bluuebunny/crossref_metadata_2025 huggingface dataset:
Prehospital management of diabetic emergencies – a population‐based intervention study
Authors: Holstein A. , Plaschke A. , Vogel M.‐Y. , Egberts E.‐H.
Published: December 2004

Background: Diabetes‐related emergencies are frequent and potentially life‐threatening. A study was performed to obtain reliable data about the prevalence of diabetic emergencies and to improve the quality of prehospital care of patients with diabetes‐related emergencies.

Methods: A prospective population‐based study in a German emergency medical service district in the period from 1997 to 2000 was conducted. After initial diabetes training for the entire emergency team, a standardized protocol was introduced for prehospital emergency therapy of severe hypoglycaemia (SH) and severe hyperglycaemic disorders. A rapid blood glucose test was performed on all emergency patients with the exception of resuscitations and deaths. Indicators of treatment quality before and after these interventions were compared.

Results: A rapid blood glucose test was performed in 6631 (85%) of the 7804 emergencies that occurred during the period investigated. The prevalence of acute diabetic complications was 3.1%, and 213 cases of SH and 29 severe hyperglycaemic disorders were recorded. Education of the emergency team led to a significant improvement in the quality of treatment. Larger volumes of iv 40% glucose solution (50 ± 20 ml (1997–2000) vs. 25 ± 17 ml (1993–96); P < 0.0001) were administered to patients with SH. Insulin‐treated patients who were well educated about their diabetes were more often treated only at the emergency scene, after SH (25% vs. 8%; P = 0.007), and without complications. In 50 patients who experienced sulfonylurea‐induced SH, the mandatory additional glucose infusions and hospitalization for further observation reduced mortality from 4.9% to 0% (P = 0.2).

Conclusion: Training of the emergency team is an effective and efficient intervention to improve quality of treatment and prognosis outcome for patients with diabetic emergencies. Treatment of SH at the emergency scene only was demonstrated to be safe in type 1 diabetic patients who had previously received structured patient education.
Intrathecal hyperbaric bupivacaine 3 mg + fentanyl 10 µg for outpatient knee arthroscopy with tourniquet
Authors: Korhonen A‐M. , Valanne J. V. , Jokela R. M. , Ravaska P. , Korttila K.
Published: December 2004

Background:  Combination of local anesthetic and opioid enables the use of less spinal anesthetic and increases the success of anesthesia. Intrathecal opioid does not prolong motor recovery and thus should not delay discharge home. We hypothesized that 3 mg of hyperbaric bupivacaine with 10 µg of fentanyl permits fast‐tracking or shorter stay in post anesthesia care unit (PACU), and earlier discharge home, compared with 4 mg of hyperbaric bupivacaine.

Methods:  In this double‐blind study, 100 outpatients undergoing knee arthroscopy received randomly either 4 mg of bupivacaine (B4) or 3 mg of bupivacaine + 10 µg fentanyl (B3F) intrathecally. The volume of 0.8 ml was injected at the L2/3 interspace over a 2‐min period. A lateral decubitus position was maintained for 10 min. The sensory block was recorded by using thermal stimuli, and motor block was assessed according to a modified Bromage scale. Fast‐tracking criteria were complete recovery of motor block, sensory block Th12 or lower and stable vital signs.

Results:  One block (1%) failed. Motor recovery was faster in the B3F group: 60% of the patients recovered in 80 min or less compared with 28% in group B4 (P = 0.002). The PACU‐time was shorter: 36 (10–103) vs. 55 (10–140) min, respectively (P = 0.005). Seventeen (B3F) vs. nine patients (B4) could bypass PACU (NS). Time to discharge home was similar in both groups. In the B3F group, 75% of the patients developed pruritus.

Conclusion:  Both solutions produced reliable spinal anesthesia for outpatient knee arthroscopy. The PACU‐time was shorter in the bupivacaine‐fentanyl group, but both groups reached home‐readiness equally.
Rocuronium and cisatracurium‐positive skin tests in non‐allergic volunteers: determination of drug concentration thresholds using a dilution titration technique*
Authors: Berg C. M. , Heier T. , Wilhelmsen V. , Florvaag E.
Published: December 2004

Background: Muscle relaxants are believed to be responsible for 2/3 of the cases of anaphylactic reactions during anesthesia. This assumption is based mainly on positive skin tests obtained in individuals that have experienced anesthesia‐related anaphylaxis. A positive skin test is supposed to be associated with mast cell degranulation of vasoactive amines. In the present study we tested the frequency of positive skin tests with two commonly used muscle relaxants, rocuronium and cisatracurium, in a selected group of volunteers with low potential for allergic reactions.

Methods: Thirty healthy volunteers without known allergy or previous exposure to muscle relaxants were studied. Low potential for allergic reactions was determined prior to inclusion in the study, using various allergy tests. Each individual was tested with intradermal and skin prick tests, and molar drug concentration thresholds for positive skin reactions were determined using a dilution titration technique. The presence or absence of mast cell degranulation was tested by electron microscopic investigation of skin biopsies obtained from positive and negative skin reactions.

Results: None of the volunteers had a positive skin prick test. More than 90% of the volunteers had a positive intradermal test with both rocuronium and cisatracurium. The highest molar drug concentration that was not associated with a positive intradermal test was 10−6 M (rocuronium) and 10−7 M (cisatracurium), equivalent to vial dilution 1 : 1000 for both drugs. In none of the volunteers was mast cell degranulation detected.

Conclusion: Non‐mast‐cell‐mediated positive intradermal skin reactions are frequently occurring with rocuronium and cisatracurium, even at vial dilution 1 : 1000. A clinically applicable test technique is needed that is able to separate positive skin tests associated with mast cell degranulation from non‐mast‐cell‐mediated reactions.
Warming of infusion syringes caused by electronic syringe pumps
Authors: Cornelius A. , Frey B. , Neff T. A. , Gerber A. C. , Weiss M.
Published: December 2004

Purpose: To evaluate inadvertent warming of the infusion syringe in four different types of electronic syringe pumps.

Methods: Ambient temperature and syringe surface temperature were simultaneously measured by two electronic temperature probes in four different models of commercially available syringe pumps. Experiments were performed at an infusion rate of 1 ml h−1 using both battery‐operated and main power‐operated pumps. Measurements were repeated four times with two pumps from each of the four syringe pump types at a room temperature of approximately 23°C. Differences among the four syringe pump brands regarding ambient to syringe temperature gradient were compared using ANOVA. A P‐value of less than 0.05 was considered statistically significant.

Results: Syringe warming differed significantly between the four syringe brands for both the battery‐operated and main power‐operated mode (ANOVA, P< 0.001 for both modes). Individual differences between syringe surface and ambient temperature ranged from 0.3 to 1.9°C for battery operation and from 0.5 to 11.2°C during main‐power operation.

Conclusion: Infusion solutions can be significantly warmed by syringe pumps. This has potential impact on bacterial growth and the stability of drug solutions and blood products infused, as well as on the susceptibility to hydrostatic pressure changes within the infusion syringe.
Benefit of using a triple‐lumen catheter to monitor left atrial pressure
Authors: Ceyran H. , Akçalý Y. , Asgun F. , Tezcaner T. , Tasdemir K. , Emirogullarý O. N. , Ersepciler M.
Published: December 2004

Background: Left atrial pressure (LAP) monitoring provides a useful option for management of hemodynamic status in pediatric open‐heart surgical patients during the postoperative period.

Patients and method: We used a triple‐lumen catheter placed into the left atrium transseptally to measure left atrial pressure. Twenty children that were operated on in our clinic are included in this study: 11 males and nine females. A 5‐Fr. triple‐lumen radio‐opaque polyethylene catheter was used for the procedure. After the repair of the primary cardiac defect, the distal end of the catheter was repositioned transseptally and advanced into the left atrium. The proximal and middle line's distal orifices were left in the right atrium. Distal line was used as a left atrial pressure line, the middle line as a central venous pressure line, and the proximal line as a route for fluid infusion or drug administration.

Results: No mortality and no catheter‐related complication were observed. No failure or complication occurred during withdrawal of the catheter.

Conclusion: We conclude that this preliminary technique can be a useful and easy way of monitoring LAP, as well as providing central venous access.
The vasoconstriction threshold is increased in obese patients during general anaesthesia
Authors: Kasai T. , Hirose M. , Matsukawa T. , Takamata A. , Tanaka Y.
Published: December 2004

Background: In anaesthetized patients, body temperature decreases often, but overweight patients become less hypothermic. Obesity in itself protects body heat, and thermoregulatory reflexes may maintain normothermia in obese patients. We tested the hypothesis that even slight obesity increases the vasoconstriction threshold.

Methods: Twenty male patients aged 30–65 years scheduled for open abdominal surgery were allocated to two groups: body fat ≥25% (obese group, n = 10), or <25% (normal weight group, n = 10). Anaesthesia was maintained with 0.4% isoflurane and opioid. The thermoregulatory vasoconstriction threshold was defined by the tympanic membrane temperature at which the skin temperature gradient equalled 0°C. Plasma adrenaline, noradrenaline and leptin were measured.

Results: Age, height, heart rate and blood pressure did not differ between the two groups of patients. In the obese group the vasoconstriction threshold was higher than that in the normal weight group: 36.0 ± 0.1 vs. 35.5 ± 0.2°C. Consequently, after 4 h of anaesthesia, the core temperature was highest in the obese patients: 36.4 ± 0.1 vs. 35.5 ± 0.2°C.

Conclusions: These results suggest that core temperature is maintained in obese patients because their vasoconstriction threshold to a low environmental temperature is high.
Electromyographic assessment of blink and corneal reflexes during midazolam administration: useful methods for assessing depth of anesthesia?
Authors: Mourisse J. , Gerrits W. , Lerou J. , Van Egmond J. , Zwarts M. J. , Booij L.
Published: December 2004

Background: There are at least three components of the anesthetic state: loss of consciousness, amnesia and obtundation of reflex responses to noxious stimuli. To investigate the third component, we used a standard electrical stimulus to evoke a blink reflex, which was electromyographically recorded. These data may give information on the anesthetic state.

Methods: The relation between the electrically evoked blink and corneal reflexes and the depth of sedation and anesthesia induced with intravenous midazolam was investigated. Ten patients received i.v. increments of midazolam (1 mg, 2 mg, 3 mg, 3 mg, 3 mg, etc., until a 21‐mg total dose) to create a step‐wise deepening of sedation and anesthesia. Depth of anesthesia was assessed by the Observer's Assessment of Alertness/Sedation (OAAS) scale, ranging from 5 ( =  awake and alert) to 0 ( =  no motor response to tetanic stimulation).

Results: Latency of the first (R1) and second (R2) blink components and the corneal (C) reflex component increased, whereas duration and area decreased with increasing depth of sedation and anesthesia. R1 was last seen at an OAAS score [mean (SD)] of 1.8 (0.8), R2 at a score of 3.1 (1.1), C at a score of 3.8 (0.8), and R3 at 4.8 (0.5). These end‐points were all statistically different from each other, except R2 vs. C.

Conclusions: Our results suggest that the differential sensitivity of the components of the blink reflex could be useful to monitor depth of sedation and light levels of anesthesia during the administration of midazolam.
Hemodynamic and oxygenation profiles in the early period after hyperbaric oxygen therapy: an observational study of intensive‐care patients
Authors: Ratzenhofer‐Komenda B. , Offner A. , Quehenberger F. , Klemen H. , Berger J. , Fadai J. H. , Spernbauer P. , Prause G. , Smolle‐Jüttner F. M.
Published: December 2004

Background: We studied whether hemodynamic and oxygenation profiles are altered in critically ill patients after exposure to hyperbaric oxygen (HBO).

Methods: Ten intensive‐care patients (two females, eight males) undergoing HBO treatment after major abdominal surgery, after burn injury and after CO poisoning were included. All subjects were put on mechanical ventilation and received continuous sedation, and had HBO treatment at 2.2 absolute atmospheres for 50 min.

Design: Observational prospective study, and repeated measure design.

Results: Hemodynamic and oxygen transport patterns were determined before (C0), 1 h (C1) and 2 h (C2) after HBO therapy with continuous cardiac output dual oximetry pulmonary arterial catheter, a central venous and radial arterial line. Data were analyzed with non‐parametric repeated measure analysis. Key results are expressed as a percentage of baseline (C0 values correspond to 100%) at C1 and C2 (median values, lower and upper limit of confidence interval): cardiac index [C1: 105% (98–135), C2: 99% (91–117), P = 0.19], systemic (P = 0.62) and pulmonary vascular (P = 0.76) resistance indices were unchanged, but pulmonary venous admixture (Qs/Qt) increased [C1: 173% (112–298), C2: 140% (92–241), P = 0.00002)] and arterial oxygen tension decreased [C1: 76% (67–94), C2: 82% (72–112), P = 0.010].

Conclusion: The hemodynamic profile remained unaffected. The increase in Qs/Qt and the decrease in PaO2 may be attributed to the inhalation of HBO, and both are reversible.
Bronchial rupture with a left‐sided polyvinylchloride double‐lumen tube
Authors: Yüceyar L. , Kaynak K. , Cantürk E. , AykaÇ B.
Published: December 2004

Bronchial rupture after intubation with a double‐lumen endobronchial tube has been infrequently reported. Overinflation of the bronchial cuff was speculated to be a frequent cause of the bronchial damage. We report the case of a 78‐year‐old woman with non‐small cell carcinoma of the right upper lobe. Her trachea and left main‐stem bronchus were intubated with a left‐sided polyvinylchloride (PVC) double‐lumen endobronchial tube (Broncho‐Cath® 37 Fr, Mallinckrodth Medical, Athlone, Ireland). She underwent an uneventful right upper lobectomy. At the end of the resection, the surgeons noticed the herniating cuff from the ruptured left main‐stem bronchus. Laceration was repaired. Subsequent course of the patient was uneventful: she developed neither bronchial leak nor mediastinitis. Ten days later the patients was discharged home in a satisfactory condition. Factors that seem to increase the risk of injury by a double‐lumen tube are discussed.
Fluid extravasation during cardiopulmonary bypass in piglets – effects of hypothermia and different cooling protocols
Authors: Farstad M. , Heltne J. K. , Rynning S. E. , Lund T. , Mongstad A. , Eliassen F. , Husby P.
Published: December 2004

Background: Hypothermic cardiopulmonary bypass (CPB) is associated with capillary fluid leak and edema generation which may be secondary to hemodilution, inflammation and hypothermia. We evaluated how hypothermia and different cooling strategies influenced the fluid extravasation rate during CPB.

Methods: Fourteen piglets were given 60 min normothermic CPB, followed by randomization to two groups: 1: rapid cooling (RC‐group) (∼15 min to 28°C); 2: slow cooling (SC‐group) (∼60 min to 28°C). Ringer's solution was used as CPB prime and for fluid supplementation. Fluid input/losses, plasma volume, colloid osmotic pressures (plasma, interstitial fluid), hematocrit, serum‐proteins and total tissue water (TTW) were measured and fluid extravasation rates calculated.

Results: Start of normothermic CPB resulted in a 25% hemodilution. During the first 5–10 min the fluid level of the reservoir fell markedly due to an intravascular volume loss necessitating fluid supplementation. Thereafter a steady state was reached with a constant fluid need of 0.14 ± 0.04 ml kg−1 min−1. After start of cooling the fluid needs increased in the following 30 min to 0.91 ± 0.11 ml kg−1 min−1 in the RC group (P < 0.001) and 0.63 ± 0.10 ml kg−1 min−1 in the SC‐group (P < 0.001) with no statistical between‐group differences.

Fluid extravasation rates after start of hypothermic CPB increased from 0.20 ± 0.08 ml kg−1 min−1 to 0.71 ± 0.13 (P < 0.01) and 0.62 ± 0.13 ml kg−1 min−1 (P < 0.05) in the RC‐ and SC‐groups, respectively, without any changes in degree of hemodilution. TTW increased in most tissues, whereas the intravascular albumin and protein masses remained constant with no between group differences.

Conclusion: Hypothermia increased fluid extravasation during CPB independent of cooling strategy. Intravascular albumin and protein masses remained constant. Since inflammatory fluid leakage usually results in protein rich exudates, our data with no net protein leakage may indicate that mechanisms other than inflammation could contribute to fluid extravasation during hypothermic CPB.
Pain relief and safety after major surgery A prospective study of epidural and intravenous analgesia in 2696 patients
Authors: Flisberg P. , Rudin Å. , Linnér R. , Lundberg C. J. F.
Published: December 2004

Background:  Adverse effects may still limit the use of continuous epidural and intravenous analgesia in surgical wards. This study postulated that postoperative epidural analgesia was more efficient, and had fewer side‐effects than intravenous morphine. The aim was to investigate efficacy, adverse effects and safety of the treatments in a large patient population.

Methods:  During a five‐year period 2696 patients undergoing major surgery, received either epidural or intravenous analgesia for postoperative pain relief. The patients were prospectively monitored in surgical wards. Pain was evaluated with a numeric rating scale (0–10) at rest/mobilization. Treatment duration, respiratory depression, sedation/hallucinations/nightmares/confusion, nausea/vomiting, pruritus, orthostatism/leg weakness, and insufficient pain relief were registered. Pain relief for all patients aimed at a pain scoring of less than 4 at rest.

Results:  Epidural analgesia was used in 1670 patients, and intravenous morphine in 1026 patients. Patients with epidural analgesia experienced less pain both at rest and during mobilization. Insufficient treatment effects such as dose adjustments, orthostatism/leg weakness, and pruritus were more common in the epidural group. Respiratory depression and sedation/hallucinations/nightmares/confusion occurred more often in the intravenous group. Thoracic epidural catheters caused a lower incidence of motor blockade compared to lumbar catheter placements.

Conclusion:  In a large patient population the use of epidural and intravenous postoperative analgesia was considered safe in surgical wards, and the incidence of adverse effects was low. Patients with epidural analgesia experienced overall less pain, while opioid related side‐effects were more common with intravenous morphine analgesia.
International publishing in anaesthesia – how do different countries contribute?
Authors: Figueredo E. , Sánchez Perales G. , Muñoz Blanco F.
Published: December 2004

Background: The evaluation of the international distribution in biomedicine research is a subject that creates expectations. This study assesses the recent evolution of world‐wide distribution of research in the anaesthesiology field and discusses some of the possible factors which could give rise to changes in the interpretation of absolute results.

Methods: A search on Medline was run to obtain the source country of the journal articles (with abstract) from 10 important anaesthesia journals in the 1997–2001 period. The data were analysed and standardized to journal impact factor values of each publication and population size. Annual evolution in the number of publications in the countries with the largest scientific production was analysed. Furthermore, the distribution of articles by country of origin was studied for each journal.

Results: The 9724 publications came from 65 countries. In absolute numbers, the USA leads research in anaesthesiology (24.4%). The evaluation of the contribution of the more productive countries revealed a progressive increase in the German contribution (from 5.1% to 9.4%) and a decrease in the American contribution (from 28.6% to 21.8%) over the 5 years analysed. In relative terms, Finland, Sweden and Denmark were the most productive countries per million inhabitants (8.8, 7.2 and 6 publications/year, respectively).

Conclusion: The geographic distribution of the publications on anaesthesiology must not only be analysed in absolute numbers, where the USA is the most productive. The North‐European countries show the largest production/number of inhabitants ratio; whereas the largest percentage increase during the period is found in Germany.
Neck haematoma and airway obstruction in a patient with goitre: complication of internal jugular vein cannulation
Authors: Silva F. S.
Published: December 2004

Attempted jugular vein cannulation in a patient with a discrete goitre resulted in a rapid growing haematoma and airway obstruction. This life‐threatening complication is rare, and is usually related to two conditions: pre‐existing coagulopathy and/or arterial puncture by a large bore cannula or vessel dilator. None of these was present in this patient.

Investigations revealed a retrosternal goitre causing tracheal compression and major changes in the calibre and the anatomical relationships of neck vessels. Possible origin and mechanism for the sudden haematoma are discussed, as well as the airway management.

This case clearly illustrates how internal jugular vein cannulation using the traditional blind technique, guided by external landmarks, can be extremely hazardous in patients with distorted anatomy of the neck.
Effect of isoflurane on monocyte adhesion molecule expression in human whole blood*
Authors: De Rossi L. W. , Horn N. A. , Weingartz E. , Buhre W. , Rossaint R.
Published: December 2004

Background: Recruitment of monocytes to inflamed tissue is a crucial step in the acute inflammatory reaction. Adherence of monocytes to endothelial cells followed by transmigration depends on monocyte surface adhesion molecules, inflammatory cytokines and chemoattractant chemokines. In the present study, we determined the effect of isoflurane on monocyte adhesion receptor expression in vitro.

Methods: Citrated whole blood was incubated for 60 min with either 0.5 or 1 MAC isoflurane. In unstimulated blood samples and after stimulation with N‐formyl‐methionyl‐leucyl‐phenylalanine (FMLP) monocyte cell‐surface expression of the selectins PSGL‐1 and L‐selectin, and the β2‐integrins CD11a and CD11b were evaluated by flow cytometry.

Results: Isoflurane reduced significantly the expression of PSGL‐1 on unstimulated monocytes, whereas the remaining selectins and β2‐integrins were not affected. At both concentrations, the FMLP‐induced removal of PSGL‐1 from the monocyte surface was increased. Furthermore, at 1 MAC isoflurane the FMLP‐induced increase in CD11a expression was significantly inhibited. The surface expression of L‐selectin and CD11b was not affected following exposure to isoflurane.

Conclusion: Isoflurane increases the removal of the selectin PSGL‐1 from the monocyte surface. Since PSGL‐1 is important during the initial step of monocyte adhesion to endothelial P‐selectin, the decrease in monocyte surface PSGL‐1 may have profound effects on monocyte–endothelial interactions. Furthermore, the effects of isoflurane on monocyte adhesion molecule expression are different from those reported for neutrophils.
The effect of heat and moisture exchanger on humidity and body temperature in a low‐flow anaesthesia system
Authors: Johansson A. , Lundberg D. , Luttropp H. H.
Published: December 2004

Background: Artificial humidification of dry inspired gases seems to reduce the drop in body temperature during surgery. The aim of this study was to evaluate the humidity and temperature of anaesthetic gases with heat and moisture exchangers (HMEs). The secondary aim was to evaluate if HMEs in combination with low‐flow anaesthesia could prevent a decrease in the body temperature during general anaesthesia.

Methods: Ninety patients scheduled for general surgery were randomised to receive a fresh gas flow of 1.0, 3.0 or 6.0 l min−1 with or without HMEs in a circle anaesthesia system. Relative humidity, absolute humidity, temperature of inspired gases and body temperatures were measured during 120 min of anaesthesia.

Results: The inspiratory absolute humidity levels with HMEs were 32.7 ± 3.1, 32.1 ± 1.1 and 29.2 ± 1.9 mg H2O l−1 and 26.6 ± 2.3, 22.6 ± 3.0 and 13.0 ± 2.6 mg H2O l−1 without HMEs after 120 min of anaesthesia with 1.0, 3.0, or 6.0 l min−1 fresh gas flows (P < 0.05, between with and without HME). The relative humidity levels with HMEs were 93.8 ± 3.3, 92.7 ± 2.2 and 90.7 ± 3.5%, and without the HMEs 95.2 ± 4.5, 86.8 ± 8.0 and 52.8 ± 9.8% (P < 0.05, between with and without HMEs in the 3.0 and 6.0 l min−1 groups). The inspiratory gas temperatures with HMEs were 32.5 ± 2.0, 32.4 ± 0.5 and 31.0 ± 1.9°C, and 28.4 ± 1.5, 27.1 ± 0.8 and 26.1 ± 0.6°C without HMEs after 120 min of anaesthesia (P < 0.05, between with and without HME). The tympanic membrane temperatures at 120 min of anaesthesia were 35.8 ± 0.6, 35.5 ± 0.6 and 35.4 ± 0.8°C in the groups with HMEs, and 35.8 ± 0.6, 35.3 ± 0.7 and 35.3 ± 0.9°C in the groups without the HMEs (NS).

Conclusions: The HMEs improved the inspiratory absolute humidity, relative humidity and temperature of the anaesthetic gases during different fresh gas flows. However, the HMEs were not able to prevent a body temperature drop during low‐flow anaesthesia.
A randomised double‐blind evaluation of adenosine as adjunct to sufentanil in spinal labour analgesia
Authors: Rane K. , Sollevi A. , Segerdahl M.
Published: December 2004

Background: Intrathecal injection of sufentanil offers labour pain relief of short duration. This double‐blind randomised study evaluates if the combination of adenosine to sufentanil could give relevant prolongation (40%) of the duration of sufentanil spinal analgesia.

Methods: Twenty‐five healthy parturients requesting labour analgesia were included. Patients received 10 µg of sufentanil + 500 µg of adenosine or 10 µg of sufentanil intrathecally. Pain intensity and duration of pain relief were assessed.

Results: Pain relief was equal between groups. Duration of analgesia was not increased by adenosine + sufentanil, 99 ± 54 min, vs. sufentanil, 89 ± 56 min.

Conclusion: Adding 500 µg of adenosine to 10 µg of sufentanil could not provide any prolongation of labour pain relief.
Ketamine reduces swallowing‐evoked pain after paediatric tonsillectomy
Authors: Elhakim M. , Khalafallah Z. , El‐fattah H. A. , Farouk S. , Khattab A.
Published: December 2004

Background: Ketamine efficacy as an analgesic adjuvant has been studied in several clinical settings with conflicting results. The aim of this study was to investigate the effect of ketamine on spontaneous and swallowing‐evoked pain after tonsillectomy.

Methods: Fifty children were randomized to receive premedication with either ketamine 0.1 mg kg−1 i.m. or placebo given 20 min before induction of a standard general anaesthesia. All children received rectal diclofenac 2 mg kg−1 and fentanyl 1 µg kg−1 i.v. before surgery.

Results: The ketamine group showed significantly lower pain scores both at rest and on swallowing, with less total paracetamol consumption (P < 0.05) during the 24 h after surgery. Significantly more patients required postoperative morphine titration in the control group (P < 0.05). The time to the first oral intake, and duration of i.v. hydration, were significantly shorter and the quality of oral intake was significantly better in the ketamine group (P < 0.05). There were no differences in the incidence of vomiting or dreaming between the groups.

Conclusion: Premedication with a small dose of ketamine reduces swallowing‐evoked pain after tonsillectomy in children who received an analgesic regimen combining an opioid and a NSAID.
Plasma cytokines do not reflect expression of pro‐ and anti‐inflammatory cytokine mRNA at organ level after cardiopulmonary bypass in neonatal pigs*
Authors: Brix‐Christensen V. , Vestergaard C. , Chew M. , Johnsen C. K. , Andersen S. K. , Dreyer K. , Hjortdal V. E. , Ravn H. B. , TØnnesen E.
Published: December 2004

Background: Plasma concentrations of inflammatory markers are increased in response to the trauma of cardiac surgery and cardiopulmonary bypass (CPB). It is, however, unknown whether the plasma cytokine levels and cytokine mRNA expression at organ level reflect each other.

Methods: Twenty‐six piglets (17–19 days) were allocated to the sham‐group (sternotomy only, n = 13) or to the CPB‐group (sternotomy, 120 min CPB procedure with 60‐min aortic cross‐clamp, n = 13). The pigs were observed for 0.5 h or 4 h post‐CPB. Plasma levels of IL‐1β, IL‐6, IL‐8 and IL‐10 and mRNA expression of TNF‐α, IL‐1β, IL‐6, IL‐8, IL‐10 and iNOS in organs were registered with concomitant changes in oxygenation index (OI) and expiratory nitric oxide (NO).

Results: In pigs killed 0.5 h post‐CPB there was a significant increase in IL‐10 mRNA in the lungs and kidneys compared with the sham‐group. IL‐1β mRNA was detectable in the kidneys and lungs of the CPB‐pigs, while IL‐6 mRNA was up regulated only in lungs. In pigs killed 4 h post‐CPB a significantly higher IL‐6 mRNA was found in heart tissue and a lower IL‐10 mRNA was found in lungs of CPB pigs compared with the sham‐group. There was a concomitant significant increase in OI and increased plasma IL‐8 and IL‐10 concentrations in the CPB‐pigs compared with the sham‐pigs.

Conclusion: The cytokine mRNA expression pattern was very different for the pigs killed already 0.5 h after the CPB procedure compared with the pigs killed 4 h post‐CPB. The plasma cytokine levels poorly reflected mRNA expression of the pro‐ and anti‐inflammatory cytokines.
A fatal case of malignant hyperthermia complicated by generalized compartment syndrome and rhabdomyolysis
Authors: Green G.
Published: December 2004

A healthy 21‐year‐old male who had previously been anaesthetized without complications underwent a laparotomy following a skiing accident. He developed severe malignant hyperthermia. The initial reaction was successfully treated with dantrolene, but during the following days the patient developed several compartment syndromes requiring fasciotomies. The patient died of hyperkalaemia in spite of continuous dialysis. We present a detailed description of the case and also discuss the role of propofol and rhabdomyolysis.
Circulatory effects of angiotensin II during anaesthesia, evaluated by real‐time spectral analysis
Authors: Ullman J. , Härgestam R. , Lindahl S. , Chan S. H. H. , Eriksson S. , Rundgren M.
Published: December 2004

Background: General anaesthesia may stimulate the renin‐angiotensin system. Exogenous administration of angiotensin II elevates blood pressure mainly via increased total peripheral resistance caused by direct vasoconstrictor actions. It is also well established that the hypertensive effect of angiotensin II involves a cerebrally mediated component. The hypertensive effect of an intravascular infusion of angiotensin II is substantially reduced by isoflurane anaesthesia. A likely mechanism is that isoflurane anaesthesia reduces the cerebral component of the angiotensin II effect on blood pressure, which involves influences on autonomic nervous activity. In an experimental study in sheep we used real‐time spectral analysis of arterial blood pressure signals to obtain information on parasympathetic, respectively, sympathetic autonomic nervous activity in response to angiotensin II administration during isoflurane anaesthesia.

Methods: The study was performed on conscious and isoflurane‐anaesthetized sheep that were subjected to an intracarotid infusion of angiotensin II (85 ng kg−1 min−1) during 20 min followed by a recovery period of 30 min and thereafter an injection of the angiotensin II, AT1‐receptor antagonist losartan (10 mg kg−1) i.v. Systemic and regional (renal and femoral) circulation was monitored in parallel to real‐time spectral analysis of the arterial blood pressure signal.

Results: Isoflurane anaesthesia reduced both magnitude and duration of the hypertensive response to angiotensin II infusion. The power spectral density in the frequency band that represents sympathetic activation, correlated to the changes in mean arterial pressure in conscious animals, but not during isoflurane anaesthesia.

Conclusion: We conclude that the cerebrally mediated component of the hypertensive effect of circulating angiotensin II is largely eliminated by isoflurane anaesthesia. Spectral power analysis of the blood pressure signal indicates that the cerebral angiotensin II effect involves activation of sympathetic nervous activity.
Lactic acidosis following convulsions
Authors: Lipka K. , Bülow H.‐H.
Published: December 2004

Lactic acidosis is a common cause of metabolic acidosis and is usually connected with high mortality. However, changes in the level of lactate and pH can also be seen after generalized epileptic attacks, due to local muscle hypoxia during the seizures. Although these changes can be quite marked, the condition is self‐limiting and usually does not call for any specific treatment. We report five cases of lactic acidosis following convulsions from our centre.
Anaesthetic complications associated with myotonia congenita: case study and comparison with other myotonic disorders
Authors: Farbu E. , Søfteland E. , Bindoff L. A.
Published: December 2004

Myotonia congenita (MC) is caused by a defect in the skeletal muscle chloride channel function, which may cause sustained membrane depolarisation. We describe a previously healthy 32‐year‐old woman who developed a life‐threatening muscle spasm and secondary ventilation difficulties following a preoperative injection of suxamethonium. The muscle spasms disappeared spontaneously and the surgery proceeded without further problems. When subsequently questioned, she reported minor symptoms suggesting a myotonic condition. Myotonia was found on clinical examination and EMG. The diagnosis MC was confirmed genetically. Neither the patient nor the anaesthetist were aware of the diagnosis before this potentially lethal complication occurred. We give a brief overview of ion channel disorders including malignant hyperthermia and their anaesthetic considerations.
Respiratory burst activity of polymorphonuclear cells is dependent on the cell preparation technique
Authors: Zhao J. , Juettner B. , Scheinichen D. , Jaeger K. , Heine J. , Piepenbrock S.
Published: December 2004

Background: Controversial results have been reported regarding the effect of anaesthetics on superoxide anion production during the respiratory burst (RB) of polymorphonuclear cells (PMN). The differences could be caused by the cell preparation methods and the aim of this study was to compare two techniques.

Methods: RB activity was measured in cell suspensions isolated with the single‐step Ficoll procedure and in unfractionated whole blood. Two concentrations of propofol (therapeutic and 10‐fold of this, 6 µg ml−1 or 60 µg ml−1) were investigated after cell preparation with both methods. RB was stimulated with Escherichia coli (E. coli), phorbol 12‐myristate 13‐acetate (PMA) or N‐formyl‐methionyl‐leucyl‐phenylalanine (fMLP) and measured by means of fluorescence intensity in a flow cytometer.

Results: The percentage of PMNs in whole blood which generate superoxide anions in response to fMLP was significantly lower (2.5 ± 0.7%; mean ± SEM) than that in Ficoll isolated cell suspensions (15.1 ± 1.7%). Incubation with propofol led to a concentration‐related decrease of RB activity in Ficoll separated PMNs after both PMA and fMLP stimulation. No significant effect of propofol was observed on the RB in PMA stimulated whole blood samples.

Conclusion: The results suggest that the influence of cell preparation methods should be considered when the in vitro effects of anaesthetics on PMN functions are studied with flow cytometric methods.
Fatal lipoid pneumonia due to bronco‐aspiration of isoparaffin after ingestion of an organophosphate insecticide
Authors: Nogué S. , Sanz P. , Borondo J. C. , Picón M. , De La Red G. , Mestre G.
Published: December 2004

A 66‐year‐old‐male patient with a history of depression voluntarily ingested around 400 ml of an insecticide composed of 5% methylparathion, 75% isoparaffin, 8% etoxylated oleic acid, 4% 1,2,4‐trimethylbenzene, 6% naphtha, 1% 1,3,5‐ trimethylbenzene, 0.4% propylbenzene and 0.3% xylene.

The patient was conscious and alert at admission. Gastric lavage was performed and activated charcoal administered. There were no clinical symptoms of organophospate ingestion despite reduced concentrations of erythrocyte and plasma cholinesterase. Chest X‐ray showed pulmonary infiltrate compatible with bronco‐aspiration. The patient evolved to respiratory failure refractory to treatment and died from multiorganic failure 23 days after ingesting the insecticide.

The pathological findings included a pulmonary fibrosis in the alveolar spaces which caused enlargement of the intra‐alveolar septa. Abundant lipin‐laden macrophages were observed within the alveolar spaces.

We review the most relevant aspects of cases of fatal lipoid pneumonia and point out that on occasion severe or fatal intoxication is due to the substances accompanying the active ingredients.
Fentanyl decreases propofol requirement for laryngeal mask airway insertion
Authors: Goyagi T. , Tanaka M. , Nishikawa T.
Published: December 2004

Background:  Since fentanyl is a potent depressant of the upper airway reflex, preadministration of fentanyl may facilitate insertion of the laryngeal mask airway (LMATM) using propofol. Accordingly, we tested the hypothesis that fentanyl pretreatment would reduce the dose of propofol required for the LMA insertion.

Methods:  Forty‐one healthy patients without sedative premedication were randomly assigned to either fentanyl group, receiving fentanyl 2 µg kg−1 intravenously, or control group, receiving equal volumes of normal saline. Then, 3 ml of 2% lidocaine was given intravenously to alleviate pain associated with propofol administration. Thirty s after the fentanyl or saline injection, a predetermined dose of 1% propofol was given at a rate of 100 mg min−1. Insertion of the LMA was attempted 90 s after the completion of the propofol injection. The dose of propofol given to a particular patient was determined by the response of the preceding patient in that group to a higher or lower dose, using the up‐and‐down method. The first patient in each group received 2.5 mg kg−1 of propofol, while the step‐size was 0.25 mg kg−1.

Patients responses were assessed by a blinded observer.

Results:  ED50 and ED95 of propofol requirements were significantly less in the fentanyl group (0.82, 1.17 mg kg−1, respectively) than those in the control group (2.39, 2.62 mg kg−1, P < 0.001).

Conclusion:  Our results indicate that preadministration of fentanyl 2 µg kg−1 decreases the propofol requirement for the LMA insertion.
Milrinone improves lung compliance in patients receiving mechanical ventilation for cardiogenic pulmonary edema
Authors: Takeda S. , Matsumura J. , Ikezaki H. , Kim C. , Sato N. , Nakanishi K. , Sakamoto A. , Ogawa R. , Tanaka K.
Published: December 2004

Background:  Cardiogenic pulmonary edema is a frequent cause of respiratory failure. We investigated whether milrinone improved lung compliance.

Methods:  We selected 10 patients with respiratory failure due to severe cardiogenic pulmonary edema to receive mechanical ventilation. Patients were administered a bolus injection of milrinone (50 µg kg−1) over 10 min, followed by continuous intravenous infusion (0.5 µg kg−1 min−1). Lung compliance, blood gas values, hemodynamic parameters, and sample plasma milrinone levels were assessed over 120 min after the onset of the continuous infusion of milrinone.

Results:  Ten min following milrinone infusion, dynamic compliance (Cdyn) and static compliance (Cst) increased from 37 ± 12 to 42 ± 12 ml cmH2O−1 and from 40 ± 13 to 45 ± 12 ml cmH2O−1, respectively (P < 0.01). Plasma milrinone levels reached a therapeutic level for vasodilator and positive inotropic effect at 10 min after milrinone infusion. A significant decrease in mean pulmonary artery pressure and pulmonary artery wedge pressure occurred simultaneously with an increase in respiratory system compliance. However, an increase in cardiac index was observed later than these changes. There were significant correlations between the mean pulmonary artery pressure and Cdyn (r = −0.39, P < 0.01) and Cst (r = −0.38, P < 0.01).

Conclusions:  Milrinone‐induced improvement in lung compliance along with an improvement of hemodynamics was found together with an inverse relationship between compliance and mean pulmonary artery pressure.
EMLA® does not permit pain‐free retrobulbar injection*
Authors: Kuvaki̇ B. , Gökmen N. , Günenç F. , Ceyhan Kara H. , Üzümlü H. , Özden G. , Söylev M. , Gökel E.
Published: December 2004

Background:  Retrobulbar injection can be associated with significant pain, due to both needle insertion and deposition of the local anaesthetic solution. The local anaesthetic cream EMLA® (eutectic mixture of local anaesthetics) which contains a mixture of lignocaine and prilocaine has been shown to reduce the pain associated with skin puncture. The efficacy of EMLA® in alleviating the pain of retrobulbar injection for cataract surgery was assessed in this study.

Methods:  In this, randomised double‐blind study, EMLA® (n = 53) or lignocaine 5% ointment (n = 50) was administered to the inferior orbital margin at least 45 min before retrobulbar block in 103 patients. Pain assessed during retrobulbar block was marked subjectively by the patient on a 10‐point numerical rating scale.

Results:  Median verbal pain scores were 3.0 with an interquartile range of 1.5–6.5 in the control group and 3.50 with an interquartile range of 2.0–6.0 in the EMLA® group (P = 0.67).

There was no significant difference between the EMLA® group and the lignocaine ointment group according to this pain assessment.

Conclusion:  EMLA® does not permit pain‐free retrobulbar injection.
Concordance between trifluoroacetic acid and hepatic protein trifluoroacetylation after disulfiram inhibition of halothane metabolism in rats
Authors: Spracklin D. K. , Emery M. E. , Thummel K. E. , Kharasch E. D.
Published: December 2004

Background:  Cytochrome P4502E1(CYP2E1)‐mediated oxidation of halothane to a reactive intermediate (trifluoroacyl chloride) that covalently binds to hepatic proteins forming trifluoroacetylated neoantigens is believed to be the initiating event in a complex immunologic cascade culminating in antibody formation and severe hepatic necrosis (‘halothane hepatitis’) in susceptible patients. Trifluoroacyl chloride may also hydrolyze to the stable metabolite trifluoroacetic acid (TFA). CYP2E1 inactivation by disulfiram or its primary metabolite, diethyldithiocarbamate, inhibits human halothane oxidation to TFA in vitro and in vivo. Nevertheless, disulfiram effects on hepatic protein trifluoroacetylation by halothane in vivo are unknown. This investigation tested the hypotheses that disulfiram prevents halothane‐dependent protein trifluoroacetylation in vivo, and that TFA represents a biomarker for hepatic protein trifluoroacetylation.

Methods:  Rats were pretreated with isoniazid (CYP2E1 induction), isoniazid followed by disulfiram (CYP2E1 inhibition), or nothing (controls), then anesthetized with halothane or nothing (controls). Plasma and urine TFA were quantified by ion HPLC; hepatic microsomal TFA‐proteins were analyzed by Western blot.

Results:  CYP2E1 induction increased both TFA and TFA‐protein formation compared with uninduced halothane‐treated rats. Disulfiram, even after CYP2E1 induction, nearly abolished both TFA and TFA‐protein formation. Pretreatments similarly affected both TFA and TFA‐protein formation across all groups.

Conclusions:  Disulfiram inhibition of CYP2E1‐mediated halothane oxidation prevents hepatic protein trifluoroacetylation. Based on the concordance between TFA and TFA‐protein formation, TFA appears to be a valid biomarker for TFA‐protein formation. Disulfiram inhibition of human halothane oxidation in vivo, previously assessed by diminished TFA formation, probably also confers inhibition of hepatic TFA‐protein formation.
Withdrawal of medical treatment in the ICU. A cohort study of 318 cases during 1994–2000*
Authors: Nolin T. , Andersson R.
Published: December 2004

Background:Many deaths in intensive care occur after life support has been withdrawn or withheld. In Sweden there are no guidelines for the withholding or withdrawal of life‐sustaining treatments, and information on the frequency of such decisions is scarce. Open and conscious accounts of crucial standpoints in theses decisions are important. The aim of this study was to determine the incidence of decisions to withdraw medical therapy in a Swedish, general intensive care unit (ICU), the underlying reasons and outcomes.

Methods:In this historical cohort study in a 10 bed ICU, we studied the records of the 3904 patients admitted during the period 1994–2000.

Results:Medical therapy was withdrawn in 318 (8.1%) patients. During the study period, 466 patients died in the ICU, of which 191 (41.0%) had had a withdrawal decision. Of the 318 patients with a withdrawal decision followed up, 191 (60.1%) died in the ICU, 104 (32.7%) later on a general ward, and 23 (7.2%) were discharged alive from the hospital. The main reasons for withdrawing therapy were failure to respond to treatment in 119 (37%), poor prognosis of the acute disease in 119 (37%), poor prognosis of coexisting chronic disease in 62 (20%) and the patient's own request in 18 (6%) of the cases. The median time from ICU‐admission to a withdrawal decision was 2.8 days. The median time from a withdrawal decision to death was 0.6 days (191 patients) in the ICU, 2.4 days (104 patients) in the general ward and 1.4 months (19 patients) for those dying after hospital discharge. In five cases a renewed evaluation was performed.

Conclusion:Medical therapy was withdrawn in the ICU in 8.1% of patients and the chief reasons were failure to respond to therapy or poor prognosis of the acute disease. Four patients were still alive five years later. The time interval from admission to a withdrawal decision was short.