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Effect of low-dose N-acetyl-cysteine infusion on tourniquet-induced ischaemia-reperfusion injury in arthroscopic knee surgery.
Saricaoglu F, Dal D, Salman AE, Atay OA, Doral MN, Salman MA, Kilinc K, Aypar U.
Department of Anaesthesiology and Reanimation, Hacettepe University Faculty of Medicine, Ankara, Turkey. fatmasaricao@yahoo.com
BACKGROUND: Temporary occlusion of blood flow is used during arthroscopic knee surgery in order to provide a bloodless surgical field. The resulting ischaemia-reperfusion causes lipid peroxidation, which contributes to tissue injury. The aim of the study was to investigate the effect of low-dose n-acetyl cysteine (NAC) infusion on oxidative stress by determining malondialdehyde (MDA) levels during arthroscopic knee surgery. METHODS: Thirty patients, ASA I - II, undergoing arthroscopic knee debridement under a tourniquet were divided into NAC and control groups. Anaesthesia was induced with propofol, fentanyl and vecuronium bromide and maintained with desflurane in an equal parts O(2)-N(2)O mixture. In the NAC group, an infusion of NAC, 5 mg kg(-1).h(-1), was started after intubation, and continued until extubation. An equal volume of saline was infused to the control group. Duration of ischaemia, anaesthesia time, total dose of NAC infused were also recorded. Venous blood and synovial membrane tissue samples were obtained 10 min after the onset of NAC infusion but before tourniquet inflation (t1), after 30 min of ischaemia (t2), and after 5 min of reperfusion following tourniquet release (t3). RESULTS: Plasma MDA levels were significantly lower in the NAC group on reperfusion. There were no differences between the groups in tissue MDA levels at ischaemia and reperfusion times. CONCLUSION: Low-dose n-acetyl cysteine infusion attenuates lipid peroxidation and ischaemia-reperfusion injury in arthroscopic knee surgery requiring tourniquet application.
Publication Types:
PMID: 15954970 [PubMed - indexed for MEDLINE]
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Does repetition of post-tetanic count every 3 min during profound relaxation affect accelerographic recovery of atracurium blockade?
Motamed C, Kirov K, Combes X, Duvaldestin P.
Service d'Anaesthesie Reanimation Hopital Henri Mondor, Creteil-APHP, Universite Paris (12), Paris, France. motamed@igr.fr
BACKGROUND: Post-tetanic count is a valuable method to assess profound neuromuscular blockade. However, subsequent responses to repetitive stimulation might be altered due to post tetanic facilitation (PTF). To avoid PTF, it has been advocated to limit the interval of stimulation from 6 to 10 min. The impact of PTF on 90% recovery of the TOF ratio has not been evaluated. Therefore, we assessed the effect of repetitive PTC stimulation on atracurium blockade with the primary outcome being the time to reach 90% TOF recovery in comparison to classical TOF stimulation. METHODS: After informed consent 20 patients ASA I-II, scheduled for peripheral surgery under general anaesthesia and requiring tracheal intubation were enrolled into the study. Anaesthesia was induced with fentanyl, propofol, and atracurium, 0.5 mg kg(-1). Neuromuscular characteristics were assessed at the adductor pollicis by a TOF Watch((R)) accelerometer (Organon, Teknika, Holland) on each arm. After onset of maximum neuromuscular blockade, repetitive PTC every 3 min on one arm and repetitive TOF stimulation every 15 s on the opposite arm was performed. The following parameters were recorded: onset of maximum blockade, mean time of PTC stimulation, the maximum number of responses to PTC, time of the first and second TOF responses, and recovery profile until 90% TOF ratio. RESULTS: Time to reach 90% TOF recovery was similar on both arms (48 +/- 9 min), with a difference of 16 +/- 38 s between the arms (P = 0.64). The first and second responses of the TOF on the PTC-stimulated arm appeared at 29 +/- 8 min and 33 +/- 7 min, respectively. On the other arm the responses appeared at 30 +/- 8 min and 35 +/- 8 min, respectively (P < 0.05). CONCLUSION: Repetitive PTC stimulation every 3 min hastened the first and second responses of the TOF stimulation but we could not detect a significant difference in the 90% recovery of TOF ratio during atracurium blockade.
Publication Types:
PMID: 15954964 [PubMed - indexed for MEDLINE]
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Propofol attenuates responses of the auditory cortex to acoustic stimulation in a dose-dependent manner: a FMRI study.
Dueck MH, Petzke F, Gerbershagen HJ, Paul M, Hesselmann V, Girnus R, Krug B, Sorger B, Goebel R, Lehrke R, Sturm V, Boerner U.
Department of Anaesthesiology, University of Cologne, Cologne, Germany. M.Dueck@uni-koeln.de
BACKGROUND: Functional magnetic resonance imaging (fMRI) using blood-oxygen-level-dependent (BOLD) contrasts is a common method for studying sensory or cognitive brain functions. The aim of the present study was to assess the effect of the intravenous anaesthetic propofol on auditory-induced brain activation using BOLD contrast fMRI. METHODS: In eight neurosurgical patients, musical stimuli were presented binaurally in a block design. Imaging was performed under five conditions: no propofol (or wakefulness) and propofol plasma target concentrations of 0.5, 1.0, 1.5, and 2.0 microg ml(-1). RESULTS: During wakefulness we found activations in the superior temporal gyrus (STG) corresponding to the primary and secondary auditory cortex as well as in regions of higher functions of auditory information processing. The BOLD response decreased with increasing concentrations of propofol but remained partially preserved in areas of basic auditory processing in the STG during propofol 2.0 microg ml(-1). CONCLUSIONS: Our results suggest a dose-dependent impairment of central processing of auditory information after propofol administration. These results are consistent with electrophysiological findings measuring neuronal activity directly, thus suggesting a dose-dependent impairment of central processing of auditory information after propofol administration. However, propofol did not totally blunt primary cortical responses to acoustic stimulation, indicating that patients may process auditory information under general anaesthesia.
PMID: 15954960 [PubMed - indexed for MEDLINE]
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Positive end-expiratory pressure improves arterial oxygenation during prolonged pneumoperitoneum.
Meininger D, Byhahn C, Mierdl S, Westphal K, Zwissler B.
Department of Anaesthesiology, Intensive Care Medicine and Pain Control, J.W. Goethe-University Hospital, Frankfurt, Germany. dirk_meininger@gmx.de
BACKGROUND: Laparoscopic surgery usually requires the use of a pneumoperitoneum by insufflating gas in the peritoneal space. The gas most commonly used for insufflation is carbon dioxide. Increased intra-abdominal pressure causes cephalad displacement of the diaphragm resulting in compressed lung areas, which leads to formation of atelectasis, especially during mechanical ventilation. The aim of this prospective study was to investigate the effect of prolonged intraperitoneal gas insufflation on arterial oxygenation and hemodynamics during mechanical ventilation with and without positive end-expiratory pressure (PEEP). METHODS: Twenty patients undergoing totally endoscopic robot-assisted radical prostatectomy were randomly allocated to one of two groups. In the PEEP group (n = 10) a constant PEEP of 5 cmH(2)O was used, whereas in the ZPEEP group (n = 10) no PEEP was used. RESULTS: Application of PEEP (5 cmH(2)O) resulted in significantly higher P(a)O(2) levels after 3 h (182 +/- 49 vs. 224 +/- 35 mmHg) and 4 h (179 +/- 48 vs. 229 +/- 29 mmHg) of pneumoperitoneum; after desufflation, P(a)O(2) values decreased significantly below preinsufflation values. While there were no significant differences in heart rate, central venous pressure (CVP) and mean arterial blood pressure (MAP) during pneumoperitoneum between both groups, baseline values in CVP and MAP differed significantly between both groups with higher levels in the ZPEEP group. CONCLUSION: The application of a constant positive airway pressure of 5 cmH(2)O preserves arterial oxygenation during prolonged pneumoperitoneum.
Publication Types:
PMID: 15954959 [PubMed - indexed for MEDLINE]
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Aftermath of an adverse event: supporting health care professionals to meet patient expectations through open disclosure.
Manser T, Staender S.
Department of Anesthesia, Stanford University, Palo Alto, CA 94304, USA. tmanser@ethz.ch
An important element of how adverse events are handled is effective communication between health care providers and patients and their families. This review addresses the main questions: What do patients expect in the aftermath of an adverse event? What is known about the practice of open disclosure? How can organizations support health care providers in the aftermath of an adverse event, both professionally and personally? Patients clearly expect open disclosure to include an explanation of what happened, an apology for harm done, that appropriate remedial action will be taken and an explanation of what will be done to learn from the event and to prevent recurrence. Research has found that open disclosure is not very common although the ethical duty to disclose is widely acknowledged. Barriers to open disclosure include discomfort and a lack of training how to disclose, a fear of litigation, a culture of infallibility among health professionals, and inadequate systems for analysis, discussion and learning from mistakes. Significant commitment is required from health care organizations and managers to develop frameworks for open disclosure to occur, to assure its quality and to support health care providers in this process. Organizations also need to address the emotional needs of health care professionals in the aftermath of an adverse event. Last but not least, adequate systems for debriefing and incident analysis need to be in place to learn from adverse events and to avoid recurrence.
Publication Types:
PMID: 15954950 [PubMed - indexed for MEDLINE]
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Disclosure.
Davies JM.
Publication Types:
PMID: 15954949 [PubMed - indexed for MEDLINE]
New dental anaesthetic launched.
[No authors listed]
PMID: 16215582 [PubMed - as supplied by publisher]
Nitrous oxide anaesthesia and intraocular gases.
Kwan AS.
London, UK.
PMID: 16215264 [PubMed - in process]
Intraoperative interventions: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery.
Creswell LL, Alexander JC Jr, Ferguson TB Jr, Lisbon A, Fleisher LA; American College of Chest Physicians.
Division of Cardiothoracic Surgery, Washington University School of Medicine, 11155 Dunn Rd, Suite 204N, St. Louis, MO 63136, USA. creswelll@msnotes.wustl.edu
A comprehensive evidence review was conducted of the medical literature regarding the relationship between intraoperative interventions and the incidence of postoperative atrial arrhythmias, including, most commonly, atrial fibrillation (AF). Fifteen randomized, controlled studies and one large-scale concurrent cohort study were identified that reported on the following issues: systemic temperature during surgery (one report); "beating heart" surgery vs conventional bypass surgery (three reports); type of myocardial protection (five reports); the use of adjunctive posterior pericardiotomy (one report); the use of thoracic epidural anesthesia (TEA) [two reports]; the use of glucose-insulin-potassium (GIK) solutions (two reports); and the use of heparin-coated circuits for cardiopulmonary bypass (CPB) [two reports]. Based on a systematic review of the reported data and an analysis of the quality of the reported data, we recommend the following: (1) that mild hypothermia, rather than moderate hypothermia, may be effective in reducing the frequency of postoperative AF; (2) the use of posterior pericardiotomy may be a useful adjunct to reduce the frequency of postoperative AF; and (3) the use of heparin-coated CPB circuits is associated with less postoperative AF. Because of conflicting or inadequate data, we cannot conclude that the frequency of postoperative AF is affected by (1) the use of beating-heart techniques, (2) the type of myocardial protection strategy used, (3) the use of TEA, or (4) the use of GIK solutions perioperatively.
Publication Types:
PMID: 16167662 [PubMed - indexed for MEDLINE]
Sub-anaesthestic doses of ketamine impair cardiac parasympathetic regulation.
Penttila J, T Laitio MM, Langsjo J, Hinkka S, Scheinin H.
Publication Types:
PMID: 16211790 [PubMed - in process]
General anaesthesia for a super obese patient.
Leykin Y, Pellis T, Albano G, Zannier G.
Publication Types:
PMID: 16211787 [PubMed - in process]
Impact of the Narcotrend Index on propofol consumption and emergence times during total intravenous anaesthesia with propofol and remifentanil in children: a clinical utility study.
Weber F, Pohl F, Hollnberger H, Taeger K.
University of Regensburg, Department of Anaesthesia, Regensburg, Germany. frank.weber@klinik.uni-regensburg.de
Background and objective: The electroencephalographic Narcotrend Index (NI) is a measure of the hypnotic component of general anaesthesia. The purpose of this study was to evaluate the impact of Narcotrend guidance on propofol consumption and emergence times in children receiving total intravenous anaesthesia with propofol and remifentanil. Methods: Thirty children, aged 1-11 yr, scheduled for paediatric urological surgery were enrolled. Remifentanil was given to all patients at a constant infusion rate of 0.3 microg kg [-1] min[-1] throughout anaesthesia. Patients were randomly allocated to receive a continuous propofol infusion adjusted either according to a conventional clinical practice (Group C: n=15) or guided by Narcotrend monitoring (Group NI: n=15; target NI 60+/-5). All patients were connected to the Narcotrend Monitor, but in Group C the anaesthetist was blinded to the screen of the monitor. Propofol consumption (mg kg[-1]h[-1]) and emergence times (min) were the primary and secondary outcome measures. Results: Propofol consumption (median [inter-quartile range]) was significantly lower in Group NI compared to Group C (NI: 7.0 [6.4--8.2] vs. C: 9.3 [8.3--11.0] mg kg[-1]h[-1]; P<0.001), whereas Log-Rank-analysis revealed no intergroup difference in emergence times (Group NI: mean [95% confidence interval (CI)] 12.8 [11.2--14.4] min; Group C: 16.4 [12.6--20.2] min; P=0.10). Haemodynamic variables remained stable within age-related limits, and there were no observations of adverse events, especially no clinical signs of intraoperative awareness in any patient. Conclusion: Narcotrend monitoring for guidance of propofol/remifentanil anaesthesia in children results in reduced propofol consumption compared to a conventional clinical practice.
PMID: 16211731 [PubMed - in process]
Role of ATP-Sensitive K+-Channels in Hemodynamic Effects of Peroxynitrite in Anesthetized Rats.
Graves JE, Lewis SJ, Kooy NW.
From the *Department of Physiology and Pharmacology, University of Georgia, Athens, Georgia; daggerDivision of Critical Care Medicine, Children's Hospital Medical Center, Cincinnati, Ohio.
The aim of this study was to determine whether the hypotensive and vasodilator actions of peroxynitrite in pentobarbital-anesthetized rats involve the activation of ATP-sensitive K-channels (KATP-channels). The effects of the KATP-channel agonist, cromakalim (9-36 mug/kg, iv), peroxynitrite (0.5-10 mumol/kg iv), and L-S-nitrosocysteine (12.5-200 nmol/kg, iv) on mean arterial blood pressure (MAP) and mesenteric (MR) and hindquarter (HQR) vascular resistances were determined before and after injection of the KATP-channel blocker, glibenclamide (40 mumol/kg, iv). Cromakalim, peroxynitrite, and L-S-nitrosocysteine produced dose-dependent reductions in MAP, MR, and HQR. Administration of glibenclamide did not affect resting hemodynamic parameters but markedly attenuated the hemodynamic actions of cromakalim. The maximal falls in MAP and HQR produced by peroxynitrite were attenuated by glibenclamide whereas the maximal falls in MR were not affected. In addition, the duration of the hypotensive and vasodilator effects of peroxynitrite in the mesenteric and hindquarter beds were markedly diminished by glibenclamide. In contrast, glibenclamide did not affect the maximal hypotensive or vasodilator effects of L-S-nitrosocysteine or the duration of these responses. These results suggest that the hypotensive and vasodilator actions of peroxynitrite in anesthetized rats involve the activation of KATP-channels whereas the hemodynamic actions of L-S-nitrosocysteine do not.
PMID: 16220073 [PubMed - as supplied by publisher]
Comparison of the effectiveness of oral diazepam and midazolam for the sedation of autistic patients during dental treatment.
Pisalchaiyong T, Trairatvorakul C, Jirakijja J, Yuktarnonda W.
Department of Pediatric Dentistry, Faculty of Dentistry, Chulalongkorn University, Bankok, Thailand. tanaporn18@yahoo.com
PURPOSE: This study was undertaken to compare the effectiveness of oral diazepam and midazolam in sedating autistic patients during dental treatment. METHODS: The treatment regimen consisted of nitrous oxide/oxygen inhalation in conjunction with oral administration of either diazepam 0.3 mg/kg or midazolam 0.5 mg/kg in a cross-over design study of 13 subjects aged 5.8 to 14.7 years. A drug was classified as being effective when over 70% of the patients taking the drug were judged as "success" in all 3 behavioral criteria: (1) sleeping; (2) body movement; and (3) crying behaviors. The study was observed by an independent clinician with an intraexaminer reliability of 88%. RESULTS: For sleeping behavior, midazolam was found to be significantly more effective than diazepam as the duration of stimulation increased (P<.05). For the movement and crying behaviors, midazolam also proved to be significantly more effective from the start of treatment through the 35- and 40-min markers, respectively (P<.05). For the remainder of treatment, however, there was no statistically significant difference in these behaviors between the trials (P>.05). Diazepam and midazolam were rated as 77% and 100% successful, according to the overall behavior evaluation criteria (P=.02). CONCLUSIONS: Both diazepam and midazolam were shown to be effective sedative agents, successfully and safely used to sedate autistic patients for dental treatment. Midazolam was significantly more effective than diazepam in those portions of the procedure with increased stimulation.
Publication Types:
PMID: 16173223 [PubMed - indexed for MEDLINE]
Comparison of chloral hydrate, meperidine, and hydroxyzine to midazolam regimens for oral sedation of pediatric dental patients.
Chowdhury J, Vargas KG.
Pediatric Dentistry Program, The University of Iowa, College of Dentistry, Iowa City, Iowa, USA.
PURPOSE: The purpose of this retrospective study was to compare the effects of oral administration of a combination of chloral hydrate (CH) 25 mg/kg, hydroxyzine (H) 1 mg/kg, and meperidine (M) 1 mg/kg to midazolam 0.65 mg/kg using 50% nitrous oxide (N2O) on behavioral and physiological parameters of young children sedated for dental procedures. Factors associated with sedation effectiveness were identified, including age, preoperative behavior, and type of procedure. METHODS: Records of 116 sedation sessions of 66 healthy, uncooperative children ages 24 to 60 months at The University of Iowa Centers for Disabilities and Development were reviewed. Patients received 1 of the 2 regimens. Intraoperative behavior was rated using a dichotomous scale. Physiological variables including heart rate and oxygen saturation were recorded at baseline and at 10-minute intervals of the session. Data were analyzed using SPSS Version 9. RESULTS: Overall, 81 % of sessions were rated successful. Sedation sessions using CH+H+M combination had significantly higher success rate (P<.01, odds ratio=3.38, 95% confidence interval= 1.06 to 7.15) compared to sessions with midazolam. Sedation success was not associated with age, preoperative behavior, or type of dental procedure performed. Physiological variables were within the normal range for both regimens, although midazolam regimen recorded higher heart rates. CONCLUSIONS: CH+H+M combination using 25 mg/kg CH resulted in significantly more effective sedation sessions compared to midazolam. Both regimens used 50% N2O and were found to be safe.
Publication Types:
PMID: 16173222 [PubMed - indexed for MEDLINE]
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