bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of sevoflurane and isoflurane anesthesia on arterial ketone body ratio and liver function
Authors: Nishiyama T. , Yokoyama T. , Hanaoka K.
Published: March 2003

Background: The purpose of this study was to compare the effect on arterial ketone body ratio (AKBR), which indicates hepatic mitochondrial energy charge in relation to hepatic blood flow, and liver function test (serum levels of liver enzymes) between sevoflurane and isoflurane anesthesia.

Methods: Serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (TBil), alkaline phosphatase (ALP), γ‐glutamyl transpeptidase (GTP), and lactate dehydrogenase (LDH) were measured before and 1, 2, 3, 7, and 14 days after anesthesia in each of 60 patients receiving either sevoflurane or isoflurane anesthesia for neurosurgery (tumor resection). In 13 patients of both groups, arterial concentrations of acetoacetate and 3‐hydroxybutyrate were also measured before, during and after (up to 12 h) anesthesia and the AKBR was calculated.

Results: AST, ALT and GTP increased, peaking 7 days after anesthesia, especially in the isoflurane group. There was a significantly greater number of patients with abnormal AST and ALT values in the isoflurane group than in the sevoflurane group. The increase of TBil had its peak 1 day after anesthesia in both groups. AKBR decreased after anesthesia induction and recovered to the control value 12 h after anesthesia in both groups. There was no difference between the two anesthetic groups in AKBR.

Conclusion: Isoflurane induced an elevation of serum levels of liver enzymes more frequently than did sevoflurane 3 to 14 days after anesthesia, while AKBR until 12 h after anesthesia did not show any significant difference between sevoflurane and isoflurane anesthesia.
Ventricular fibrillation related to reversal of the neuromuscular blockade in a patient with long QT syndrome
Authors: Pleym H. , Bathen J. , Spigset O. , Gisvold S. E.
Published: March 2003

The long QT syndrome (LQTS) is associated with syncopal attacks or even sudden death at a young age due to ventricular fibrillation. We report a patient with an undiagnosed LQTS who had an episode of cardiac arrest during the final part of general anesthesia, immediately after the drugs for reversal of the neuromuscular blockade were given. We suggest that the administration of glycopyrronium might have been the provoking factor in this patient.
Focus on mobilisation after lower abdominal surgery. A double‐blind randomised comparison of epidural bupivacaine with morphine vs. lidocaine with morphine for postoperative analgesia
Authors: Rygnestad T. , Zahlsen K. , Bergslien O. , Dale O.
Published: March 2003

Background: Epidural infusion of morphine, usually with bupivacaine, for postoperative pain relief has proved to be safe and effective. Lidocaine with its short duration of action and low toxicity may be an alternative to bupivacaine. The clinical importance of the choice of local anaesthetic drug on mobilisation after lower abdominal surgery has not been studied previously.

Methods: A total of 52 patients was randomised to epidural infusion of morphine (1.6–4.4 μg  ·  kg−1  ·  h−1) with either lidocaine (0.44–0.98 mg  ·  kg−1  ·  h−1) or bupivacaine (0.10–0.28 mg  ·  kg−1  ·  h−1) in a double‐blind fashion. The time to mobilisation, degree of pain relief, blood pressure, respiration and motor function were recorded at regular intervals postoperatively for 40 h. Serum concentrations of lidocaine, its main metabolite monoethylglycinexylidide (MEGX) and bupivacaine were measured at 3, 15 and 40 h.

Results: There were no significant differences in the clinical characteristics between the two patient groups. There were no significant differences in the time from the end of surgery to the time the patients were able to stand without support (bupivacaine: median 24 h (interquartile range (IQR): 22–31), lidocaine: median 28 h (IQR 23–40), P=0.15) or were able to walk without support (bupivacaine: median 46 h (IQR 28–62), lidocaine: median 48 h (IQR 35–54), P=0.78). No significant differences between the groups were recorded with respect to pain relief, blood pressure, respiration, sedation score and motor function. The plasma concentration of lidocaine and bupivacaine increased significantly during the treatment period (P<0.01 for both drugs), but not the concentration of MEGX. The highest venous lidocaine concentration was 17.5 μmol/l and the highest bupivacaine concentration was 18.8 μmol/l. There was a significant correlation between the concentration of both lidocaine and bupivacaine and the concentration of α1‐acid glycoprotein (AAG) (lidocaine: r=0.77, P<0.001, bupivacaine: r=0.60, P<0.001), suggesting that the free fraction of the drugs did not increase. No patients showed serious signs of toxicity. The epidural infusion rates remained stable in both groups during the study period.

Conclusion: There were no clinically or statistically significant differences in the postoperative course after lower abdominal surgery in patients who received an epidural infusion of morphine combined with bupivacaine as compared to patients who received morphine with lidocaine. Further clinical studies to establish the place of lidocaine in postoperative epidural analgesia should be performed.
Lumbar versus thoracic epidural buprenorphine for postoperative analgesia following coronary artery bypass graft surgery
Authors: Mehta Y. , Juneja R. , Madhok H. , Trehan N.
Published: March 2003

Background: Thoracic epidural analgesia (TEA) is reported to provide effective analgesia following cardiac surgery. We compared the effect of buprenorphine (BN) through the lumbar and thoracic epidural routes for postoperative analgesia following coronary artery bypass graft surgery (CABG).

Methods: Forty patients with normal left ventricular ejection fraction scheduled for CABG were randomly divided into two groups, the TEA group (n=19) and the lumbar epidural analgesia (LEA) group (n=20). For postoperative pain relief they received epidural BN 0.15 mg at the first demand for pain relief following extubation. A top‐up dose of BN 0.15 mg was administered in cases where visual analogue scale (VAS) score was >3 at 1 h after first dose. Subsequent breakthrough pain was treated with 30 mg intramuscular ketorolac tromethamine (ketorolac). Pain assessed by VAS score on a 0–10 scale, respiratory rate, FEV1, FVC, mean arterial blood pressure, cardiac index, PaO2 and PaCO2 were measured at frequent intervals. Side effects of epidural opioids were noted.

Results: Both groups were comparable in demographic characteristics, had similar VAS scores from 1 to 24 h postoperatively, required similar amounts of intramuscular ketorolac for breakthrough pain and had comparable pulmonary functions and side effects.

Conclusion: This study shows that BN by the lumbar epidural route for analgesia after CABG compares favourably with the same drug through the thoracic route in terms of quality of analgesia and incidence of side effects.
Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery
Authors: Ortega D. , Viviand X. , Lorec A. M. , Gamerre M. , Martin C. , Bruguerolle B.
Published: March 2003

Background: There is a lack of information and knowledge about the practical importance of even low concentrations of the excretion of local anesthetics into breast milk, particularly concerning bupivacaine. The present work aims to confirm, under practical clinical conditions of admission of parturients, the passage of local anesthetics (lidocaine and bupivacaine) into breast milk after an epidural anesthesia.

Methods: Twenty‐seven pregnant women admitted for cesarean delivery received epidural anesthesia with 0.5% bupivacaine and 2% lidocaine. Blood and milk samples were simultaneously collected at 2, 6 and 12 h after the beginning of the epidural infusion. Lidocaine, bupivacaine and its main metabolite, pipecolylxylidide (PPX), were determined in serum and milk by a gas‐liquid chromatographic technique. APGAR scores were systematically performed at delivery and a clinical examination was done 24 h after delivery.

Results: Our data indicate that lidocaine and bupivacaine as well as PPX are excreted into breast milk. The milk/serum ratio based upon area under the curve values were 1.07±0.82, 0.34±0.24 and 1.37±0.61 mean±SD for lidocaine, bupivacaine and PPX, respectively. Most of the newborns had a maximal APGAR score. Our study does not reveal any adverse reactions related to the excretion of local anesthetics into breast milk.

Conclusion: This study documents the magnitude of excreted lidocaine, bupivacaine and PPX in breast milk, and indicates that the use of both lidocaine and bupivacaine for epidural anaesthesia is safe with regard to breast‐feeding.
Comparison of transarterial and multiple nerve stimulation techniques for axillary block using a high dose of mepivacaine with adrenaline
Authors: Koscielniak‐Nielsen Z. J. , Rotbøll Nielsen P. , Loumann Nielsen S. , Gardi T. , Hermann C.
Published: March 2003

Background: High‐dose transarterial (TA) technique results in high effectiveness of the axillary block. The technique is fast and simple, but does not produce a satisfactory success rate when using the manufacturer’s recommended dose of mepivacaine. The multiple nerve stimulation (MNS) technique requires more time and experience. This double‐blind study compared effectiveness, safety and the time used to obtain an effective analgesia in 101 patients, having an axillary block by either TA or MNS techniques.

Methods: Mepivacaine with adrenaline (MEPA), 850 mg, was used for the initial block. Five millilitres of 1% solution was injected subcutaneously. In the TA group, 20 mL of 2% solution was injected deep to, and 20 mL superficial to the axillary artery. In the MNS group, four terminal motor nerves were electrolocated in the axilla, and injected with 10 mL each. Analgesia was assessed every 10 min and, when needed, supplemented after 30 min. The block was effective when analgesia was present in all sensory nerve areas distal to the elbow.

Results: The MNS group required median 11 min for block performance compared with 8 min for the TA group (P<0.001). Latency of the initial block was shorter and the frequency of supplemental analgesia lower in the MNS group (median 10 min and 6%) than in the TA group (30 min and 36%, respectively), P<0.001. All incomplete blocks were successfully supplemented. However, the total time to obtain an effective block was shorter in the MNS group (23 min) than in the TA group (37 min), P<0.001. Two patients in each group had signs and symptoms of systemic toxicity, the most serious being atrial fibrillation and temporary loss of consciousness in a cardiovascularly medicated patient. The local adverse effects (intravascular injections and haematomas) were fewer in the MNS group, P<0.001.

Conclusion: The MNS technique of axillary block by four injections of 10 mL of 2% MEPA produces faster and more extensive block than the TA technique by two injections of 20 mL. Therefore, the MNS technique requires fewer supplementary blocks and results in faster patient readiness for surgery. However, high doses of MEPA may result in dangerous systemic toxic reactions.
Responses to propofol in the pulmonary vascular bed of the rat
Authors: Kaye A. , Anwar M. , Banister R. , Feng C. , Turner K. , Kadowitz P. , Nossaman B.
Published: March 2003

Background: Although a great deal is known about responses to propofol, controversy remains about its mechanism of action. The present study was undertaken to investigate the direct effects of 2,6‐diisopropyl phenol, disodium edetate, and its intralipid emulsion in the rat pulmonary vascular bed and to better understand the mechanisms involved in propofol‐mediated responses.

Methods: The effects of Nω‐l‐nitro‐l‐arginine benzyl ester (L‐NABE), an inhibitor of nitric oxide synthase, of the cyclooxygenase blocker, meclofenamate, and the K+ATP channel antagonist, U‐37883A, an ATP‐sensitive potassium channel antagonist, on responses to propofol, acetylcholine, nitroglycerin, and isoproterenol were investigated in the isolated blood‐perfused rat lung under low tone and high steady‐state tone.

Results: Propofol produced a dose‐dependent decrease in pulmonary arterial perfusion pressure. L‐NABE significantly reduced vasodilator responses to acetylcholine, whereas the nitric oxide synthase inhibitor had no significant effect on responses to propofol. Meclofenamate significantly reduced vasodilator responses to arachidonic acid without effecting responses to propofol. Responses to propofol were not significantly changed in the presence of U‐37883A, whereas U‐37883A reduced vasodilator responses to levcromakalim. Additionally, 2,6‐diisopropylphenol in a pure preparation as well as an intralipid preparation similar to propofol emulsion had no significant effect while disodium edetate had a dose‐dependent depressor effect under high steady‐state tone.

Conclusion: Propofol has significant vasodilator activity in the pulmonary vascular bed of the rat but responses to propofol are not mediated or modulated by the release of nitric oxide, opening of K+ATP channels, or the release of vasodilator cyclooxygenase products.
Percutaneous dilatational tracheostomy in a patient with thyroid cancer and severe airway obstruction
Authors: Aadahl P. , Nordgård S.
Published: March 2003

A patient with extensive metastatic thyroid cancer scheduled for palliative tracheostomy is presented. He had laryngeal dislocation with severe airway obstruction and few anatomical landmarks due to tumour infiltration and radiation. Successful percutaneous dilatational tracheostomy was performed under local anaesthesia.
The role of arterial and venous pressure for volume regulation of an organ enclosed in a rigid compartment with application to the injured brain
Authors: Kongstad L. , Grände P. O.
Published: March 2003

Background: Treatment of increased intracranial pressure often includes an active change in arterial and venous pressure, sometimes with draining of cerebrospinal fluid. We evaluated tissue and perfusion pressure during corresponding interventions in an organ enclosed in a rigid compartment with capillaries permeable for electrolytes and impaired autoregulation, conditions comparable to those present in the injured brain.

Method: An isolated cat skeletal muscle enclosed in a closed fluid‐filled plethysmograph served as a model for the injured brain surrounded by cerebrospinal fluid and the cranium. Tissue pressure and blood flow were measured during variation in arterial and venous pressures and in intraplethysmographic fluid volume. Autoregulation was depressed by papaverine.

Results: 1) Tissue pressure was not influenced by the venous pressure when this was below the tissue pressure, hereby generating venous collapse and a venous outflow resistance. When venous pressure was higher than the tissue pressure (no venous outflow resistance), these two parameters changed in parallel. 2) A change in arterial pressure induced a similar large change in tissue pressure at steady state, whereas blood flow remained unchanged. 3) Variation in tissue pressure induced by a change in the intraplethysmographic fluid volume was transient.

Conclusions: If applicable to the injured brain, the results indicate that 1) a venous pressure change has a small influence on the intracranial pressure when a venous outflow resistance is present, 2) brain oedema can be reduced by lowering of the arterial inflow pressure, and blood flow will be maintained, 3) the decrease in intracranial pressure obtained by draining cerebrospinal fluid will be transient.
Interaction between fluconazole and midazolam in intensive care patients
Authors: Ahonen J. , Olkkola K. T. , Takala A. , Neuvonen P. J.
Published: March 2003

Background: Midazolam is used for sedation of intensive care unit (ICU) patients and it is extensively metabolised by CYP3A4 enzymes. The antimycotic fluconazole is often used in these patients as well and has been shown to inhibit CYP3A4‐mediated drug metabolism.

Methods: In a study of the effect of fluconazole on midazolam in the ICU, ten mechanically ventilated patients (age 29 to 61 years, 8 male) sedated with a stable midazolam infusion were enrolled after a decision to start fluconazole treatment. Fluconazole was infused for 30 min at intervals of 24 h, with an initial dose of 400 mg and following doses of 200 mg. The midazolam infusion rate remained unchanged during the study period of 48 h. Plasma concentrations of midazolam, α‐hydroxymidazolam, and α‐hydroxymidazolam conjugate were determined at baseline, and at 6, 12, 18, 24, 36, and at 48 h thereafter.

Results: Concentrations of midazolam were significantly increased (range 0 to 4‐fold, P<0.05) after start of fluconazole treatment. These increases were most marked in patients with renal failure. During the study period, the ratio of α‐hydroxymidazolam to midazolam decreased progressively (P<0.05).

Conclusion: In ICU patients receiving fluconazole, reduction of midazolam infusion rate should be considered if the degree of sedation is found to be increasing.
Splanchnic circulation is maintained during passive hyperventilation in orthotopic liver recipients
Authors: Krenn C. G. , Pernerstorfer T. , Pokorny H. , Metnitz P. G. H. , Steltzer H.
Published: March 2003

Background: Mechanical hyperventilation is an established treatment to reduce brain edema and intracranial pressure in patients with encephalopathia caused by acute liver failure. Hyperventilation and ensuing hypocarbia may also affect central and systemic circulation and thereby influence graft performance in patients following orthotopic liver transplantation (OLT).

Methods: We measured the effects of normocapnia and hypocapnia on systemic hemodynamics, gastric tonometry, as a marker of splanchnic oxygenation, and the indocyanine green kinetic, as a global marker of graft function, in humans post OLT.

Results: Hyperventilation was performed to a paCO2 of 4.2±0.4 kPa (31±3.4 mm Hg) for about 1 h in 14 liver transplant recipients. Systemic hemodynamics as well as indices of splanchnic oxygenation and indocyanine green kinetics remained statistically unchanged.

Conclusion: We did not observe any statistically significant circulatory effects or changes in indocyanine green kinetics in liver transplant recipients in the immediate OLT postoperative period caused by short‐term mechanical hyperventilation.
EEG bispectral index monitoring in sevoflurane or propofol anaesthesia: analysis of direct costs and immediate recovery
Authors: Yli‐Hankala A. , Vakkuri A. , Annila P. , Korttila K.
Published: March 2003

Background: Recent studies have suggested that electroencephalogram (EEG) bispectral index (BIS) monitoring can improve recovery after anaesthesia and save money by shortening patients’ postoperative stay. We wanted to evaluate the direct costs of BIS monitoring and to measure immediate recovery after anaesthesia in patients with or without BIS monitoring.

Methods: Eighty patients undergoing gynaecological surgery were studied. At first, 40 patients were randomized to receive either propofol or sevoflurane anaesthesia. In these patients, BIS was collected but the information was not displayed. Thereafter, the anaesthesiologists were trained to follow and understand the BIS information, and 40 patients were anaesthetized with aid of the monitoring. Recovery times were measured by a study coordinator. Drug consumption was calculated.

Results: BIS monitoring improved the immediate recovery after propofol anaesthesia, while no differences were seen in patients receiving sevoflurane. The consumption of both propofol and sevoflurane decreased significantly (29% and 40%, respectively). BIS monitoring increased direct costs in these patients; the break‐even times (704 min for propofol and 282 min for sevoflurane) were not reached.

Conclusion: BIS monitoring decreased the consumption of both propofol and sevoflurane and hastened the immediate recovery after propofol anaesthesia. Detailed cost analysis showed that the monitoring increased direct costs of anaesthesia treatment in these patients, mainly due to the price of special EEG electrodes used for relatively short anaesthesias.
A comparison of train‐of‐four monitoring: Mechanomyography at the thumb vs acceleromyographyat the big toe
Authors: Heier T. , Hetland S.
Published: March 2003

Background: It is not known if the information on neuromuscular function obtained from the hand is interchangeable with that of the foot. In the present study the agreement of thumb mechanomyography with acceleromyography of the big toe was studied.

Methods: Ten healthy patients scheduled for oral surgery were studied. Anaesthesia was induced with fentanyl 2 μg kg−1 and propofol 2 mg kg−1, and maintained with propofol 100–175 μg kg−1 min−1, nitrous oxide 60–70%, and fentanyl 1–2 μg kg−1 h−1. Vecuronium 0.1 mg kg−1 was used for muscle relaxation. Mechanomyography (MMG) of the thumb (Myograph 2000) and acceleromyography (AMG) of the big toe (TOF‐Guard) were recorded simultaneously in all patients, and onset, period of no‐twitch response, duration of action, and spontaneous recovery time obtained from both muscle groups. The agreement between methods was tested by calculation of bias and limits of agreement.

Results: The onset time and duration of action were significantly shorter (87 s vs 154 s, and 35 min vs 38 min, respectively), and the spontaneous recovery time significantly longer in the thumb than in the big toe (32 min vs 19 min). Period of no‐twitch response was not significantly different in the two muscle groups. Limits of agreement (thumb big toe) were −21 to −113 s, −7 to 1 min, and −9 to 35 min, for onset time, duration of action, and spontaneous recovery time, respectively.

Conclusion: We conclude that clinically acceptable agreement between thumb mechanomyography and big toe acceleromyography was found for the period of no‐twitch response, suggesting that the timing of supplemental doses of vecuronium can be guided by AMG at the big toe. However, the spontaneous recovery time agreement (to TOF ratio=0.75) between the thumb and the big toe was poor.
Chronic pain after thoracic surgery: a follow‐up study
Authors: Perttunen K. , Tasmuth T. , Kalso E.
Published: March 2003

Background: The incidence of long‐term post‐thoracotomy pain is reported to be up to 67%. A relationship between the severity of acute postoperative pain and the development of chronic post‐thoracotomy pain has been suggested.

Methods: Patients scheduled for elective thoracotomy were interviewed before and one week after surgery to find out if they had pain before surgery and how much pain they experienced postoperatively. The amount of analgesics the patients were given were registered during the first 5 postoperative days. The patients were interviewed by letter 3, 6 and 12 months after surgery to find out if they still had pain due to surgery and to what extent this pain interfered with their daily activities.

Results: One hundred and ten patients entered the study. Information about the complete study period was obtained from 67 patients. The incidence of chronic post‐thoracotomy pain was 80% at 3 months, 75% at 6 months and 61% one year after surgery. The incidence of severe pain was 3–5%. Chronic post‐thoracotomy pain interfered with the patient’s normal daily life in more than half of the patients. High consumption of analgesics during the first postoperative week was associated with a higher risk of chronic post‐thoracotomy pain.

Conclusion: A significant proportion of patients undergoing thoracotomies will suffer from chronic pain. Surgeons and anaesthetists should be aware of this fact and they should look for effective means of preventing and treating this pain syndrome.
Epidural ropivacaine 7.5 mg/ml for elective Caesarean section: A double‐blind comparison of efficacy and tolerability with bupivacaine 5 mg/ml
Authors: Bjørnestad E. , Smedvig J. P. , Bjerkreim T. , Narverud G. , Kollerøs D. , Bergheim R.
Published: March 2003

Background: Ropivacaine is a new local anaesthetic drug known to be less cardiotoxic than bupivacaine. The aims of this comparative study with bupivacaine were to evalute efficacy, safety and tolerability for the mother and the neonate when using ropivacaine 7.5 mg/ml for epidural anaesthesia for elective Caesarean section.

Methods: In a double‐blind, multicentre trial the patients were randomised to receive 20 ml of either ropivacaine 7.5 mg/ml or bupivacaine 5 mg/ml. The quality of the peroperative analgesia and abdominal muscle relaxation as well as tolerability and safety in both the mother and the neonate were evaluated.

Results: A total of 122 patients were evaluated for efficacy and tolerability. There were no significant differences in the onset time and the extent of the sensory spread or motor block. The peroperative quality of anaesthesia and muscle relaxation was similar in both groups. No significant side effects were observed, except for a more profound drop in systolic blood pressure in the ropivacaine group. The anaesthetics were well tolerated by the neonate in both groups, evaluated by Apgar and NACS scores.

Conclusion: Ropivacaine 7.5 mg/ml administered epidurally resulted in equally effective anaesthesia for Caesarean section as bupivacaine 5 mg/ml. Because of the lower cardiotoxicity of ropivacaine, the new amide has a potential in replacing bupivacaine when used epidurally for Caesarean section.
Block of the brachial plexus branches by the humeral route. A prospective study in 503 ambulatory patients. Proposal of a nerve‐blocking sequence
Authors: Gaertner E. , Kern O. , Mahoudeau G. , Freys G. , Golfetto T. , Calon B.
Published: March 2003

Background: Brachial plexus is usually approached by the supraclavicular or axillary route. A technique for selective blockade of the branches of the plexus at the humeral canal using electrolocation has recently been proposed. The aim of the present study was to assess the feasibility of this technique in the ambulatory patient and to determine the optimal sequence of nerve‐blocking.

Methods: The nerves originating from the brachial plexus were located in the humeral canal, at the junction of the proximal and the middle third of the arm, with a stimulator and blocked using either lidocaine or a mixture of lidocaine and bupivacaine, depending on the anticipated duration of surgery. The minimal stimulating intensity eliciting an adequate response, type of local anaesthetic and injected volume, and time of onset of surgical anaesthesia were collected.

Results: The study included 503 consecutive ambulatory patients due to undergo surgery of the elbow, wrist or hand in one year. Suitable anaesthesia was obtained with the humeral blockade in 82.1% of cases. In the remaining 17.9%, an additional block at the elbow was required, mainly for ulnar and median nerves. The onset times of sensory blocks were the longest for the median nerve, similar for the radial and ulnar nerves, shorter for the musculocutaneous nerve and the shortest for the medial brachial and antebrachial cutaneous nerves. The difference was more significant with the lidocaine‐bupivacaine mixture, than with lidocaine alone (P<0.001 vs P<0.05, respectively). The onset times of motor blocks were the longest for the median nerve (P<0.05) and the shortest for the musculocutaneous nerve (P<0.001). Neither nervous nor vascular complications occurred.

Conclusion: This study shows that the nerve block at the humeral canal is an efficient and safe technique. Considering the onset times of nerve blocks, the following sequence for blockade can be recommended: median, ulnar, radial, musculocutaneous, medial (brachial and antebrachial) cutaneous nerves. The selective blockade of the main nerves of the upper limb at the humeral canal can be recommended for surgery of the forearm and the hand in the ambulatory patient.
An alternative method to intubate with laryngeal mask and see‐through‐bougie
Authors: Hammarskjöld F. , Lindskog G. , Blomqvist P.
Published: March 2003

Background: Different ways of managing the difficult airway is an important issue for the anaesthetist. We have investigated a technique with a see‐through‐bougie and laryngeal mask for intubation.

Methods: We report our experience with intubation of 30 patients using a see‐through‐bougie guided through a laryngeal mask with a fibreoptic bronchoscope. The bougie is then used as a guidance for a tracheal tube.

Results: In 29 of the 30 investigated patients, this method could be used. In one patient the method had to be abandoned because of a tortuous trachea. Seventeen patients were intubated within 2 min, 11 between 2 and 5 min and 1 required 10 min. The time was mainly dependent on the endoscopic experience of the anaesthetist. No patient sustained arterial desaturation.

Conclusion: We conclude that intubation using a see‐through‐bougie and a laryngeal mask is a valuable method in the difficult intubation situation, when a temporary airway can be achieved with laryngeal mask, since it permits continuous ventilation and visual control throughout the procedure.
Slow‐resolving pneumonia secondary to bronchiolitis obliterans organizing pneumonia
Authors: Possamai C. , Corbanese U.
Published: March 2003

We report a case of slow‐resolving pneumonia secondary to bronchiolitis obliterans organizing pneumonia (BOOP) in a 73‐year‐old woman. Owing to a delayed diagnosis of BOOP, the clinical course was quite long.This syndrome is caused by a nonspecific inflammatory pneumonitis, either idiopathic or associated with infectious or irritant agents (or drugs). It generally presents as a flu‐like illness, followed by progressive dyspnea, cough, fever, and bilateral patchy alveolar infiltrates, and lasts several weeks. The diagnostic work‐up of slow‐resolving pneumonia is discussed.
Intrathecal co‐administration of NMDA antagonist and NK‐1 antagonist reduces MAC of isoflurane in rats
Authors: Ishizaki K. , Sasaki M. , Karasawa S. , Obata H. , Nara T. , Goto F.
Published: March 2003

Background: Intravenous administration of N‐methyl‐D‐aspartate (NMDA) receptor antagonists and α‐amino‐3‐hydroxy‐5‐methyl‐4‐isoxazole propionic acid (AMPA) receptor antagonists reportedly reduce the minimum alveolar anaesthetic concentration (MAC) for inhalation anaesthetics. If pain perception can be prevented by the intrathecal administration of antinociceptive receptor antagonists, these agents may reduce the requirements for inhalation anaesthetics. We studied the effect of intrathecal administration of an AMPA/kainate receptor antagonist, a metabotropic glutamate (mGlu) receptor antagonist and co‐administration of NMDA and a neurokinin‐1(NK‐1) receptor antagonist drugs at low doses on the MAC.

Methods: After Wistar rats (n=36) were fitted with indwelling intrathecal catheters, the MAC of isoflurane was determined following intrathecal administration of a non‐NMDA receptor antagonist (CNQX) at 10 μg, a mGlu receptor antagonist (AP3) at 10 μg, or a combination of NMDA receptor antagonist (APV) at 0.01 μg to 1 μg with NK‐1 receptor antagonist (CP96345, CP) at 0.1 μg to 10 μg. Subsequently, a reversal dose of intrathecal NMDA with substance P (SP) was administered, and the MAC of isoflurane was redetermined. Conscious rats (n=15) were also examined for the presence of locomotor dysfunction following the intrathecal co‐administration of APV and CP.

Results: Neither CNQX nor AP3 reduced the MAC of isoflurane. APV at 0.01 μg plus CP at 1 μg, as well as APV at 0.1 μg plus CP at 10 μg, reduced the MAC of isoflurane, with respective reductions of 7.6% and 14%; (P<0.05). Co‐administration of NMDA plus SP reversed the decrease in the MAC of isoflurane. Locomotive activity was not changed.

Conclusions: The NMDA receptor and the NK‐1 receptor are important determinants of the MAC of isoflurane, exerting this influence by inhibition of pain transmission in the spinal cord, while mGlu and AMPA receptors have no effect on the MAC of isoflurane.
Single‐injection paravertebral block compared to general anaesthesia in breast surgery
Authors: Pusch F. , Freitag H. , Weinstabl C. , Obwegeser R. , Huber E. , Wildling E.
Published: March 2003

Background: Breast surgery is frequently associated with postoperative nausea, vomiting, pain and painful restricted movement. Paravertebral block may be an alternative to general anaesthesia for this type of surgery. We studied the single‐injection paravertebral block at the level of T4 and report a comparison of single‐injection paravertebral block to general anaesthesia for breast surgery.

Methods: After written informed consent was obtained, 86 patients were enrolled in this prospective study. Forty‐four women were randomly allocated to receive a single‐injection paravertebral block at the level of T4, while 42 women received general anaesthesia. The surgical procedures varied from lumpectomy (wide local excision of a tumour) to modified radical mastectomy with axillary dissection. The block was performed according to the guidelines described by Eason and Wyatt using 0.3 ml  ·  kg−1 (maximum dose 150 mg) of bupivacaine 0.5%. The skin and the underlying tissues were infiltrated with local anaesthetic solution two fingers (about 3 cm) from the anatomical midline and level with the cephalad end of the vertebral spine.

Results: Time for performance of blocks lasted from 4 to 9 min. Recovery from anaesthesia or sedation was shortened, while postoperative pain scores (VAS), the incidence of vomiting and the requirement for analgesics were lower in the paravertebral group. Less painful restricted movement was observed in the paravertebral block group. Paravertebral block was inadequate in 6.8% of patients. Epidural spread with paraparaesis and Horner triad was assumed in one patient.

Conclusion: Single‐injection paravertebral block at the level of T4 represents a suitable alternative to general anaesthesia in women undergoing breast surgery.
Intravenous ketoprofen and epidural sufentanil analgesia in children after combined spinal‐epidural anaesthesia
Authors: Kokki H. , Tuovinen K. , Hendolin H.
Published: March 2003

Background: Epidural opioid analgesia has become more popular for postoperative pain treatment in children. Epidural opioids are associated with adverse effects such as respiratory depression, excessive sedation, protracted vomiting, urinary retention and pruritus. Following minor surgery, ketoprofen has a synergistic effect with opioids, resulting in an improved analgesia without increase in incidence of adverse effects. To see whether this is also true following major surgery, we compared the effect of i.v. ketoprofen and placebo as an adjuvant to epidural sufentanil analgesia.

Methods: A prospective, randomised, double‐blind, placebo‐controlled, parallel‐group study design was used in 58 children, aged 1–15 years, receiving a standardised combined spinal‐epidural anaesthesia. Intravenous ketoprofen or saline was provided as a bolus and a continuous infusion in addition to epidural sufentanil infusion, which was adjusted as clinically required. Epidural bupivacaine was used for rescue analgesia. The study drug infusion was discontinued when pain scores were <3 on a 0–10 scale for 6 h with an epidural sufentanil infusion rate of 0.03 μg kg−1 h−1.

Results: Children in the ketoprofen group received less rescue analgesia (none/29 vs. 8/29 children in the placebo group). In the ketoprofen group, criteria to discontinue epidural sufentanil were achieved more often (14 vs. 6 children) before the end of the 72 h study period. Less children in the ketoprofen group suffered pruritus (13 vs. 4). The incidence of nausea/retching and vomiting was similar (11 vs. 12) in both groups.

Conclusion: In this study, ketoprofen as a background analgesic to epidural sufentanil provided improved postoperative analgesia and reduced incidence of adverse effects of the epidural opioid.
Gastric intramucosal pH as a monitor of gut perfusion after thrombosis of the superior mesenteric vein
Authors: Ruettimann U. , Urwyler A. , Von Flue M. , Reinhardt D. , Pargger H.
Published: March 2003

Gastric intramucosal pH (pHi) when measured by a tonometer is a simple and minimally invasive method to determine gut ischemia. In a case of severe mesenteric venous thrombosis, we measured pHi intra‐ and postoperatively over a period of five days. The goal was to monitor improvement or deterioration of gastrointestinal perfusion in the intensive care unit and to perform a second‐look laparotomy if the condition worsened. We observed that gastric pHi is a more sensitive parameter for detecting intestinal ischemia than parameters such as arterial pH, base excess, or lactate. This patient’s pHi rose continuously, which allowed us to proceed in a conservative way without any further invasive diagnostic interventions. Thus, the application of a gastric tonometer in cases of mesenteric venous thrombosis may help to reduce costs by preventing unnecessary postoperative diagnostic maneuvers such as angiography, computed tomography, or even second‐look laparotomy.
Combination of intra‐articular tenoxicam, lidocaine, and pethidine for outpatient knee arthroscopy
Authors: Elhakim M. , Nafie M. , Eid A. , Hassin M.
Published: March 2003

Background: Studies of intra‐articular non‐steroidal anti‐inflammatory drugs have revealed an analgesic effect equivalent to that of intra‐articular local anaesthetic agents and morphine. The aim of this study was to evaluate the analgesic effect of intra‐articular lidocaine, pethidine and tenoxicam compared with that of lidocaine and pethidine on postoperative pain after arthroscopy.

Methods: After day‐case knee arthroscopy, 60 patients were randomly allocated to one of three groups to receive 20 ml of a solution containing 0.9% saline (group S), 2% lidocaine and 10 mg preservative‐free pethidine (group LP) and 2% lidocaine, 10 mg preservative‐free pethidine and 20 mg tenoxicam (group LPT). Postoperative pain was assessed using a visual analogue scale and measuring analgesic requirements.

Results: Pain scores were significantly lower in the LP group than in the S group at 1 and 2 h after surgery. From 4 h until the end of the first postoperative day, pain scores were significantly lower in the LPT group of patients at rest and on knee flexion than in the other two groups; these patients also used less oral analgesics (P<0.05).

Conclusion: The combination of 20 ml lidocaine 2%, 10 mg pethidine and 20 mg tenoxicam given intra‐articularly provided superior analgesia and reduced oral analgesic requirement during the first day after arthroscopy compared with lidocaine and pethidine alone.
Pneumoperitoneum in healthy humans does not affect central blood volume or cardiac output
Authors: Andersson L. , Wallin C‐J. , Sollevi A. , Odeberg‐Wernerman S.
Published: March 2003

Background: This study addresses the question of whether the elevation of the mean arterial pressure and central venous pressure in response to pneumoperitoneum for laparoscopic surgery is caused by increases in central blood volume and/or cardiac output.

Methods: Eleven patients in good cardiopulmonary health and scheduled for laparoscopic cholecystectomy, with a mean age of 42 years, were included. After induction of anaesthesia with fentanyl and propofol, radial arterial and central venous lines were introduced. The central blood volume and cardiac output were determined by the indicator‐dilution technique, using in‐line densitometric measurements of indocyanine green (ICG). The measurements were made before and after the establishment of pneumoperitoneum by insufflation of carbon dioxide to an intra‐abdominal pressure level of 11–13 mmHg.

Results: The mean arterial pressure (62±6 mmHg) increased after induction of pneumoperitoneum by 40±26% (P<0.05) and the central venous pressure increased from 6±4 mmHg to 8±6 mmHg (P<0.05). The cardiac output (4.3±0.9 L/min) and central blood volume (1.5±0.5 L) were not affected by the induction of pneumoperitoneum.

Conclusions: In healthy anaesthetized subjects, the elevation of mean arterial pressure and central venous pressure in response to pneumoperitoneum was not caused by enhancement in cardiac output or central blood volume.
Modified natural and synthetically reconstituted surfactant therapies for acute lung injury caused by endotoxin in rats
Authors: Tashiro K. , Nishizuka K. , Matsumoto Y. , Ohta K. , Suzuki Y , Kobayashi T.
Published: March 2003

Background: Impairment of surfactant is involved in development of acute respiratory distress syndrome. To develop artificial surfactant substitute for clinical use, we prepared synthetically reconstituted surfactant (SRS) by adding porcine surfactant‐associated protein B and C (SP‐B and SP‐C) to synthetic phospholipids, and compared its effect with that of modified natural surfactant (MNS) in rats with acute lung injury caused by endotoxin.

Methods: Escherichia coli endotoxin (71±18 mg · kg−1, mean±SD) was injected into the tracheas of 27 anesthetized and mechanically ventilated rats (FIO2 of 1.0). When the PaO2 had decreased to below 26.7 kPa, the rats were randomly assigned to three groups. The MNS and SRS groups (n=9, each) were given 100 mg · kg−1 of MNS and SRS through the airway, respectively. The control group (n=9) was given air in the same volume.

Results: The PaO2 of the control group remained below 13.3 kPa until the end of the experiment (6 h after the assignment). The PaO2 of the MNS group increased to 45.3±9.5 kPa and that of the SRS group to 45.5±3.7 kPa 0.5 h after the assignment (P<0.05 vs. control group). The PaO2 of both groups remained above 40 kPa throughout the experiment.

Conclusion: In this acute lung injury model, the effects of replacement therapy with surfactant consisting of synthetic phospholipids, SP‐B and SP‐C, were the same as those observed with MNS. These results warrant development of surfactant substitutes based on natural SP‐B and SP‐C, and synthetic phospholipids.
Hepatolobectomy‐induced depression of hepatic circulation and metabolism in the dog is counteracted by isoflurane, but not by halothane
Authors: Matsumoto N. , Koizumi M. , Sugai M.
Published: March 2003

Background: The effects of isoflurane and halothane anesthesia on hepatic circulation and oxygen metabolism during hepatolobectomy were investigated in the dog, in an attempt to assess which of the anesthetics was the better one for hepatic resection.

Methods: Mongrel dogs (n=24) were divided into two groups and accordingly anesthetized with isoflurane (n=12) or halothane (n=12). Each test anesthetic was administered in air. Electromagnetic flowmeters were used to measure hepatic arterial and portal venous blood flows 1) before the inhalation of each anesthetic (baseline); 2) 1 h inhalation of 1.5 MAC (minimum alveolar concentration) of each anesthetic; and 3) 1 h after hepatolobectomy with each anesthesia. Measurements of systemic hemodynamics, blood gas tensions, and the arterial ketone body ratio were made at the same time.

Results: Isoflurane maintained portal venous, hepatic arterial and total hepatic blood flows better than halothane anesthesia before and after hepatolobectomy. With halothane anesthesia, hepatolobectomy decreased prominently hepatic arterial blood flow. Hepatic arterial and mesenteric vascular resistance increased in the halothane group, but remained constant in the isoflurane group after hepatolobectomy. Hepatic oxygen delivery was significantly suppressed in the halothane group, but did not change in the isoflurane group. No significant difference was found in hepatic oxygen consumption between the two groups, but the arterial ketone body ratio decreased significantly only in the halothane group before and after hepatolobectomy.

Conclusion: The present data indicate that isoflurane has less adverse effect than halothane anesthesia on hepatic circulation, oxygen delivery and energy charge in hepatolobectomy cases.
The interaction of temperature with thiopental and etomidate on extracellular dopamine and glutamate levels in Wistar‐Kyoto rats subjected to forebrain ischemia
Authors: Lesser J. B. , Koorn R. , Vloka J. D. , Kuroda M. M. , Thys D. M.
Published: March 2003

Background: Many studies demonstrate an association between brain damage and the extracellular release of catecholamines and amino acids during cerebral ischemia. While the clinical value of hypothermia during periods of compromised cerebral blood flow and oxygen delivery is well established, the role of anesthetic agents is less clear. Furthermore, the interaction between these agents and hypothermia remains to be elucidated. The purpose of this study was to examine the interactive effects of temperature, sodium thiopental (STP) and etomidate (ETOM) on extracellular neurotransmitter accumulation in the rat corpus striatum during cerebral ischemia.

Methods: Animals were randomly assigned to one of six subgroups: normal saline (NS‐norm, pericranial t≈37°C, and NS‐hypo, t=30°C), etomidate (ETOM‐norm and ETOM‐hypo), and sodium thiopental (STP‐norm and STP‐hypo). Microdialysis probes were inserted into the corpus striatum. Dopamine (DA), glutamate, 3,4‐dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) levels were measured. At zero minutes, animals received a 10‐min infusion of STP (3 mg · kg−1 · min−1), ETOM (0.6 mg · kg−1 · min−1), or NS. Prior to ischemia, animals were given either intravenous STP (10 mg · kg−1), ETOM (3 mg · kg−1), or NS in bolus form. Each animal was then subjected to 10 min of forebrain ischemia (Is1) followed by a reperfusion interval (Rep1). The entire sequence was then repeated.

Results: There were significant interactions between temperature and drug for DA (Is1, P=0.006, Is2, P=0.032) and its metabolites (DOPAC, Is1P=0.01, HVA, Is1P=0.03), and for glutamate (Is1, P=0.03, Is2P=0.06). The nature of this interaction differed for DA and glutamate. The reduction in DA accumulation seen during hypothermia was offset by the addition of either STP or ETOM, whereas the addition of these drugs did not affect the reduced glutamate levels seen with hypothermia. During normothermia, STP and ETOM resulted in diminished DA accumulation compared to controls, yet they increased the accumulation of extracellular glutamate.

Conclusions:: Consistent with other studies, hypothermia was associated with diminished extracellular DA concentrations during forebrain ischemia. However, depending on the temperature condition, the addition of STP or ETOM in our forebrain ischemia model led to unexpected findings. The administration of these agents during normothermia diminished ischemia‐induced DA accumulation yet resulted in significantly higher concentrations of extracellular glutamate. In contrast, STP and ETOM during hypothermia were noted to significantly offset the DA‐reducing effects of hypothermia.