthesia
Authors: Sindrup J. H. , Petersen L. J. , Kastrup J. , Wroblewski H. , Secher N. H.
Published: January 2009

Background: Subcutaneous blood flow increases during sleep and we evaluated if this increase is affected by epidural anaesthesia.

Methods: Lower leg subcutaneous blood flow was determined by 133Xenon clearance in ten subjects during continuous epidural anaesthesia at L2‐L3 including eight hours of sleep, while the upper abdominal subcutaneous blood flow served as control.

Results: Epidural anaesthesia to the level of the umbilicus was followed by an increase in the lower leg subcutaneous blood flow from 3.4 (1.8‐6.3) to 7.8 (3.6–16.9) ml min‐1 100 g‐1 (median and range; P<0.001) and returned to 3.5 (2.4–7.6) ml min‐1 100 g‐1 after 88 (45–123) min. In contrast, until the period of sleep the upper abdominal region blood flow remained at 5.2 (3.2–6.4) ml min‐1 100 g‐1. During sleep, lower leg subcutaneous blood flow did not change significantly, but the upper abdominal flow increased to 6.2 (5.2–7.2) ml min‐1 100 g‐1 after 34 (29–70) min (P<0.01), and it remained elevated for 125 (100–164) min.

Conclusions: The results indicate that although epidural anaesthesia induced only a temporary increase in lower leg subcutaneous blood flow, it hindered the rise in subcutaneous blood flow normally manifest during early sleep.
Intensive care unit stay is prolonged in chronic alcoholic men following tumor resection of the upper digestive tract
Authors: Spies C. D. , Nordmann A. , Brummer G. , Marks C. , Conrad C. , Berger G. , Runkel N. , Neumann T. , Müller C. , Rommelspacher H. , Specht M. , Hannemann L. , Striebel H. W. , Schaffartzik W.
Published: January 2009

Background: The prevalence of chronic alcohol misuse in patients with oral, pharyngeal, laryngeal or esophageal carcinomas exceeds 60%. No data is available, to our knowledge, on the morbidity and mortality of chronic alcoholics in surgical intensive care units (ICU) following tumor resection. We investigated whether the subsequent ICU stay in chronic alcoholics following tumor resection was prolonged and whether the incidence of pneumonia and sepsis was increased.

Methods: 213 patients with carcinomas of the upper digestive tract were evaluated regarding their drinking habits. Chronic alcoholics met either the DSM‐III‐R criteria for alcohol abuse or dependence. Conventional laboratory markers and serum carbohydrate‐deficient transferrin were determined preoperatively. Major intercurrent complications during ICU stay such as an alcohol withdrawal syndrome, pneumonia and sepsis as well as the frequency of death were documented.

Results: Patients did not differ significantly between groups regarding age or APACHE score on admission to the ICU. 121 patients were diagnosed as being chronic alcoholics, 39 as being social drinkers and 61 as being non‐alcoholics. In chronic alcoholics the frequency of death was significantly increased. Due to the increased incidence of pneumonia and sepsis the ICU stay was significantly prolonged in chronic alcoholics by approximately 8 days.

Conclusions: The increased mortality and morbidity rate demonstrates that chronic alcoholics undergoing major tumor surgery have to be considered as high‐risk patients during their postoperative ICU stay. Further studies are required with respect to the immuno‐competence of chronic alcoholics and the prevention of alcohol withdrawal syndrome, pneumonia and sepsis in these patients.
Isovolaemic haemodilution with hydroxyethylstarch has no effect on somatosensory evoked potentials in healthy volunteers
Authors: Detsch O. , Heesen M. , Mühling J. , Thiel A. , Bachmann‐Mennenga B. , Hempelmann G.
Published: January 2009

Background: An animal study in anaesthetized baboons demonstrated that somatosensory evoked potentials (SSEP) can be affected by extreme haemodilution. This might lead to misinterpretation and reduce the value of intraoperative SSEP monitoring when colloids are administered. In the present study the effect of haemodilution (HD) and subsequent retransfusion of autologous blood on SSEP was determined in healthy non‐premedicated volunteers.

Method: Acute isovolaemic HD served as a model for blood loss immediately replaced with colloids. In 12 volunteers, 20 ml/kg·bw blood was withdrawn within 30 minutes and simultaneously replaced with 6% hydroxyethylstarch (HES). 30 minutes later, the autologous blood was retransfused within 30 minutes. Recording sites and parameters were: 1. Median nerve SSEP: cortical, cervical (C2), Erb's point; 2. Posterior tibial nerve SSEP: cortical, cervical (C2), lumbar (L1). In addition to SSEP latency and amplitude, median and tibial nerve central conduction times, spinal conduction time and nerve conduction velocity were determined. Serial SSEP measurements were made before, during and after HD and retransfusion every 15 minutes.

Results: HD consisting of a withdrawal volume of 1550±155 ml (mean±SD) induced a decrease in haematocrit from 42.0±3.1% to 29.6±1.6% (P<0.001). Following retransfusion, haematocrit increased to 35.0±2.1% (P<0.001). Neither HD nor retransfusion influenced SSEP parameters.

Conclusion: We conclude from our data that the therapy of blood loss up to 30% of estimated blood volume with HES does not affect SSEP monitoring as long as normovolaemia is maintained.
Renal function during intravenous infusion of urological irrigating fluids in the sheep
Authors: Hahn R. G. , Nilsson A. , Hjelmqvist H. , Zhang W. , Rundgren M.
Published: January 2009

Background: Oliguria or anuria is an important sign of the transurethral resection syndrome, but the mechanism is not clear.

Methods: We gave an intravenous infusion of 40 ml/kg of glycine 1.5%, sorbitol 2%‐mannitol 1%, and isotonic saline (control) in 6 conscious ewes and studied if irrigating fluids cause acute disturbances of kidney function.

Results: Both the electrolyte‐free solutions induced an increase in urine flow and persistent hypo‐osmolality. The renal clearances of p‐aminohippuric acid and inulin as well as the unilateral renal blood flow, which was measured via ultrasonic flow probes, increased in response to infusion of glycine but not to sorbitol‐mannitol. After the infusions, the renal clearances decreased transiently to below baseline levels.

Hypertonic saline was given after half of the infusions of electrolyte‐free irrigating fluid. This treatment redistributed water from the cells to the extracellular fluid, but had no effect on renal function.

Conclusions: We conclude that 2500 ml of electrolyte‐free irrigating fluid had no detrimental effects on kidney function in sheep. The changes we observed were essentially the same as after infusion of isotonic saline.
Aspiration in transtracheal jet ventilation
Authors: Jawan B. , Lee J. H.
Published: January 2009

Background: Transtracheal jet ventilation (TJV) has been used successfully for managing difficult airways. However, there are some controversies regarding pulmonary aspiration. It has been shown that TJV caused no aspiration as long as the frequency of ventilation was kept higher than 60/ min. On the other hand, it has been demonstrated that manual translaryngeal jet ventilation at 20 breaths per minute also provided good protection from aspiration even with 30‐degree head‐up position. The purpose of this study was to reevaluate this controversy with observation of the trachea and the lungs together during TJV.

Methods: Eight mongrel dogs were anesthetized, paralyzed and ventilated transtracheally with jet ventilator at frequencies variying from 600 to 10/min. The airway pressures below and above the jetting port were measured. The mouth of the dog was then filled with barium and chest x‐rays were taken 5 minutes after each different jetting frequency.

Results: No tracheal or pulmonary aspiration was observed on chest x‐rays as long as the frequencies were set above 80 per minute. With frequencies of 60 per minute, barium was seen in the trachea but at a level above the jetting port. Slowing down the frequency to 10/min did not affect the level of barium.

Conclusion: No aspiration could be visualized on chest x‐rays. The mechanism for preventing pulmonary aspiration is thought to be due to forceful continuous gas outflow through the larynx. The epiglottis seems to play no role in this mechanism. The limited tracheal aspiration was probably due to the existence of a negative pressure in the upper airway. Cessation of the TJV will cause a drop in this pressure gradient and results in pulmonary aspiration. It is recommended that the airway above the jetting port be totally cleansed prior to discontinuation of the tanstracheal jet ventilation.
Intravenous ketoprofen for pain relief after total hip or knee replacement
Authors: Kostamovaara P. A. , Laitinen J. O. , Nuutinen L. S. , Koivuranta M. K.
Published: January 2009

Background: There are few studies in which ketoprofen, a propionic acid derivate NSAID, has been tested as an intravenous postoperative analgesic. The aim of this double‐blind, randomized, placebo‐controlled work was to study the tolerability and efficacy of intravenous ketoprofen in seventy‐six patients undergoing hip or knee total endoprothesis surgery using three different doses.

Methods: The patients received either ketoprofen 50 mg, 100 mg or 150 mg, or placebo as an initial intravenous loading, followed by an infusion containing 50 mg, 100 mg or 150 mg or placebo, respectively, over the following eleven and a half hours. The consumption of fentanyl was recorded and the patients assessed their pain intensity on a 10‐cm visual analogue scale (VAS) at 0, 2, 4 and 12 hours. Possible side‐effects were recorded at the same intervals.

Results: Patients receiving ketoprofen showed significantly lower total fentanyl consumption and significantly better pain relief at 12 hours was achieved by a 300 mg dose of ketoprofen than by placebo. Side‐effects were minimal, with no differences between the groups.

Conclusion: A bolus of ketoprofen following continuous infusion of ketoprofen, coupled with a PCA‐system, was an effective and safe approach for the relief of postoperative pain.
Introducing epidural fentanyl for on‐ward pain relief after major surgery
Authors: Salomäki T. E. , Kokki H. , Turunen M. , Havukainen U. , Nuutinen L. S.
Published: January 2009

Background: Epidural opioids have been recommended for analgesia after major surgery. In this report we describe how we introduced a low‐cost, on‐ward, nurse‐based acute pain service using epidural fentanyl after major surgery in the University Hospitals of Oulu and Kuopio.

Methods: In order to evaluate the feasibility of epidural fentanyl infusion administered by ward nurses, we prospectively assessed pain and side effects during fentanyl infusion (median duration 41 h) after major surgery in 305 consecutive patients in Kuopio.

Results: 92% of the patients on the ward who had received epidural fentanyl infusion at 31–54 μg h‐1 reported at most three episodes of severe pain (/ Numerical Rating Scale > 3/10) during the initial postoperative days, but there were some patients (8%) who reported several episodes (>3) of more severe pain (Numerical Rating Scale > 3). Three patients (0.9%) showed a diminished respiratory rate (<10/min), but only one of them (0.3%) was somnolent. One other patient (0.3%) was not arousable until the cessation of infusion. Nausea and pruritus were minor problems in our patients, but a majority needed a urinary catheter.

Conclusion: With well‐trained nurses, careful monitoring and appropriate protocols, epidural fentanyl infusion proved to be a feasible method for pain relief after major surgery on a surgical ward.
Preoperative application of piroxicam gel compared to a local anaesthetic field block for postoperative analgesia
Authors: O'Hanlon J. J. , McCleane G. , Muldoon T.
Published: January 2009

The non‐steroidal anti‐inflammatory drugs inhibit prostaglandin synthesis and hence have an analgesic action. Following topical administration, the drug is concentrated in the tissues and so can have a local analgesic effect. This study investigated the effect of the preoperative application of topical piroxicam on postoperative analgesic requirement compared to a placebo group and a conventional local anaesthetic field block.

Forty‐two patients presenting for in‐patient inguinal hernia repair were randomly allocated on a double‐blind basis to have either piroxicam gel 15gm applied preoperatively, or an inguinal field block with 20ml of 0.375% bupivacaine following induction of anaesthesia, or no treatment. Postoperative Visual Analogue Scores for pain on moving in group P, I or C on admission and at 1 h, 2 h, and 4 h following surgery were: 2 vs 1 vs 6.5; 3 vs 3 vs 5; 3 v 2 vs 4.5; 3 vs 2 vs 5.0, respectively (P<0.005). Median(range) time to first analgesia was 25.4(15–70) min in group 1,30.3(10–49) min in group P; this was not significantly different from group C 21.5(7–70) min. Over the first 24 hours the postoperative morphine requirement was significantly less in the two treatment groups 30(20)mg in group I and 34(17)mg in group P and 71(15) in group C, P<0.0001. There were no apparent NSAID‐induced side‐effects, or effects on wound healing.

The preoperative administration of piroxicam (15gm) topically compared favourably with a preoperative local anaesthetic field block with respect to VAS scores, time to first analgesia and total morphine consumption. And both treatment groups provided significantly superior analgesia than the control group.
Response to double‐burst appears before response to train‐of‐four stimulation during recovery from non‐depolarizing neuromuscular blockade
Authors: Kirkegaard‐Nielsen H. , Helbo‐Hansen H. S. , Severinsen I. K. , Lindholm P. , Bülow K.
Published: January 2009

Background: Double‐burst stimulation (DBS) it a relatively new nerve stimulation mode introduced for improved manual detection of residual neuromuscular blockade. Previous studies have shown that DBS3,3 50/50 (3 stimuli at 50 Hz followed 0.75 seconds later by 3 stimuli at 50 Hz) can detect deeper degrees of neuromuscular blockade than train‐of‐four (TOF) stimulation.

Aim: The aim of the present study was to examine if DBS3,3 80/40 (3 stimuli at 80 Hz followed 0.750 s later by 3 stimuli at 40 Hz) can detect even deeper degrees of neuromuscular blockade than DBS3,3 50/50 and to determine the time lapse from reappearance of response to each of the two DBS modes until reappearance of response to the TOF mode of nerve stimulation.

Methods: The study comprised 20 women undergoing gynaecological surgery and anaesthetised with fentanyl, thiopentone, halothane, and nitrous oxide. Neuromuscular transmission was monitored by using mechanomyography and stimulation of the ulnar nerve. Atracurium was used for neuromuscular blockade.

Results: Elapsed time from reappearance of response to DBS3,3 80/40 and DBS3,3 50/50 to reappearance of response to TOF stimulation was 459±196 (mean±SD) and 360±150 seconds, respectively, (P<0.05).

Conclusions: DBS3,3 80/40 is capable of detecting deeper degrees of blockade than DBS3,3 50/50 which again is capable of detecting deeper degrees of blockade than TOF.
The effect of topical lignocaine on intubating conditions after propofol‐alfentanil induction
Authors: Bolow K. , Nielsen T. G. , Lund J.
Published: January 2009

Background: Recent studies have found satisfactory conditions for intubation of the trachea without using muscle relaxants using an intravenous technique combining propofol and alfentanil. In this study we evaluate intubating conditions with this method and either lignocaine applied topically in the larynx and trachea or placebo.

Methods: Sixty adult patients of ASA class I were premedicated with diazepam 15–20 mg and randomly allocated to one of two groups. For induction of anaesthesia both groups were given propofol 2.5 mg/kg and alfentanil 30 μg/kg. One group received 4 ml of lignocaine 40 mg/ml (≤3 mg/kg) topically into the larynx and trachea (group L), the other group an equal amount of isotonic saline (group S) in a double‐blind design. Intubation conditions were assessed as excellent, good, moderately good, poor or impossible, scored on the basis of jaw relaxation, ease of insertion of the tube and coughing on intubation.

Results: The total score for group L was significantly better than the score for group S (P<0.0001) with significant differences with respect to ease of intubation and coughing after intubation.

Conclusions: Induction of anaesthesia with propofol 2.5 mg/kg and alfentanil 30 μg/kg combined with 4 ml of lignocaine‐spray 40 mg/ml into the larynx and trachea offered consistent and satisfactory intubation conditions. We thus recommend this method for tracheal intubation, where the use of muscle relaxants is not indicated.
Nebulized tetracaine attenuates the hemodynamic response to tracheal intubation
Authors: Stevens J. B. , Vories P. A. , Walker S. C.
Published: January 2009

Background: Local anesthetics, principally lidocaine, are commonly administered in an attempt to blunt the hemodynamic response to tracheal intubation. There are no prior investigations evaluating the use of tetracaine in this setting.

Methods: In the present study, 30 female patients (ASA HI) scheduled for elective surgery were randomized to receive inhaled nebulized tetracaine 0.5 mg/kg or nebulized saline. Subsequently, anesthesia was induced with thiopental 5mg/ kg and succinylcholine 1.0 mg/kg. Sixty seconds later, the trachea was intubated. Vital signs were recorded at intubation and at 1‐minute intervals for the next 5 minutes.

Results: Patients treated with tetracaine had a significantly (P<0.05) lower mean heart rate at intubation and all subsequent times. Similarly, there were significant differences (P<0.05) in mean arterial pressure between tetracaine and control patients at all times post‐intubation except at 2 minutes. The inhalation of nebulized tetracaine produced no adverse side effects.

Conclusion: We conclude that nebulized tetracaine significantly attenuates the hemodynamic response to tracheal intubation.
Respiratory compliance during orthotopic liver transplantation
Authors: Tallgren M. , Hockerstedt K. , Lindgren L.
Published: January 2009

After liver transplantation, respiratory complications are frequent. The purpose of this study was to assess if intraoperative monitoring of respiratory compliance is of clinical value in predicting such complications.

Respiratory compliance was continuously monitored with a side‐stream respiratory gas flow and pressure sensor (Datex, Helsinki, Finland) at the endotracheal tube in 18 adult patients undergoing orthotopic liver transplantation without veno‐venous bypass.

Respiratory compliance decreased along with blood volume expansion under anaesthesia before the start of surgery (P<0.05). Compliance improved as ascites was removed at the beginning of laparotomy (P<0.001). The highest compliance values were seen during liver surgery. In the patients without ascites preoperatively, compliance was lower at the end of surgery than at anaesthesia induction (P<0.001). In the patients with ascites, compliance at the end of surgery was equally low as at anaesthesia induction. Compliance at the end of surgery was lower in the patients with bilateral than in those with right‐sided or no pleural effusions in the postoperative chest X‐rays (P<0.001).

In conclusion, intraoperative monitoring of respiratory compliance is one useful method for clinical use in predicting postoperative bilateral pleural effusions.
Use of the Univent System tube® for difficult intubation and for achieving one‐lung anaesthesia
Authors: GarcíA‐Aguado R. , Mateo E. M. , Onrubia V. J. , Bolinches R.
Published: January 2009

Background: One‐lung ventilation in major thoracic surgery is the most commonly accepted technique, not only for surgery on the lung but also in procedures involving the oesophagus, mediastinum and thoracic aorta. Conventional double‐lumen tubes may sometimes be difficult to place correctly in patients in whom intubation is difficult. In such cases, the Univent System tube® may be of help. It has a curved movable blocker of small calibre, and is designed to slide inside the bronchial tree and occlude all or part of the target lung.

Case Report: We describe a new application of the Univent System tube® in three cases where intubation was presumed to be difficult, and in another with unexpected difficult intubation.

The laryngeal approach was carried out with the distally displaced blocker, inserting it through the sub‐epiglottis or the posterior commissure visible orifice. The tube was firmly held and slid through the length of the blocker, rotating slowly until fully introduced. The advantages and criteria for its use are discussed.

Conclusion: Although the double‐lumen tube is the first choice for one‐lung ventilation, the Univent tube is a good option for selective bronchial intubation and in patients in whom difficult intubation is predicted.
Myoelectric activity in the stomach and duodenum after epidural administration of morphine or bupivacaine
Authors: ThÖorn S.‐E. , Wickbom G. , Philipson L. , Leissner P. , Wattwil M.
Published: January 2009

Background:Gastric emptying is delayed in patients receiving postoperative pain relief with epidural morphine compared to patients receiving epidural bupivacaine. The electrophysiological basis for this effect is unknown. The aim of this study was to compare the effects of epidural morphine with epidural bupivacaine on gastroduodenal myoelectric activity (EMG) in patients after surgery.

Methods:Fourteen patients with epidural analgesia who underwent open cholecystectomy were randomly assigned to receive either epidural morphine (EM) or epidural bupivacaine (EB) for postoperative pain relief. During surgery EMG electrodes were placed in the subserosa in the antrum and duodenum and the EMG registration started 3.5 hours after the end of surgery. Gastric emptying measured with the acetaminophen test was studied in the morning the day after surgery.

Results:The spike activity in the antrum was significantly lower 160–340 minutes after the administration of morphine in the EM‐group compared to the activity in the EB‐group (P<0.04). The incidence of regular slow wave rhythm in the antrum was significantly lower 160–520 minutes after the administration of morphine in the EM‐group compared to the EB‐group (P<0.03). Duodenal Phase III activity measured with EMG was significantly more frequent during 160–520 minutes after the morphine administration in the EM‐group compared to the EB‐group (P<0.02). The acetaminophen absorption was significantly delayed in the epidural morphine group compared to the epidural bupivacaine group.

Conclusions:Gastroduodenal electromyographic activity was significantly changed during epidural morphine compared to epidural bupivacaine. The delayed gastric emptying during epidural morphine may be explained by decreased and uncoordinated contractile activity in the antrum, shown by decreased spike activity and irregular slow wave rhythm. The increased pressure activity in the duodenum, shown by increased Phase III activity, may also impair gastric emptying.
The effects of warming intravenous fluids on intraoperative hypothermia and postoperative shivering during prolonged abdominal surgery
Authors: Camus Y. , Delva E. , Cohen S. , Lienhart A.
Published: January 2009

Background: The infusion of several liters of crystalloid solution at room temperature may significantly contribute to intraoperative hypothermia because warming fluid to core temperature requires body heat. The aim of this study was to evaluate the effect of delivering warmed intravenous (IV) fluid to the patient on preventing intraoperative hypothermia.

Methods: Intraoperative core and mean skin temperatures were measured during prolonged abdominal surgery in 18 patients randomly divided into two groups according to intraoperative IV fluid management. In 9 patients (control group) all IV fluids infused were at room temperature. In the other 9 patients (group receiving warmed fluids) all IV fluids were warmed using an active IV fluid tube‐warming system. In all 18 patients a warming blanket covered the skin surface available for cutaneous warming. Intraoperative changes in total body heat content (kJ) were calculated from core and mean skin temperatures.

Results: At the end of surgery, core temperature was 36.7±0.2°C in the group receiving warmed fluids and 35.8±0.2°C in the control group (P<0.05). The estimated reduction in heat loss provided by warming IV fluid was 217 kJ, a value very close to the theoretical value expected from thermodynamic calculation. During recovery, one patient shivered in the group receiving warmed fluids and seven in the control group (P<0.05).

Conclusion: In conclusion, infusion of warmed fluids, combined with skin‐surface warming, helps to prevent hypothermia and reduces the incidence of postoperative shivering.
Predicting postoperative adverse events. Clinical efficiency of four general classification systems The Project Perioperative Risk
Authors: Arvidsson S. , Ouchterlony J. , SjÖoUstedt L. , SvÄaUrdsudd K.
Published: January 2009

Background: The Project Perioperative Risk in Gothenburg is a prospective clinical‐epidemiological study designed to elucidate factors affecting the perioperative risk in unselected adult patients undergoing elective general or orthopaedic surgery. In this report on postoperative adverse events of varying severity, the predictive ability of four simple classification systems, ASA physical status, patient age, surgical stress and a visual analogue scale for intuitively appreciated global risk (RISK‐VAS), is described.

Methods: 1361 patients undergoing 1471 surgical procedures were subjected to a detailed and standardised preoperative assessment and classified according to ASA, age, procedure magnitude and RISK‐VAS. Postoperative adverse events were prospectively registered during the entire hospital stay.

Results: The four classifications all correlated to postoperative adverse events. ASA physical status, RISK‐VAS and patient age all appear to be more efficient in predicting severe than mild events, while surgical stress predicted severe events and mild ones equally well.

Conclusion: The most efficient predictor of severe events appeared to be RISK‐VAS, where a relative risk of 28.1 of acquiring a severe postoperative adverse event could be demonstrated for those who had a score of 4 or more compared with those who had scores less than 4.
Peroperative adenosine infusion reduces isoflurane concentrations during general anesthesia for shoulder surgery
Authors: Segerdahl M , Persson E. , Ekblom A. , Sollevi A.
Published: January 2009

Background:Adenosine (ADO), and stable analogs thereof, have been shown to exert antinociceptive action under experimental conditions in animals and in humans. The aim of this randomized double‐blind placebo‐controlled study was to evaluate if a low dose of intravenous (i.v.) ADO could reduce isoflurane requirements during joint‐associated surgery, as an indication of antinociception in deep somatic pain.

Methods:Thirty‐two patients, age 19–62 years, ASA I and II, scheduled for shoulder joint surgery, were assigned to receive an i.v. infusion of either adenosine, 80 μg kg‐1min‐1, or placebo, during the surgical procedure. Anesthesia was maintained with isoflurane/N2O/O2inhalation.

Results:The peroperative isoflurane concentration was significantly reduced at 50 minutes of surgery in the group receiving adenosine infusion. Also, the systolic blood pressure level was peroperatively more stable during adenosine infusion than during placebo. Other clinical parameters, such as pain, postoperative analgesic requirements and nausea, were not different between groups.

Conclusion:A peroperative infusion of a low dose of adenosine during shoulder joint surgery may reduce the peroperative isoflurane requirement.
Heart rate variability in diabetic and non‐diabetic renal transplant patients
Authors: Kirvela M. , Salmela K. , Toivonen L. , Koivusalo A.‐M. , Lindgren L.
Published: January 2009

Backround: Heart rate variability (HRV) has been used to investigate the autonomic modulation of heart rate. Diminished HRV has been observed in diabetic autonomic neuropathy, a condition associated with increased mortality. Uraemia is associated with impaired autonomic function, but reports on the effects of uraemia on HRV are scarce.

Methods: HRV and its circadian variation were studied in 12 diabetic and 11 non‐diabetic renal transplantation and in 12 control patients. HRV in time and frequency domains was determined from 24‐hour ECG recordings.

Results: In the diabetic group, all time domain and frequency domain measures of HRV were markedly reduced (P<0.05), when compared with the control group, and the circadian variation of HRV was absent. The mean (SD) amplitudes (ms) in the frequency bands were: high frequency: 3 (1), 6 (3) and 15 (3); low frequency: 9 (7), 16 (10) and 25 (8); very low frequency: 14 (8), 23 (12) and 30 (11) in the diabetic and non‐diabetic uraemic and in the control patients, respectively. In non‐diabetic uraemic patients, a tendency to reduced HRV was observed, but no statistical differences in HRV measures were found when compared with the control group.

Conclusion: The severe impairment of HRV in patients with end‐stage diabetic nephropathy is probably due to autonomic neuropathy and partly also to the co‐existing heart diseases. It may be a contributing risk factor for ventricular arrhythmias and sudden death in these patients. Uraemia alone causes similar but less severe changes in HRV.
Effects of halothane, isoflurane and sevoflurane on calcium‐related contraction in porcine coronary arteries
Authors: Zhang X. P. , List W. F.
Published: January 2009

Background:Volatile anaesthetics have a direct inhibitory effect upon epicardial coronary arterial smooth muscles (1–4). The site and mode of their action at the cellular level need to be clarified, which was the purpose of our study. The present investigation attempted to answer the question in what way volatile anaesthetics influence Ca2+‐related contraction in isolated porcine epicardial coronary to understand their intracellular mechanism.

Methods:Isolated helical strips of porcine epicardial coronary artery without endothelium were suspended for isotonic contraction recordings in Krebs‐Ringer's solution. 9.4×10‐2MK+, 2.5×10‐1M Ca2+‐induced shortening of the strips was regarded as the reference value (100%). After incubation in Ca2+‐free solution with 10‐3M ethlene glycol bis (β‐aminoethyl ether)‐N, N‐tetraacetic acid (EGTA) for 60 minutes, the muscle strips were exposed to increasing Ca2+concentrations (10‐4‐10‐2) either in the presence or absence of 1.5 or 2.5 minimum alveolar concentration (MAC) halothane, isoflurane or sevoflurane, with 9.4×10‐2M K+bath solution.

Results:All three drug groups produced apparent biphasic effects with a cumulative increase of Ca2+concentration compared with control groups. An initial increase at low Ca2+concentration was followed by a decrease of Ca2+‐activated contractions. Isoflurane affected Ca2+‐induced contraction significantly more than halothane and sevoflurane.

Conclusions:The results imply that volatile anaesthetics influence Ca2+‐dependent activity of coronary smooth muscle by complex mechanisms, which involve promotion of intracellular Ca2+release and other mechanisms that alter sensitivity to calcium.
Quantitative EEG analysis as a supplement to the clinical coma scale RLS85
Authors: Matousek M. , Takeuchi E. , Starmark J. E. , Stalhammar D.
Published: January 2009

Background: The aim of the study was to investigate the correlation between EEG indicators and clinical scores based on the RLS85 (Reaction Level Scale 85) in comatose patients. The results of a simple visual assessment of the EEG, using an arbitrary scale with typical EEG patterns, were compared with those obtained by quantitative electroencephalography (qEEG).

Method: The RLS85 scores were examined in 34 patients with impaired consciousness due to brain tumours, vascular lesions or head injuries. The EEG was recorded shortly before or after the clinical examination. The semiquantitative assessment was made by visual inspection of the tracings, using an arbitrary scale where 12 EEG patterns with increasing proportion of slow activity were displayed. Parallel to the visual analysis, the EEGs were processed by means of EEG spectrum analysis and the power/amplitude in slow frequency bands was used as an indicator. The results were based on correlation between various types of EEG variables and the RLS scores which were obtained in the same patients.

Results: The correlation between the visual EEG indicators and coma scores ranged between 0.53 and 0.57 (P<0.01). As regards the computerised EEG analysis, the correlation between the clinical scores and various EEG spectrum values did not exceed 0.45 (P<0.01). A higher correlation could be obtained by combining eight EEG variables; the multiple correlation coefficient was then 0.68.

Conclusions: The amount of EEG slow activity is significantly correlated to the RLS85 score. This means that the EEG also provides information on the level and not only on the changes of the coma degree. Surprisingly, the indicators based on quantitative EEG, as used in commercially available instruments, did not give better results than the visual assessment. However, the results of the computerised analysis could be improved using multivariate statistical methods. The study also showed a way to improve communication between the neurophysiologist and clinician by presenting the EEG findings in terms similar to those used in the clinical scales. However, the clinician should be aware of the fact that the “EEG score” and the clinical score is not the same: the intention is to supplement rather than to simulate the clinical observation.
Effects on skeletal muscle oxygenation and capillary blood flow by adenosine‐, sodium nitroprusside‐ and acetylcholine‐induced hypotension
Authors: Gustafsson U. , Sollevi A. , SirsjÖoU A. , SjÖoUberg F.
Published: January 2009

Background:Adenosine (ADO)‐induced hypotension during diethyl ether anesthesia has been shown to increase skeletal muscle oxygenation. Whether this beneficial effect of ADO hypotension is present also during another anesthetic technique was tested in the present study using ketamine‐xylazine anesthesia, and its actions were compared with sodium nitroprusside (SNP) and acetylcholine (ACh) induced hypotension in rabbits.

Methods:Local oxygen pressure and capillary blood flow were measured with a multiwire microelectrode which was placed on the surface of the left vastus medialis muscle. The experiments were performed in three groups, in which either ADO, SNP or ACh was infused into a central vein in a dose that produced a reduction of the mean arterial pressure by 20–25%, to approximately 60 mmHg.

Results:In the ADO group (60–170 μg kg‐1min‐1) the tissue oxygen pressures increased by 23% while capillary blood flow decreased by 38%. During SNP administration (1–3 μg kg‐1min‐1) the oxygen pressures decreased by 21% and an increase of 31% in capillary flows was seen. When ACh was infused (1–4 μg kg‐1min‐1) the oxygen pressures decreased by 21% and, in parallel, capillary blood flow decreased by 50%. During hypotension no low tissue oxygen pressure values (<1.5 kPa) were found in the ADO group, whereas they were present in both the SNP and ACh group.

Conclusion:Compared to sodium nitroprusside and acetylcholine, adenosine appears to have an oxygen‐sparing effect in the skeletal muscle during pharmacologically induced hypotension.
Percutaneous dilatational tracheostomy
Authors: Holdgaard H. O. , Pedersen J. , Paaske P. B. , Jensen R. H. , Outzen K. E. , Hostrup P. , Juhl B.
Published: January 2009

Methods: Fifteen patients electively selected for percutaneous dilatational tracheostomy as performed with the Ciaglia Percutaneous Tracheostomy Introducer Set are reported in this preliminary study.

Results: The median time for insertion of the tracheostomy tube was 13.9 min. Complications were cuff puncture of the translaryngeal tube at an early stage of the procedure in one case, and minor bleeding controllable by the compressible effect of the dilatational procedure in three cases. During the posttracheostomy period, complications were one case of minor bleeding controllable by digital compression and one case of minor infection, i.e. cellulitis in a few millimetres around the stoma without purulent secretion.

Conclusions: Our preliminary results indicate the technique as performed with the Ciaglia Introducer Set to be effective and safe with only minor complications. Furthermore, we now use it as a bedside procedure in the ICU, thus avoiding the transportation of critically. ill patients to the operating theatre. The conclusion of the superiority of percutaneous tracheostomy to dissectional tracheostomy has to await clinical randomized studies, including more patients.
Analgesic effect of intraarticular morphine. A controlled, randomised and double‐blind study
Authors: Christensen O. , Christensen P. , Sonnenschein C. , Nielsen P. R. , Jacobsen S.
Published: January 2009

Background: Opioids produce antinociceptive effect by acting on receptors on peripheral nerves. The clinical relevance of this effect is still debated. The aim of the study was to compare the analgesic effect of morphine intraarticularly with the intramuscular route of administration after knee surgery.

Methods: Sixty‐one patients, ASA 1–2, having elective arthroscopic surgery of the knee were randomised to either an intraarticular or intramuscular dose of morphine 5 mg. The pain sensation was estimated by visual analogue scale and a verbal rating score 0,1,2 and 4 hours postoperatively and verbal rating score on the third day. The use of acetaminophen and supplementary opioids were recorded for the first 4 hours postoperatively, from 4 hours until the third day, and from day 3 to day 7 postoperatively.

Results: The groups were comparable. Three patients were excluded. There were no statistically significant differences in painscore and consumption of analgesics. Fifty‐nine per cent in each group had macroscopic synovitis. In the intraarticular group, there was no increased effect of morphine in the patients with synovitis compared to patients without synovitis.

Conclusions: The clinical analgesic effect of 5 mg morphine given intraarticularly is equal to 5 mg morphine given intramuscularly. The occurrence of villous synovitis seems to be of no clinical importance concerning the local effect of morphine.
Pre‐emptive effect of pre‐incisional versus post‐incisional infiltration of local anaesthesia on children undergoing hernioplasty
Authors: Dahl V. , RÆder J. C. , ErnØ P. E. , Kovdal A.
Published: January 2009

Background: Although promising in experimental studies of post‐traumatic pain, the concept of pre‐emptive analgesia is still controversial in a clinical setting. Thus, we wanted to compare the clinical efficacy of wound infiltration with local anaesthesia before surgery with wound infiltration after hernioplasty in children.

Methods: Fifty children aged 2–10 years scheduled for hernioplasty were randomly assigned into two groups. Group 1 (n=28) was infiltrated before surgery with bupivacaine 2.5mg/ml, lmg/kg after induction of general anaesthesia. After surgery they were infiltrated with the same volume of 0.9% saline. Group 2 (n=22) was infiltrated with 0.9% saline before surgery and bupivacaine 2.5 mg/ml, lmg/kg after surgery. The study was performed double‐blindly. In both groups anaesthesia was induced with thiopenthone and maintained with nitrous oxide and halothane, adjusted to keep haemodynamic measurements stable. All children were given paracetamol 15–20 mg/kg rectally when admitted to the recovery ward. Painscore (OPS) and analgesic requirements were registered postoperatively. After 48 h the parents completed a standardised questionnaire and they were interviewed by telephone after one week.

Results: The pre‐incisional group needed significantly less halothane during the procedure compared with the post‐incisional group (P<0.05). The pre‐incisional group also had a tendency towards faster awakening after the end of anaesthesia and a significantly lower OPS‐pain score 30 min after the operation (P<0.03). There were no differences between the two groups regarding need for additional analgesia: meperidine i.v. during the first 5 h postoperatively, and paracetamol thereafter. There were no differences between the groups regarding activity level, appetite and quality of sleep in the first week. In both groups the need for opioid analgesics was low:54% in the pre‐incisional group and 45% in the post‐incisional group did not receive any opioid analgesic treatment. The children were virtually fully recovered after the first 24 h.

Conclusion: Perioperative infiltration with a local anaesthetic in children undergoing hernioplasty results in a smooth recovery with little need for opioids postoperatively. Apart from a lower anaesthetic requirement and a reduced postoperative pain level after 30 min in the pre‐incisional bupivacaine group, there was no difference between infiltration before (pre‐emptive) or after surgery.
Quantitative methodological studies of motor and sensory blockade in epidural analgesia with special reference to early mobilization and a new local anesthetic — ropivacaine
Authors: Zaric D.
Published: January 2009

Abstract: In six studies of epidural analgesia, sensory and motor blockade caused by ropivacaine and bupivacaine was evaluated by quantitative methods. The dose response to single injections of high (0.5%,0.75% and 1%) and low concentrations (0.1%, 0.2% and 0.3%) of ropivacaine in continuous infusion was investigated. Motor blockade was measured by mechanotransducers and by average rectified electromyography. The presence of residual effects was determined by F response and H reflex recording. Quantitative methods for assessment of sensory blockade (Thermotest method, argon laser stimulation and recording of somatosensory evoked potentials ‐ SEPs) were introduced with 0.5% bupivacaine. A selection of these quantitative methods was applied during continuous epidural infusion (21 h) of ropivacaine. Mobilization was attempted throughout the infusion period. In ambulant subjects, postural control was evaluated by posturography.

Motor blockade with high concentrations of ropivacaine was dose‐dependent, but only in segments close to the injection site (L2/3). In the abdominal muscles, the blockade was partial and not clearly dose‐dependent. Persistent prolongation of H reflex latency was found in five subjects who received high concentrations of ropivacaine, but not in any of those receiving continuous infusion. With 0.5% bupivacaine the zone of anesthesia was smaller, and the zone of partial blockade of thermo‐ and laser‐perception larger than that of the pin‐prick analgesia. There were no significant differences in the spatial or temporal sequence of blockade between the Thermotest and laser stimulation methods. Changes in SEPs caused by epidural blockade with bupivacaine could not distinguish between the sensory blockade of low and high intensity.

During continuous infusion of 0.1% ropivacaine, motor blockade was so slight that all subjects could be mobilized, whereas with 0.2% and 0.3% ropivacaine it was moderate (40–50% of baseline force was present). The zone of analgesia was smaller with 0.1% ropivacaine than with 0.2% and 0.3% solutions. With 0.1% ropivacaine the subjects were able to perform postural tests and maintain balance, which was not the case with 0.2% and 0.3% ropivacaine. A quick recovery after discontinuation of infusion was characteristic of ropivacaine.
Effects of desflurane on systemic, preportal and renal circulatory responses to infra‐renal aortic cross‐clamping in the pig
Authors: Sundeman H. , Biber B. , Henriksson B.‐Å. , Raner C. , Seeman‐Lodding H. , Winso O.
Published: January 2009

Background: Different pharmacological approaches have been used in the control of cardiovascular responses to surgical infra‐renal aortic occlusion (AXC). The aim of the present study was to explore the modulatory effects of desflurane (DES) on these responses.

Methods: The study was performed in normoventilated chloralose‐anesthetized pigs (n=14). Measurements included cardiac output (CO), pulmonary vascular pressures, heart rate (HR) and mean arterial pressure proximal to the AXC site (MAPPROX). Renal arterial (QREN) and portal venous (QPORT) blood flows were measured ultrasonically. Systemic (SVR), preportal (RPORT) and renal (RREN) vascular resistances were derived. Sets of measurements were done a) prior to, b) during and c) 5 min after AXC. This was repeated, in a randomized fashion, at control (no DES) and with 4.9% and 9.8% DES, respectively.

Results: DES decreased MAPPROX, CO, HR, SVR, RREN and RPORT. At control, AXC increased MAPPROX (+27%), SVR (+27%), QPORT (+14%), RPORT (+12%) and RREN (+43%). DES 4.9% did not change this response pattern. With 9.8% DES, the AXC‐induced increases in MAPPROX (+17%) and SVR (+21%) were attenuated. At this stage, AXC caused no demonstrable changes in RREN or RPORT, while both QREN (+16%) and QPORT increased (+9%).

Conclusions: DES effectively controlled increases in proximal blood pressure during AXC. The increases in RREN and RPORT that were seen during AXC at control were inhibited by 9.8% DES. Consequently, at this DES dose, both QREN and QPORT increased during AXC.
Is sufentanil a useful opioid for laryngomicroscopy?
Authors: Steinfath M. , Scholz J. , Tonner P. H. , Kycia B. , Konietzko T. , Bause H. , Esch J. Schulte am
Published: January 2009

Background: Alfentanil is commonly used as opioid analgesic for short surgical procedures. Little is known about the usefulness of sufentanil for this purpose. We investigated the effects of alfentanil and sufentanil on haemodynamic characteristics, catecholamine levels, and adrenocorticotropic hormone (ACTH) and Cortisol contents during elective laryngomicroscopy and short laryngeal surgery (LM).

Methods: 100 patients (ASA class I or II) were randomly allocated into one of four groups to receive either 10 Hg/kg alfentanil (group I, ALF 10), 20 μg/kg alfentanil (group II, ALF 20), 0.25 μg/kg sufentanil (group III, SUF 0.25), or 0.5 μg/kg sufentanil (group IV, SUF 0.5) given intravenously before induction of anaesthesia. After administration of the opioid analgesic all patients received 2.0 mg/kg propofol, 15 μg/kg vecuronium, and 1 mg/kg succinylcholine. Anaesthesia was maintained as total intravenous anaesthesia with propofol (8 mg/kg/h) and oxygen (33%) in air. Heart rate (HR), mean arterial pressure (MAP), adrenaline (ADR), noradrenaline (NADR), ACTH, and Cortisol were measured before (baseline) and after induction of anaesthesia, at the beginning and cessation of LM, and 2 h after LM.

Results: In group I (ALF 10) a significant increase in all variables was observed at the beginning and at the end of LM when compared with baseline. Two hours after LM all parameters were found to be at baseline levels. In groups II and III (ALF 20 and SUF 0.25) a significant increase in HR, MAP and catecholamine levels was observed at the end of LM compared to baseline. ACTH and Cortisol contents were unchanged throughout. In group IV (SUF 0.5) HR was significantly reduced after induction, at the beginning and cessation of LM, and 2 hours following operation, whereas MAP was only decreased after induction (P<0.05 vs. baseline). ADR, NADR, ACTH, and Cortisol were similar throughout. If the duration of surgery was shorter than 12 min (20%) in group III (SUF 0.25) and 20 min (44%) in group IV (SUF 0.5), the patients had to be treated with naloxone 10 min after cessation of LM in order to antagonize respiratory depression. This side effect was not observed in group I (ALF 10) and in only one patient (4%) of group II (ALF 20) for whom surgery lasted 5 min.

Conclusion: Clinical recovery is achieved most rapidly with alfentanil in ultra short surgical procedures. However, if surgery is expected to be longer than about 12 min also sufentanil at a dose of 0.25 μg/kg seems to be useful for this kind of surgery.