bluuebunny/crossref_metadata_2025 huggingface dataset:
Postoperative muscle paralysis after rocuronium: less residual block when acceleromyography is used
Authors: Gätke M. R. , Viby‐Mogensen J. , Rosenstock C. , Jensen F. S. , Skovgaard L. T.
Published: March 2003

Background: Residual muscle paralysis after anesthesia is common after pancuronium, but less common following the intermediate‐acting drugs vecuronium and atracurium. Therefore, many anesthetists do not monitor neuromuscular function when using an intermediate‐acting agent. The purpose of this prospective, randomised and double‐blind study was to establish the incidence and degree of postoperative residual block following the use of rocuronium in patients not monitored with a nerve stimulator, and to compare it with results obtained in patients monitored using acceleromyography (AMG).

Methods: During propofol/opioid anesthesia, 120 adult patients were randomised to two groups, one monitored with AMG, the other using only clinical criteria without a nerve stimulator. Postoperatively, TOF‐ratio was measured with mechanomyography; a TOF‐ratio < 0.80 indicated residual muscle paralysis.

Results: Residual muscle paralysis was found in 10 patients in the group without neuromuscular monitoring (16.7%) (95% confidence interval, 12–21%) and in two patients in the AMG‐monitored group (3%) (95% CI, 0–8%); (P = 0.029, Fisher's exact test). Time from end of surgery to tracheal extubation was significantly longer in the AMG‐monitored group (12.5 min) than in the group not monitored with AMG (10 min).

Conclusion: Clinical evaluation of recovery of neuromuscular function does not exclude significant residual paralysis following the intermediate‐acting muscle relaxant rocuronium, but the problem of residual block can be minimized by use of AMG.
Postoperative epidural hematoma or cerebrovascular accident? A dilemma in differential diagnosis
Authors: Pay L. L. , Chiu J. W. , Thomas E.
Published: March 2003

An elderly lady developed an epidural hematoma following combined spinal‐epidural anesthesia with a local anesthetic–opioid mixture for a vaginal hysterectomy. This occurred in association with the use of prophylactic subcutaneously administered unfractionated heparin. She had diabetes, hypertension and had previously undergone coronary artery bypass surgery and right carotid endarterectomy. Warfarin and aspirin were discontinued 2 weeks before the surgery. Postoperatively, an atypical presentation of backache, bilateral sensory loss and left lower limb monoplegia ensued. The initial clinical impression was of a cerebrovascular accident. Magnetic resonance imaging, however, revealed an extensive epidural hematoma that necessitated decompression laminectomy. Progression to paraparesis occurred but the patient gradually regained much of her functionality over the next 2 years.
Computer‐aided ventilator resetting is feasible on the basis of a physiological profile
Authors: Uttman L , Jonson B
Published: March 2003

Background:  Ventilator resetting is frequently needed to adjust tidal volume, pressure and gas exchange. The system comprising lungs and ventilator is so complex that a trial and error strategy is often applied. Comprehensive characterization of lung physiology is feasible by monitoring. The hypothesis that the effect of ventilator resetting could be predicted by computer simulation based on a physiological profile was tested in healthy pigs.

Methods:  Flow, pressure and CO2 signals were recorded in 7 ventilated pigs. Elastic recoil pressure was measured at postinspiratory and post‐expiratory pauses. Inspiratory and expiratory resistance as a function of volume and compliance were calculated. CO2 elimination per breath was expressed as a function of tidal volume. Calculating pressure and flow moment by moment simulated the effect of ventilator action, when respiratory rate was varied between 10 and 30 min−1 and minute volume was changed so as to maintain PaCO2. Predicted values of peak airway pressure, plateau pressure, and CO2 elimination were compared to values measured after resetting.

Results:  With 95% confidence, predicted pressures and CO2 elimination deviated from measured values with < 1 cm H2O and < 6%, respectively.

Conclusion:  It is feasible to predict effects of ventilator resetting on the basis of a physiological profile at least in health.
Propofol infusion rate does not affect local pain on injection
Authors: Grauers A. , Liljeroth E. , Åkeson J.
Published: March 2003

Background:  Local pain at the site of an i.v. injection of propofol is a well‐known problem, particularly in infants. This randomised investigator‐blinded crossover study was designed to assess the effect of the i.v. bolus infusion rate on propofol‐induced pain at the site of injection.

Methods:  Thirty unpremedicated patients scheduled for ear‐nose‐throat or plastic surgery at Malmö University Hospital, Sweden, were given two consecutive 2.0 ml injections of propofol 10 mg/ml (Diprivan®, AstraZeneca, Sweden/UK), at different infusion rates (0.2 or 1.0 ml/s), immediately before induction of general anesthesia. Half of the patients (n=15) received the first bolus of propofol over 2 s and the second bolus over 10 s, and the other half (n=15) had their injections in reversed order. After each injection, the patient was asked by an investigator to indicate pain intensity on a visual analog scale (VAS) and to report the times of the appearance, maximum point and disappearance of pain. The injections were given approximately 2 min apart. The investigators scoring pain intensity, as indicated by the patients on a 10‐point numerical rate scale, were blinded to the order in which the injections were given, as were the patients themselves.

Results:  There were no statistically significant differences in the incidence (both 86%) of intensity (median; 25th; 75th percentiles, in VAS units: 3.1; 1.0; 5.3 and 3.3; 1.4; 5.0, respectively) or duration (66±31 and 73±26 s, respectively) of pain between the faster (1.0 ml/s) and slower (0.2 ml/s) bolus infusion rates of propofol studied.

Conclusions:  We conclude that the i.v. bolus infusion rate of propofol does not influence drug‐induced local pain on injection, at least not within the infusion rate interval studied. Therefore, adjusting i.v. injection speed does not seem to be a clinically useful tool for reducing the intensity or duration of propofol‐induced pain at the site of administration.
Increased synthesis of nitric oxide in rat brain cortex due to halogenated volatile anesthetics confirmed by EPR spectroscopy
Authors: Baumane L. , Dzintare M. , Zvejniece L. , Meirena D. , Lauberte L. , Sile V. , Kalvinsh I. , Sjakste N.
Published: March 2003

Background: Halogenated volatile anesthetics (HVAs) are considered to be inhibitors of nitric oxide synthase (NOS). On other hand, NO mediates the vasodilation produced by HVAs. Thus, both increase and decrease of NO concentration in brain tissues are possible during anesthesia. Previously, we have observed an increase of NO content in rat brain cortex under halothane anesthesia. The goal of this study was to determine whether the observed phenomenon was general for this anesthetic group, if it was specific for brain cortex, and if the NO increase was due changes in NOS activity.

Methods: NO scavengers were injected to adult rats 30 min prior to anesthesia. Rats were anesthetized by inhalation of an O2 mixture with volatile anesthetics (1.5% for halothane; 1% for isoflurane, 2% for sevoflurane). After 30 min of anesthesia, rats were decapitated and brain cortex, cerebellum, liver, heart, kidneys and testes were dissected, frozen in liquid nitrogen and subjected to EPR spectroscopy. Nitric oxide content was determined quantitatively based on the intensity of the NO–Fe–DETC complex spectrum and its comparison with the calibration curve.

Results: In rats anesthetized with HVAs, we observed a greater than twofold increase of NO content in brain cortex as compared to the nonanesthetized animals. No significant changes were detected in other organs. The NOS inhibitor Nω‐nitro‐L‐arginine abolished the increase of NO content in brain produced by volatile anesthetics.

Conclusion: The action of volatile anesthetics is coupled with an increase of NO content in the cortex dependent on NOS activity.
Serum concentration of S‐100 protein in assessment of cognitive dysfunction after general anesthesia in different types of surgery
Authors: Linstedt U. , Meyer O. , Kropp P. , Berkau A. , Tapp E. , Zenz M.
Published: March 2003

Background:  S‐100 protein serum concentration (S‐100) serves as a marker of cerebral ischemia in cardiac surgery, head injury and stroke. In these circumstances S‐100 corresponds well with the results of neuropsychological tests. The aim of the present study was to investigate the value of S‐100 and neuron specific enolase (NSE) in reflecting postoperative cognitive deficit (POCD) after general surgical procedures.

Methods:  One hundred and twenty patients undergoing vascular, trauma, urological or abdominal surgery were investigated. Serum values of S‐100 and NSE were determined preoperatively and 0.5, 4, 18 and 36 h postoperatively. Neuropsychological tests for detecting POCD were performed preoperatively and on day 1, 3, and 6 after the operation. A decline of more than 10% in neuropsychological test results was regarded as POCD. Furthermore, we retrospectively compared the S‐100 in patients with and without POCD in different types of surgery.

Results: According to our definition, forty ‐eight patients had POCD (95% confidence interval: 37.5–58.5). These patients showed higher serum concentrations of S‐100 (median 024 ng/ml; range 0.01–3.3 ng/ml) compared with those without POCD (n=69; median 0.14 ng/ml; range 0–1.34 ng/ml) 30 min postoperatively (P=0.01). Neuron specific enolase was unchanged during the course of the study. Differences of S‐100 in patients with and without POCD were found in abdominal and vascular surgery but not in urological surgery.

Conclusion:  When all patients are pooled, S‐100 appears to be suitable in the assessment of incidence, course and outcome of cognitive deficits. We suspect that in some surgical procedures, such as urological surgery, S‐100 appears to be of limited value in detecting POCD. Neuron specific enolase did not reflect neuropsychological dysfunction after noncardiac surgery.
Ultrasound‐guided central venous cannulation in infants and children
Authors: Åsheim P. , Mostad U. , Aadahl P.
Published: March 2003

Background: Percutaneous central venous cannulation in infants and children is a challenging procedure. Traditionally, an external landmark technique has been used to identify puncture site. An ultrasound‐guided technique is now available and we wanted to evaluate this method in children and infants, looking specifically at the ease of use, success rate and complications.

Methods: Forty‐two consecutive infants and children (median 16.5 [0–177] months and 10 [3–45] kg) scheduled for central venous catheter placement were registered. An ultrasound scanner made for guiding puncture of vessels was used. After locating the puncture site, a sterile procedure was performed using an accompanying kit to aid puncture of the vessel.

Results: Cannulation was successful in all patients and we had no complications during insertion of the catheters. The right internal jugular vein was preferred in most patients, and in 95% of the patients the vein was punctured at the first attempt. The median time from start of puncture to aspiration of blood was 12 (3–180) seconds.

Conclusion: The ultrasound‐guided technique for placement of central venous catheters was easy to apply in infants and children. It is our impression that it increased the precision and safety of the procedure in this group of patients.
Dynamic cerebral autoregulation in healthy adolescents
Authors: Vavilala M. S. , Newell D. W. , Junger E. , Douville C. M. , Aaslid R. , Rivara F. P. , Lam A. M.
Published: March 2003

Background: There is little information on the limits of cerebral autoregulation and the autoregulatory capacity in children. The aim of this study was to compare dynamic cerebral autoregulation between healthy adolescents and adults.

Methods: Seventeen healthy volunteers 12–17 years (n = 8) and 25–45 years (n = 9) were enrolled in this study. Bilateral mean middle cerebral artery flow velocities (Vmca; (cm/s)) were measured using transcranial Doppler ultrasonography (TCD). Mean arterial blood pressure (MAP) and end‐tidal carbon dioxide were measured continuously during dynamic cerebral autoregulation studies. Blood pressure cuffs were placed around both thighs and inflated to 30 mmHg above the systolic blood pressure for 3 min and then rapidly deflated, resulting in transient systemic hypotension.

The change of Vmca to change in MAP constitutes the autoregulatory response, and the speed of this response was quantified using computer model parameter estimation. The dynamic autoregulatory index (ARI) was averaged between the two sides.

Results: Adolescents had significantly lower ARI (3.9 ± 2.1 vs. 5.3 ± 0.8; P=0.05), and higher Vmca (75.2 ± 15.2 vs. 57.6 ± 15.0; P<0.001) than adults.

Conclusion: The autoregulatory index is physiologically lower in normal adolescents 12–17 years of age than in adults.
Procalcitonin and neopterin as indicators of infection in critically ill patients
Authors: Ruokonen E. , Ilkka L. , Niskanen M. , Takala J.
Published: March 2003

Background: In critically ill patients, severe infection and systemic inflammation due to non‐infectious causes produce very similar clinical presentations, and traditional infection markers do not always differentiate these two conditions. Both procalcitonin and neopterin have been suggested to aid in the early diagnosis of bacterial infections and in differentiating bacterial infections from systemic inflammatory, non‐infectious diseases or from viral infections.

Methods: Procalcitonin (PCT) and neopterin were analyzed in 208 ICU patients who developed acute fever or septic shock. Blood samples were taken every 8th h within 48 h of the onset of fever or septic shock.

Results: A total 162/208 of patients had infection, the most common location being the respiratory tract. Mortality was higher in infected patients (31.4% vs. 10.9%; P < 0.01). The optimum cut‐off levels in identifying patients with infection of daily peak PCT were 0.8 µg/L on day 1 and 0.9 µg/L on day 2, and both sensitivity (67.7% and 60.9%, respectively) and specificity (47.8% and 63%) were poor. Accordingly, the optimum cut‐off values of peak neopterin were 18 and 16 pg/L. The sensitivity was 62.7% on day 1 and 69.3% on day 2, while specificity was correspondingly 78.3% and 67.9%. There were no significant differences between the markers in discriminating between patients with infection or inflammation. Both PCT and neopterin increased with the severity of infection. They were higher in non‐survivors.

Conclusion: PCT and neopterin were equally effective, although not very accurate in differentiating between infection and inflammation in critically ill patients. Neopterin was more specific than PCT, suggesting that neopterin is related to the activity of inflammatory response.
Sentinel node mapping affects intraoperative pulse oximetric recordings during breast cancer surgery
Authors: Koivusalo A.‐M. , Von Smitten K. , Lindgren L.
Published: March 2003

Background:  In invasive breast cancer lymphatic mapping with patent blue vital dye (PBV) is used intraoperatively to identify the sentinel lymph nodes: the first axillary node draining the mammary lymphatic basin and first involved by the metastatic growth in breast cancer. Patent blue vital dye spreads to tissues giving a bluish tinge to patients. We have noted the possibility that intraoperative peripheral pulse oximetric (SpO2) values are artificially low when intradermal PBV is used.

Methods:  Twenty patients with normal pulmonary function undergoing breast cancer surgery in standardized anesthesia either did or did not receive intradermal PBV sentinel node marking. The radial artery was cannulated for blood‐gas‐analysis; arterial oxygen tension (PaO2); and arterial oxygen saturation (SaO2). Peripheral oxygen saturation was measured using the light absorption technique. Red and infrared light (660 and 900 nm), used by pulseoxymetry, is partially absorbed when passing through the tissue. The amount of light absorbed is sensored and saturation calculated. The color of the skin was evaluated.

Results:  Peripheral oxygen saturation decreased only immediately after the injection of PBV, and remained at a significantly lower level (P<0.001) throughout the operation and up to 90 min postoperatively. Arterial oxygen tension and SaO2 values did not decrease after intradermal PBV. Patent blue vital dye made patients' skin more bluish (P<0.001). No changes in SpO2, PaO2 and SaO2 were found in control patients.

Conclusion:  The spectrum of PBV has a peak absorption at 640 nm, thus making the SpO2 values incorrect. Peripheral oxygen saturation values are falsely low and true arterial oxygenation is not impaired when PBV is used during sentinel node mapping.
Rectally administered diclofenac (Voltaren) reduces vomiting compared with opioid (morphine) after strabismus surgery in children
Authors: Wennström B. , Reinsfelt B.
Published: March 2003

Background: Nausea, vomiting and pain are common complications after strabismus surgery in children. Diclofenac, a non‐steroid anti‐inflammatory drug, is widely used to treat acute and chronic pain but there are few reports of its use given rectally in children undergoing strabismus surgery. This open randomised study was designed to investigate the analgesic and anti‐emetic properties of rectally administered diclofenac compared with opioid (morphine) given i.v. in connection with strabismus surgery in children.

Methods: After obtaining approval from the local ethics committee and written informed consent from the parents, 50 ASA class I–II children, 4–16 years of age, were randomised to receive either rectally administered diclofenac (Voltaren) 1 mg/kg or i.v. opioid (morphine) 0.05 mg/kg perioperatively. The children were consecutively operated upon from May 1999 to January 2001. Anaesthesia was induced with fentanyl and propofol and maintained with propofol. Nitrous oxide was omitted. The postoperative pain was assessed after arrival at the post anaesthesia care unit (PACU) by using the validated Wong and Baker scale (FACES) Pain Rating Scale. Postoperative nausea and vomiting (PONV) was assessed by measuring the frequency of vomiting and the degree of nausea.

Results: In the diclofenac group the incidence of PONV during the first 24 h was 12% (of which one child had severe vomiting). The incidence of PONV was much higher, 72% (P = 0.0000), in the morphine group, where 56% of the children also had severe vomiting. There were no difference in pain score between the two groups. Recovery time at the PACU was longer (P < 0.002) and the postoperative analgesic requirement higher in the morphine group (10 vs. 5 children). No children needed overnight admission to the hospital.

Conclusion: Diclofenac given rectally is an effective analgesic for this kind of surgery and gives less postoperative nausea than i.v. morphine. No serious adverse events were observed.
Rapid detection of oesophageal intubation: take care when using colorimetric capnometry
Authors: Puntervoll S. A. , Søreide E. , Jacewicz W. , Bjelland E.
Published: March 2003

Background: Rapid detection of a misplaced endotracheal tube in the esophagus is crucial, especially in emergency situations. Hence, we have compared the ability of a colorimetric CO2 indicator (Colibri technology, CO2ntrol 1) and a capnography to differentiate oesophageal and tracheal intubation, with and without CO2 air in the esophagus.

Methods: Fourteen otherwise healthy patients were intubated with an endotracheal tube in the trachea under general anesthesia. After a positive verification of this endotracheal tube and established mechanical ventilation a second endotracheal tube was placed in the esophagus. Both were initially ventilated four times, and expired CO2 was measured with a mainstream capnograph and a colorimetric indicator. In the remaining five patients CO2 containing air was inserted into the esophagus first and then ventilated four times.

Results: Both the colorimetric indicator and mainstream capnograph verified correct placement of the endotracheal tube from the first ventilation.

When the tube was placed in the esophagus, both methods correctly showed that no CO2 was present. However, in patients (n=5) with CO2 installed in their esophagus, the colorimetric indicator, but not the capnograph, had readings showing that CO2 was present. This may cause a misinterpretation of correct tracheal placement.

Conclusions: We found that in emergency situations where CO2 containing air may be present in the esophagus, capnography should be the preferred method of verifying endotracheal and not oesophageal intubation. The tested colorimetric CO2 indicator (Colibri technology, CO2ntrol 1) is very sensitive to low CO2 values. It may therefore falsely indicate correct endotracheal intubation, even when the tube is in the oesophageus.
Appropriateness of leaving emergency medical service treated hypoglycemic patients at home: a retrospective study
Authors: Anderson S. , Høgskilde P. D. , Wetterslev J. , Bredgaard M. ,   Sørensen, Møller J. T. , Dahl J. B.
Published: March 2003

Background:  Hypoglycemic patients treated by the emergency medical service (EMS) system are commonly left home. The criteria for leaving hypoglycemic patients at home and the appropriateness of the procedure remains, however, unvalidated. The present retrospective article addresses these questions.

Methods:  The Copenhagen physician‐based mobile intensive care unit (MICU) responds to emergency calls in a two‐tier rendezvous system. Its prehospital data from 1995 to 1998 were retrospectively incorporated into a clinical database and cross‐referenced with clinical information from three Danish national registries, enabling identification of criteria for transportation of the patients to the hospital, and a detailed 72‐h follow up on patients left at home.

Results:  The MICU treated 1148 hypoglycemic patients within the period, of which 84% were released at home. Treatment or no treatment before arrival of the MICU and level of consciousness following MICU treatment, were found to be strong predictors of a need for transportation to hospital; although other factors were implicated. Within the 72‐h following MICU treatment less than 8% of the patients left at home needed secondary MICU or hospital treatment because of glucose regulatory problems, and less than 5% experienced secondary hypoglycemia. Less than 1% was admitted to hospital beds with recurrent hypoglycemia within 24 h. Poor compliance with the diabetic treatment instructions often appeared to be involved in cases of recurrent hypoglycemia. A delay in admission was not to blame for a serious secondary patient course in any of the cases.

Conclusion:  The majority of patients with prehospital hypoglycemia may safely be treated and released at home in a physician‐based EMS area.
Post‐operative paraplegia following spinal cord infarction
Authors: Weinberg L. , Harvey W. R. , Marshall R. J.
Published: March 2003

Thoracic epidural analgesia is a frequently utilised technique. Neurological complications are uncommon, but of grave consequence with significant morbidity. Spinal cord infarction following epidural anaesthesia is rare. We present a case where a hypertensive patient underwent an elective sigmoid colectomy under combined general/epidural anaesthesia for a suspected malignant abdominal mass. An epidural infusion was used for intra‐operative and post‐operative analgesia. During surgery, the blood pressure was labile and she was hypotensive. Postoperatively, the patient became confused, pyrexial and tachycardic and developed systemic inflammatory response syndrome requiring intensive care management. She developed a flaccid paralysis at L3 level with areflexia, analgesia and impaired sensation. A spinal cord infarct in the region of the conus extending into the thoracic cord was diagnosed. Complications of epidural anaesthesia are easily recognised when they develop immediately; their relationship to the anaesthesia and the post‐operative period may be misjudged or underestimated when they appear after a delay, if neurological signs are masked by lack of patient cooperation and drowsiness or if the epidural anaesthesia is prolonged by long‐acting drugs. New neurological deficits should be evaluated promptly to document the evolving neurological status and further testing or intervention should be arranged if appropriate. The association with epidural anaesthesia as a cause of paraplegia is reviewed. The aetiological factors that may have contributed to this tragic neurological complication are discussed.
The sevoflurane saving capacity of a new anaesthetic agent conserving device compared with a low flow circle system
Authors: Enlund M. , Lambert H. , Wiklund L.
Published: March 2003

Background: An anaesthetic agent conserving device (ACD) has been added to a Bain system to approach the agent‐saving capacity of a low flow circle system.

Methods: Randomly selected ASA physical status I patients received a standardized anaesthetic with sevoflurane in air/O2 through either a circle system with 1.5 l/min fresh gas flow (n = 8), or through a Bain system with an added ACD with fresh gas flow 4.4–6.4 l/min (n = 8). A target controlled infusion of remifentanil was used for analgesia.

Results: The median sevoflurane consumption was 19.7 and 22.0 ml/MAC/h with the low flow circle system and the Bain system + ACD, respectively (P=0.10, Mann–Whitney U‐test), or when adjusted for weight 0.25 and 0.28 ml/MAC/h/kg (P=0.26, Mann–Whitney U‐test).

Conclusion: The expenditure of sevoflurane with a Bain system + ACD was close to that in a circle system with 1.5 l/min fresh gas flow. It is thereby possible to use sevoflurane to all its potential, performing for example rapid alterations in end‐tidal concentration using high fresh gas flows by combining a Bain system with an ACD. Although the price is not decided for this not yet commercially available device, a potential for a lower cost exists. Additionally, there will be no concerns of toxic compounds produced in the absorber.
Impact of laryngeal mask airway and tracheal tube on pulmonary function during the early postoperative period
Authors: Natalini G. , Franceschetti M. E. , Pletti C. , Recupero D. , Lanza G. , Bernardini A.
Published: March 2003

Background: The tracheal tube (TT) produces reversible bronchoconstriction and increases pulmonary airway resistance compared to the laryngeal mask airway (LMA). The possible persistence of this effect in the postoperative period has not been studied. The aim of this study was to compare the early postoperative pulmonary function in healthy patients undergoing minor surgical procedures with the LMA or with the TT.

Methods: Sixty patients scheduled for saphenous vein stripping under general anaesthesia were randomised to receive the LMA or the TT. Before anaesthesia and 20 min after LMA or TT removal, pulse oxymetry values (SpO2) were recorded and patients performed forced spirometry in the supine position.

Results: Preoperative pulmonary function was normal in both groups. There were no differences between groups in the preoperative respiratory function test and SpO2. Following surgery SpO2, forced expiratory volume in the first second (FEV1), forced vital capacity (FVC) and peak expiratory flow (PEF) decreased in both groups. The FEV1/FVC did not change in either of the groups. In the TT group, compared to patients using the LMA, there was a greater relative decrease of SpO2 (2.7 ± 2.7% vs. 1.3 ± 2.2%, P=0.017), FEV1 (17.6 ± 12.2% vs. 8 ± 17.4%, P=0.008), FVC (15.8 ± 12.4% vs. 9 ± 13.4%, P=0.023) and PEF (20.6% ± 15.3% vs. 8.1 ± 33.3%, P=0.033).

Conclusions: This study demonstrates greater early postoperative respiratory restrictive syndrome and lower arterial oxygen saturation following tracheal intubation compared to LMA use in patients without respiratory disease.
Monitoring arterial blood pressure during whole body hyperthermia
Authors: Kerner T. , Deja M. , Ahlers O. , Hildebrandt B. , Dieing A. , Riess H. , Wust P. , Gerlach H.
Published: March 2003

Background: For monitoring of arterial blood pressure (ABP) during whole body hyperthermia (WBH) different methods have been recommended. This investigation was performed to evaluate the agreement of invasive measurements at various sites, and to compare invasive and non‐invasive methods of ABP monitoring under conditions of a heat‐induced extreme vasodilation.

Methods: In 19 patients, 48 treatments with WBH were performed. Measurements of ABP in the radial and femoral artery by oscillometry and by sphygmomanometry were taken at four temperature levels during WBH (37, 40, 41.8 and 39°C).

Results: Significant differences were observed between invasive and non‐invasive methods for systolic ABP, with higher values for non‐invasive measurements. When compared with both invasive measurements for diastolic blood pressures, sphygmomanometry gave higher values and oscillometry gave lower values. Sphygmomanometry also showed higher values for mean ABP compared with all other techniques, while measurements in radial and femoral artery and by oscillometry only differed by approximately 5 mmHg.

Conclusion: The mean arterial pressure and not the systolic and/or diastolic pressure should guide hemodynamic management during WBH. The sphygmomanometric technique is not recommended for use during hyperthermia.
Use of cerebral oximetry to detect and manage cerebral desaturation with a rapidly expanding neck hematoma
Authors: Akça O. , Sessler D. I.
Published: March 2003

Background: We report a case in which cerebral oximetry was used to successfully demonstrate when cerebral oxygen saturation is dangerously low.

Methods: In a 60‐year‐old‐man with end‐stage multiple myeloma and hyperviscosity syndrome, a rapidly expanding hematoma developed after insertion of an internal jugular central venous catheter. As the hematoma expanded, the patient became lethargic and disoriented (Glasgow Coma Score of E2/M4‐5/V2‐ETT). His platelet count was 17,000.mm−3, hemoglobin was 4.5 g/dl, partial thromboplastin time was 51 s, and his international ratio was 1.7. Although carotid pulses became unpalpable, blood pressure and heart rate remained stable. Cerebral oximeter probes positioned on the patient's forehead showed that cerebral oxygen saturation was 22–26% bilaterally. The surgery team was advised to surgically evacuate the hematoma.

Results: The hematoma was evacuated and a small needle hole in the right internal jugular vein adjacent to the central‐venous catheter was found and repaired. Cerebral oxygen saturation increased to 56–58% within 1 h and stabilized near 60%. The patient awoke with normal cognitive function.

Conclusion: This case demonstrates how cerebral oximetry can be used to give quantitative evidence of cerebral hypoxia, thus showing that immediate surgical intervention is necessary.
Small‐volume resuscitation: from experimental evidence to clinical routine. Advantages and disadvantages of hypertonic solutions
Authors: Kreimeier U. , Messmer K.
Published: March 2003

Background: The concept of small‐volume resuscitatioin (SVR) using hypertonic solutions encompasses the rapid infusion of a small dose (4 ml per kg body weight, i.e. approximately 250 ml in an adult patient) of 7.2–7.5% NaCl/colloid solution. Originally, SVR was aimed for initial therapy of severe hypovolemia and shock associated with trauma.

Methods: The present review focusses on the findings concerning the working mechanisms responsible for the rapid onset of the circulatory effect, the impact of the colloid component on microcirculatory resuscitation, and describes the indications for its application in the preclinical scenario as well as perioperatively and in intensive care medicine.

Results: With respect to the actual data base of clinical trials SVR seems to be superior to conventional volume therapy with regard to faster normalization of microvascular perfusion during shock phases and early resumption of organ function. Particularly patients with head trauma in association with systemic hypotension appear to benefit. Besides, potential indications for this concept include cardiac and cardiovascular surgery (attenuation of reperfusion injury during declamping phase) and burn injury. The review also describes disadvantaages and potential adverse effects of SVR:

Conclusion: Small‐volume resuscitation by means of hypertonic NaCl/colloid solutions stands for one of the most innovative concepts for primary resuscitation from trauma and shock established in the past decade. Today the spectrum of potential indications envolves not only prehospital trauma care, but also perioperative and intensive care therapy.
Comparison of epidural pain treatment with sufentanil‐ropivacaine infusion with and without epinephrine in children
Authors: Kokki H. , Ruuskanen A. , Karvinen M.
Published: March 2003

Background:  Epidural analgesia provides outstanding pain relief after surgery, but it is also associated with numerous adverse effects. In order to improve postoperative pain management in children we determined whether the use of epinephrine added to epidural sufentanil‐ropivacaine infusion reduced drug requirements, the intensity and duration of postoperative pain and the incidence and severity of adverse effects.

Methods:  A prospective, randomized, double blind, parallel group study design was used in 61 children. The children were given continuous epidural sufentanil‐ropivacaine infusion either with (n=32) or without (n=29) epinephrine for postoperative analgesia. Intravenous ketoprofen, a non‐steroid anti‐inflammatory drug, was used for all children, and epidural ropivacaine was used for rescue analgesia. The drug consumption, intensity of pain at rest and during activity, and all adverse effects were recorded.

Results:  The need for sufentanil (P=0.001) and ropivacaine (P=0.006) was significantly lower in the with‐epinephrine group than in the without‐epinephrine group. The mean duration of epidural infusion (62 h) was similar in both groups. Four children in the without‐epinephrine group were noticed to have a low oxygen saturation (SpO2<90%), and in one child a low respiratory rate (8 breaths min−1). The incidence of pruritus was higher in the without‐epinephrine group (P=0.026).

Conclusion:  Both infusions provided effective pain relief, and epinephrine as an adjuvant to continuous epidural sufentanil‐ropivacaine infusion seems to be useful in children.
Retrospective evaluation of continuous epidural infusion for postoperative pain in children
Authors: Jylli L. , Lundeberg S. , Olsson G. L.
Published: March 2003

Background: The safety and efficacy of postoperative epidural analgesia (EDA) in children are not well documented in larger series of patients given routine postoperative care. The aims of this study were to evaluate the efficacy of pain relief, determine the incidence and type of complications during the entire period of epidural pain treatment in children, and assess the factors affecting efficacy

Methods: Children treated postoperatively with an EDA infusion during the period 18 September 1994 to 1 January 1999 were studied. Data regarding the age, gender, efficacy of analgesia, duration of epidural infusion, types of side‐effects and complications, reasons for discontinuation, and types and duration of surgery were collected daily by the Acute Pain Treatment Service. The sensory dermatomal level of the surgical incision site was included retrospectively.

Results: Five hundred and eighteen epidural infusions were given to 476 children. Pain relief was rated as ‘good’ at 76% of visits. There were no major complications or sequelae. Thirty‐seven per cent of the epidural infusions were prematurely discontinued, and 21% were discontinued because of unsatisfactory analgesia. Factors related to a higher percentage of unsatisfactory function were surgical incision site located above the umbilicus, gastrenterologic surgery, protracted surgery and age. Age and duration of surgery were significantly related to unsatisfactory function.

Conclusion: This study shows that continuous epidural infusion for postoperative pain was satisfactory in most cases, and that no major side‐effects or complications occurred in children nursed on regular wards. The early recognition of unsatisfactory function of an EDA is important for a child's well being.
Mutation screening in the ryanodine receptor 1 gene (RYR1) in patients susceptible to malignant hyperthermia who show definite IVCT results: identification of three novel mutations
Authors: Rueffert H. , Olthoff D. , Deutrich C. , Meinecke C. D. , Froster U. G.
Published: March 2003

Background: The ryanodine receptor of the skeletal muscle (RYR1) seems to be of outstanding importance in the pathogenesis of malignant hyperthermia (MH). It has been shown that point mutations in the RYR1 gene are strongly associated with the MH phenotype. A correctly determined phenotype is the basic prerequisite for adequate genetic MH screening. In this study we examined only those MH susceptible patients for the presence of potential RYR1 mutations who showed strong pathological muscle responses in the in vitro contracture test (IVCT).

Methods: A total of 56 MHS index patients who complied with the following IVCT criteria were included in the molecular genetic investigation: Contracture forces ≥4 mN at a caffeine concentration of 2.0 mmol/l and ≥8 mN at a halothane concentration of 0.44 mmol/l. DNA sequences of exons 2, 6, 9, 11, 12, 14, 15, 17, 39, 40, 45, 46, 102 of the RYR1 gene were analysed by the direct sequencing technique. Furthermore, if an MH mutation was identified in an index patient, all relatives were screened for their family specific RYR1 defect.

Results: In 39 index patients an RYR1 mutation was detected: Arg163Cys (n = 2), Asp166Asn (n = 1), Gly341Arg (n = 2), Arg401His (n = 2), Arg614Cys (n = 12), Asp2129Glu (n = 1),Vol2168Met (n = 1), Thr2206Met (n = 9), Ala2428Thr (n = 1), Gly2434Arg (n = 2), Arg2435His (n = 1), Arg2452Trp (n = 1), Arg2454His (n = 4). Three new RYR1 mutations were identified. We found a potential MH mutation in a further 130 relatives of the 39 index patients. Thirty‐seven individuals were classified as MHS exclusively by molecular genetic techniques and did not have to undergo the IVCT.

Conclusions: The ascertained high rate of successful MH mutation screening (69.64%) is obviously associated with the more clearly defined MHS diagnosis in the IVCT. According to the EMHG guidelines for the molecular genetic detection of MH susceptibility, a positive MH disposition could be determined in numerous persons by a less invasive technique.
Anterior ischemic optic neuropathy after emergency caesarean section under epidural anesthesia
Authors: Gupta M. , Puri P. , Rennie I. G.
Published: March 2003

We report a case of non arteritic anterior ischemic optic neuropathy following caesarean delivery in a patient who had epidural analgesia. There was doubt as to whether it was subdural. The patient underwent caesarean section because of second stage non‐progression of labor. We discuss the possible etiology of this unpleasant complication.
Neurohistopathologic findings after a neurolytic celiac plexus block with alcohol in patients with pancreatic cancer pain
Authors: Vranken J. H. , Zuurmond W. W. A. , Van Kemenade F. J. , Dzoljic M.
Published: March 2003

Pancreatic cancer has a very poor prognosis resulting in the death of 98% of patients. Pain may be severe and difficult to treat. Management of pain includes chemotherapy, radiotherapy, pharmacologic treatment, and neurolytic celiac plexus block. Recent reviews of the efficacy of neurolytic celiac plexus block however, have reached conflicting conclusions. In this paper, we present two patients with severe pancreatic cancer pain resistant to pharmacologic treatment. Analgesic effect following repeated neurolytic celiac plexus blocks with alcohol was limited in time. Post‐mortem neurohistopathologic examination of the celiac plexus revealed an abnormal celiac architecture with a combination of abnormal neurons with vacuolization and normal looking neuronal structures (ganglionic structures and nerve fibers) embedded in fibrotic hyalinized tissue. Our results show that a neurolytic celiac plexus block with alcohol is capable of partially destroying the celiac plexus. These findings may explain the significant but short‐lasting analgesic effect following neurolytic celiac plexus block with alcohol.
Interpretation of radial pulse contour during fentanyl/nitrous oxide anesthesia and mechanical ventilation
Authors: Söderström S. , Sellgren J. , Åneman A. , Pontén J.
Published: March 2003

Background:  Peripheral arterial blood pressure is not a reliable substitute for proximal aortic pressure. Recognition of this phenomenon is important for correct appreciation of cardiac afterload. Our aim was to evaluate the utility of the radial pulse wave to better understand ventriculo‐vascular coupling during anesthesia.

Methods:  We observed the differences between aortic systolic pressure (AoSAP, tipmanometry) and radial systolic pressure in 15 patients, (including two women) aged 53–78 years, before coronary artery bypass surgery. We studied the induction of anesthesia with fentanyl (20 µg kg−1), moderate volume loading, and thereafter the addition of 70% nitrous oxide. The circulatory effects of mechanical ventilation were studied by doubling the tidal volumes. Pulse wave contours were assessed by calculation of radical and aortic augmentation indices (AI), which measure the second systolic pressure peak.

Results:  Radial systolic pressure was higher than AoSAP in the control situation (8±2 mmHg), and this SAP gradient increased further with fentanyl (12±2 mmHg). The gradient persisted throughout the study, but was partially reduced by volume loading and nitrous oxide, respectively. Radial augmentation index was the only parameter remaining in a stepwise multivariate model to explain the variance in the SAP gradient (r2=0.48). Radial augmentation index also correlated with aortic pulse pressure (r2=0.71). Mechanical ventilation had significant and similar effects on pulse wave augmentation both in the aorta and in the radial artery, and did not affect the radial to aortic SAP gradient.

Conclusion:  These elderly coronary patients had stiff vasculature (high aortic AI) and considerable pulse wave reflection, which was beneficially delayed by fentanyl. Changes in the radial pulse wave augmentation during mechanical ventilation were mainly a result of cyclic changes in the stroke volume, and were seldom associated with an increased systolic pressure gradient from the aorta to the radial artery.
Auditory evoked potential monitoring with the AAITM‐index during spinal surgery: decreased desflurane consumption
Authors: Määttänen H. , Anderson R. , Uusijärvi J. , Jakobsson J.
Published: March 2003

Background: The auditory evoked potential (AEP) is sensitive to the depth of anesthesia. The A‐line monitor is a novel device that processes the amplitude and latency of the AEP during the mid‐latency time window to provide a simple numerical index, the AAI™‐index. The hypothesis of the present study was that titration of anesthetic depth (desflurane) by means of the AAI™‐index could decrease the consumption of the main anesthetic and shorten emergence times.

Methods: Thirty ASA I–II patients scheduled for elective open spine surgery under general anesthesia were randomly allocated to two groups. Group I (n=15), the main anesthetic, desflurane, was titrated with a target AAI™‐index of 20±5. Group II (n=15), desflurane was titrated according to routine clinical signs, including heart rate, blood pressure, sweating and tears. No fixed MAC‐multiple was sought. The primary study variable was desflurane consumption; and secondary study variables were time to extubation and orientation.

Results: All patients had an uncomplicated course and no patients showed signs of awareness or had any recall postoperatively. AAI™‐index guidance reduced desflurane consumption by 29% and improved emergence. Time until extubation and orientation and ability to state name and date of birth was significantly shortened among AAI™‐index titrated patients.

Conclusion: Titrating depth of desflurane anesthesia using AAI™‐index guidance decreased main anesthetic consumption and improved emergence during spine surgery.
Cardiac arrest after intravenous metoclopramide – a case of five repeated injections of metoclopramide causing five episodes of cardiac arrest
Authors: Bentsen G. , Stubhaug A.
Published: March 2003

We describe a patient where intravenous injection of metoclopramide was immediately followed by asystole repeatedly. The patient received metoclopramide 10 mg i.v. five times during 48 h. After interviewing the attending nurses and reviewing the written documentation, it is clear that every administration of metoclopramide was immediately (within s) followed by asystole. The asystole lasted 15–30 s on four occasions, on one occasion it lasted 2 min. The patient received atropine 0.5–1 mg and chest compressions, before sinus rhythm again took over. We interpret this as episodes of cardiac arrest caused by metoclopramide. The rapid injection via the central venous route and the concomitant tapering of dopamine infusion might have contributed in precipitating the adverse drug reaction.
Bilateral continuous paravertebral catheters for reduction mammoplasty
Authors: Buckenmaier C. C. , Steele S. M. , Nielsen K. C. , Martin A. H. , Klein S. M.
Published: March 2003

Surgical procedures of the breast can result in significant postoperative pain. Paravertebral nerve blocks have been used successfully in the management of analgesia after breast surgery but are limited by a single injection. This report describes the use of bilateral paravertebral catheters to provide extended analgesia for reduction mammoplasty.

A 48‐year‐old female underwent bilateral paravertebral catheter placement at thoracic level 3 and local anesthetic injections followed by general anesthesia for elective reduction mammoplasty. She reported no pain following the operation and required no supplemental opioids for pain management during her overnight recovery.

This case demonstrates a method for extended bilateral thoracic analgesia. The technique may offer an alternative to traditional outpatient analgesics for reduction mammoplasty.
Prolonged apnea following succinylcholine administration in undiagnosed acute organophosphate poisoning
Authors: Sener E B. , Ustun E. , Kocamanoglu S. , Tur A.
Published: March 2003

Organophosphates (OP) are irreversibly bound to cholinesterase, causing deactivation of acetylcholinesterase. As a result of inhibition of plasma cholinesterase, increased sensitivity to drugs hydrolyzed by this enzyme can occur, e.g. succinylcholine and mivacurium. A case of more prolonged succinylcholine‐induced paralysis in a child with undiagnosed acute OP insecticide poisoning is presented. A 7‐h period of apnea and paralysis after administration of succinylcholine was attributed to the decreased rate of succinylcholine metabolism resulting from inhibition of pseudocholinesterase by the insecticide. In seven previously reported cases of prolonged succinycholine apnea after OP poisoning, exposure to insecticide was in chronic or subacute form without any obvious symptoms, and the duration of apnea did not extend up to 4 h, whereas in our case with acute, severe poisoning, succinylcholine led to more prolonged muscle paralysis. In the anesthetic management of patients with acute OP poisoning, succinylcholine should be avoided.