METHODS: In 50 patients undergoing coronary artery bypass grafting, the CPB circuit was prospectively and randomly primed with either 1500 mL of 6% HES 130/0.42 in a balanced electrolyte solution (Na⁺ 140 mmol/L, Cl^– 118 mmol/L, K⁺ 4 mmol/L, Ca²⁺ 2.5 mmol/L, Mg⁺⁺ 1 mmol/L, acetate^– 24 mmol/L, malate^– 5 mmol/L) (n = 25) or with 500 mL of 5% human albumin plus 1000 mL 0.9% saline solution (n = 25). Inflammation (interleukins [IL]-6, -10), endothelial damage (soluble intercellular adhesion molecule-1), kidney function (kidney-specific proteins -glutathione S-transferase, neutrophil gelatinase-associated lipocalin), coagulation (measured by thrombelastometry [ROTEM®, Pentapharm, Munich, Germany]), and platelet function (measured by whole blood aggregometry [Multiplate® analyzer, Dynabyte Medical, Munich, Germany]) were assessed after induction of anesthesia, immediately after surgery, 5 h after surgery, and on the morning of first and second postoperative days.

RESULTS: Total volume given during and after CPB was 3090 ± 540 mL of balanced HES and 3110 ± 450 mL of albumin. Base excess after surgery was lower in the albumin-based priming group than in the balanced HES priming group (–5.9 ± 1.2 mmol/L vs +0.2 ± 0.2 mmol/L, P = 0.0003). Plasma levels of IL-6, IL-10, and intercellular adhesion molecule-1 were higher after CPB in the albumin-based priming group compared with the HES priming group at all time periods (P = 0.0002). Urinary concentrations of -glutathione S-transferase and neutrophil gelatinase-associated lipocalin were higher after CPB through the end of the study in the albumin group compared with the balanced HES group (P = 0.00004). After surgery through the first postoperative day, thrombelastometry data (clotting time and clot formation time) revealed more impaired coagulation in the albumin-based priming group compared with the HES priming group (P = 0.004). Compared with baseline, platelet function was unchanged in the high-dose balanced HES priming group after CPB and 5 h after surgery, but it was significantly reduced in the albumin-based priming group.

CONCLUSION: High-volume priming of the CPB circuit with a modern balanced HES solution resulted in reduced inflammation, less endothelial damage, and fewer alterations in renal tubular integrity compared with an albumin-based priming. Coagulation including platelet function was better preserved with high-dose balanced HES CPB priming compared with albumin-based CPB priming.

METHODS: Seven pediatric anesthesiologists with <6 mo experience with ultrasound-guided regional anesthesia performed a total of 127 scans of the II region in anesthetized children. The muscle planes and the II and IH nerves were identified and labeled. The ultrasound images were reviewed by a blinded expert to mark accuracy of structure identification and time taken for identification. Two ultrasound machines (Sonosite C180plus and Micromaxx, both from Sonosite, Bothell, WA) were used.

RESULTS: There was no difference in the frequency of correct identification of the TA muscle compared with the II/IH nerves (² test, TA versus II, P = 0.45; TA versus IH, P = 0.50). Ultrasound machine selection did show a nonsignificant trend in improving correct II/IH nerve identification (II nerve ² test, P = 0.02; IH nerve ² test, P = 0.04; Bonferroni corrected significance 0.17) but not for the muscle planes (² test, P = 0.83) or time taken (1-way analysis of variance, P = 0.07). A curve of improving accuracy with number of scans was plotted, with reliability of TA recognition occurring after 14–15 scans and II/IH identification after 18 scans.

CONCLUSIONS: We have demonstrated that although there is no difference in the overall accuracy of muscle plane versus II/IH nerve identification, the muscle planes are reliably identified after fewer scans of the inguinal region. We suggest that a reliable end point for the inexperienced practitioner of ultrasound-guided II/IH nerve block may be the TA/internal oblique plane where the nerves are reported to be found in 100% of cases.

METHODS: Thirty children (ASA physical status I–II) aged 3 mo to 6 yr undergoing a pelvic osteotomy were included in the study. The children were randomized for either morphine IV and placebo (saline) via a FIC catheter (Group M) or placebo (saline) IV and ropivacaine via a FIC catheter (Group R). All patients received general anesthesia using inhaled sevoflurane and IV fentanyl. Perioperatively, a FIC catheter was placed by the surgeon. All patients received either a bolus dose of morphine IV (Group M) or ropivacaine 0.75% via the FIC catheter (Group R) at the end of surgery. Postoperatively, Group M received morphine IV 20 µg·kg^–1·h^–1 and Group R ropivacaine 0.2% 0.1 mL·kg^–1·h^–1 via the FIC catheter. In both groups, saline was administered along the other route. All children were assessed for pain, sedation, time until first oral intake, and adverse effects for 48 h postoperatively. During this period, all children had a urinary catheter.

RESULTS: The study was completed by 28 children. In the anesthetic recovery room, children in Group M had significantly higher pain scores. These children were also significantly more sedated during the study period. The incidence of vomiting did not differ between the groups; however, children in Group R had first oral intake significantly earlier than Group M. A local retrospective study revealed an incidence of urinary retention of 4.7% in the ropivacaine-treated patients and 39% in the morphine-treated patients.

CONCLUSIONS: Continuous incisional FIC block provides excellent postoperative pain relief, less sedation, and better return of appetite than morphine IV after pelvic osteotomy in children.

METHODS: Sixty-seven patients were enrolled to receive lidocaine or saline infusion perioperatively.

RESULTS: Length of postanesthesia care unit (PACU) stay did not differ between groups. Intraoperative opioid use was significantly less in the lidocaine group, both in the PACU and during the total study period but not after discharge. In the PACU, patients in the lidocaine group reported less pain (visual analog scale score 3.1 ± 2.04 vs 4.5 ± 2.9; P = 0.043). There were no differences in postoperative nausea and vomiting.

CONCLUSION: Perioperative systemic lidocaine significantly reduces opioid requirements in the ambulatory setting without affecting time to discharge.

METHODS: This was a randomized, 2-day, crossover study. On the first study day, healthy volunteers were randomly allocated to either propofol or dexmedetomidine sedation. Drugs were administered using computer-controlled infusions targeting an effect-site concentration of 1, 2, and 4 µg/mL for propofol or a plasma concentration of 0.6, 1.2, and 2.4 ng/mL for dexmedetomidine. The relationship between BIS and OAA/S score was obtained 20 and 40 min after changing each drug concentration. BIS values at each OAA/S score were compared between drugs. The cutoff values of BIS for OAA/S score of ≤2 were obtained by analysis of receiver operating characteristic curves.

RESULTS: Nine volunteers were included in our analysis. Heart rates decreased significantly with dexmedetomidine sedation. ETco₂ was significantly increased with high doses of propofol but did not increase with high doses of dexmedetomidine. BIS values at OAA/S scores of 1, 2, 3, 4, and 5 during propofol sedation were 95.5 (90-97), 78 (71-84.5), 67 (64-70), 57 (51.5-60), and 34 (30-37), respectively. BIS values at OAA/S scores of 1, 2, 3, 4, and 5 during dexmedetomidine sedation were 95 (79-98), 62 (53.5-68.5), 45.5 (45.3-52), 39.5 (34.3-41.8), and 24.5 (22.5-30.5), respectively. BIS values were significantly less with dexmedetomidine than propofol at OAA/S responsiveness scores of 2, 3, and 4. The calculated cutoff BIS values for OAA/S scores of ≤2 were 67 (sensitivity of 86%, specificity of 97%, and area under the curve of 0.98) for propofol and 46 (sensitivity of 84%, specificity of 91%, and area under the curve of 0.96) for dexmedetomidine.

CONCLUSION: The combination of both BIS and sedative scales could provide different and complementary data to the clinician evaluating the patient’s response to sedation than would either tool alone, especially when dexmedetomidine is used.

METHODS: In this study, we used a GABA_A 4 receptor knockout mouse line to evaluate the contribution of 4-containing GABA_A-Rs to the effects of immobility, hypnosis, and amnesia produced by isoflurane. Knockout mice and their wild-type counterparts were assessed on 3 behavioral tests: conditional fear (to assess amnesia), loss of righting reflex (to assess hypnosis), and the minimum alveolar concentration of inhaled anesthetic necessary to produce immobility in response to noxious stimulation in 50% of subjects (to assess immobility).

RESULTS: Genetic inactivation of the 4 subunit reduced the amnestic effect of isoflurane, minimally affected loss of righting reflex, and had no effect on immobility.

CONCLUSIONS: These results lend support to the hypothesis that different sites of action mediate different anesthetic end points and suggest that 4-containing GABA_A-Rs are important mediators of the amnestic effect of isoflurane on hippocampal-dependent declarative memory.

METHODS: Twenty-five patients had procedures during which acute normovolemic hemodilution was a planned part of the intraoperative management. We defined 7 measurement timepoints: baseline, after the removal of 5%, 10%, and 15% of the estimated blood volume (EBV) and after replacement with an equal volume of 6% hetastarch to –10%, –5%, and baseline EBV. At each timepoint, heart rate and systolic, diastolic, and mean arterial blood pressure were obtained from standard monitors, CO and SVV measurements were obtained from the FloTrac/Vigileo monitor, and TEE images were recorded for subsequent off-line reconstruction and determination of LV end-systolic and end-diastolic volumes. For statistical evaluations, we used a mixed models analysis of variance and Dunnett’s test for post hoc comparisons with baseline values. Pearson’s correlation was used to examine the relationships between SVV and LV volume.

RESULTS: Analysis of variance demonstrated no significant change in heart rate or mean arterial blood pressure over the duration of study. CO decreased from 4.9 ± 0.3 to 4.5 ± 0.3 L/min after removal of 15% of the EBV and then increased to a final value of 5.4 ± 0.3 L/min after replacement of 15% of the EBV. SVV increased from 9.2% ± 0.9% to 20.3% ± 2.0% (P < 0.001) after removal of 15% of the EBV and returned to a final value of 7.2% ± 0.9% after replacement of 15% of the EBV. The indexed LV end-diastolic volume decreased from 42.1 ± 8.3 to 36.9.3 ± 8.3 mL/m² (P < 0.001) after removal of 15% of the EBV and then returned to a final volume of 45.9 ± 10.3 mL/m² after replacement of 15% of the EBV. The measurements of SVV correlated inversely with the 3D TEE LV volume measurements.

CONCLUSIONS: The SVV derived from the FloTrac/Vigileo system changes significantly as blood is removed and replaced during hemodilution. These changes correlate with 3D TEE measurements of LV volume. The utility of SVV in guiding optimization of intravascular volume merits further study.

METHODS: To allow a broad variance of atelectasis and therefore shunt fraction, 8 sham animals did not receive lavage, and 8 animals were treated by lung lavages with 30 mL/kg warmed lactated Ringer's solution as follows: 2 animals were lavaged once, 5 animals twice, and 1 animal 3 times. Variables were recorded at baseline and twice after induction of lung injury (T1 and T2). Retention data of sulfur hexafluoride, krypton, desflurane, enflurane, diethyl ether, and acetone were analyzed by MMIMS, and M-S was derived using a known algorithm for the multiple inert gas elimination technique. Standard formulas were used for the calculation of R-S.

RESULTS: Forty-four pairs of M-S and R-S were recorded. M-S ranged from 0.1% to 35.4% and R-S from 3.7% to 62.1%. M-S showed a correlation with R-S described by linear regression: M-S = –4.26 + 0.59 x R-S (r² = 0.83). M-S was on average lower than R-S (mean = –15.0% CO, sd = 6.5% CO, and median = –15.1), with lower and upper limits of agreement of –28.0% and –2.0%, respectively. The lower and upper limits of the 95% confidence intervals were –17.0 and –13.1 (P < 0.001, Student's t-test).

CONCLUSIONS: Shunt derived from MMIMS inert gas retention data correlated well with R-S during breathing of oxygen. Shunt as derived by MMIMS was generally less than R-S.

METHODS: After induction of general anesthesia, the trachea was intubated with a tracheal tube. The distance from the incisors to the carina was measured using a fiberoptic bronchoscope. While the anesthesiologist advanced the tracheal tube from the trachea to the bronchus, another anesthesiologist auscultated breath sounds to detect changes of the breath sounds and/or disappearance of bilateral breath sounds for every 1 cm that the tracheal tube was advanced. Two precordial stethoscopes placed at the left and right sides of the chest were used to record breath sounds simultaneously. Subsequently, at a later date, we randomly entered the recorded breath sounds into the Visual Stethoscope. The same anesthesiologist observed the visualized breath sounds on the personal computer screen processed by the Visual Stethoscope to examine changes of breath sounds and/or disappearance of bilateral breath sound. We compared the decision made based on auscultation with that made based on the results of the visualized breath sounds using the Visual Stethoscope.

RESULTS: Thirty patients were enrolled in the study. When irregular breath sounds were auscultated, the tip of the tracheal tube was located at 0.6 ± 1.2 cm on the bronchial side of the carina. Using the Visual Stethoscope, when there were any changes of the shape of the visualized breath sound, the tube was located at 0.4 ± 0.8 cm on the tracheal side of the carina (P < 0.01). When unilateral breath sounds were auscultated, the tube was located at 2.6 ± 1.2 cm on the bronchial side of the carina. The tube was also located at 2.3 ± 1.0 cm on the bronchial side of the carina when a unilateral shape of visualized breath sounds was obtained using the Visual Stethoscope (not significant).

CONCLUSIONS: During advancement of the tracheal tube, alterations of the shape of the visualized breath sounds using the Visual Stethoscope appeared before the changes of the breath sounds were detected by auscultation. Bilateral breath sounds disappeared when the tip of the tracheal tube was advanced beyond the carina in both groups.

METHODS: General anesthesia was administered to 40 patients undergoing minor surgeries. Patients were kept in neutral position (supine) for 15 min and BIS readings, mean arterial blood pressure, heart rate, end-tidal carbon dioxide, and end-tidal isoflurane were recorded. Patients were then shifted to head-down position (30°), neutral position, and lastly head-up position (30°) each of 15-min duration and the data were recorded.

RESULTS: There was a significant increase in BIS values in head-down position (median 47 vs 40) compared with neutral position, whereas head-up position significantly decreased BIS (39 vs 41) compared with neutral position (P < 0.05).

CONCLUSION: Changing a patient’s position significantly affects the BIS values, which might affect the interpretation of anesthetic depth.

METHODS: Patients with peripheral vascular disease undergoing vascular surgery under general anesthesia were monitored with both a transmittance earlobe probe and a reflectance forehead probe. Spo₂ was recorded continuously from both probes, and arterial blood gas samples were analyzed when clinically indicated. The average values from both probes over each minute were compared using Bland-Altman analysis.

RESULTS: Twenty patients were included yielding a total of 3993 1-min averaged data pairs. Neither probe failed to report a value for more than 1 min. A Bland-Altman plot showed the limits of agreement between the probes of –4.0% to +2.6%. Twenty-eight arterial blood samples were analyzed for 14 patients and Sao₂ closely matched both Spo₂ probe values at the time of sampling. Compared with Sao₂, analysis demonstrated limits of agreement of –4.7% to 6.1% for ear and –3.3% to 3.4% for forehead sites.

CONCLUSIONS: The new reflectance forehead Spo₂ probe tested has acceptable agreement with the older transmittance probe placed on the earlobe for pulse oximetry within typical ranges of Spo₂ in patients undergoing vascular surgery.

METHODS: The serum glucose and sodium concentrations were measured in 250 patients undergoing monopolar TURP using either 1.5% glycine or 5% glucose for urinary bladder irrigation. The glucose kinetics was analyzed in 10 volunteers receiving a 30-min infusion of 20 mL/kg of acetated Ringer’s solution with 1% glucose. These data were then used in computer simulations of different absorption patterns that were summarized in a nomogram for the relationship between the glucose level and administered fluid volume.

RESULTS: There was a statistically significant inverse linear relationship between the decrease in serum sodium and the increase in glucose levels after absorption of 5% glucose during TURP (r² = 0.80). The glucose concentration increased, from 4.6 (sd 0.4) to 8.3 (0.9) mmol/L, during the experimental infusions. Regardless of the absorption pattern, all simulations indicated that the uptake of 1 L of fluid containing 1% glucose corresponded to an increase in the glucose level of 3.7 (sd 1.6) mmol/L at the end of surgery, whereas 2 L yielded an increase of 6.9 (1.7) mmol/L.

CONCLUSIONS: In bipolar TURP, the addition of glucose to a concentration of 1% in the electrolyte-containing irrigation fluid can be used as a tracer of absorption that is comparable with measuring serum sodium after monopolar TURP.

METHODS: Eighty patients requiring orotracheal intubation for elective surgery were randomly allocated to either the FIS or a malleable stylet (control) to facilitate tracheal intubation using the GlideScope. TTI was recorded by blinded assessors; operators were blinded until after laryngoscopy. The operator assessed the ease of intubation using a 100-mm visual analog scale (0 = easy to 100 = difficult). The number of intubation attempts, number of failures, glottic grades, and use of external laryngeal manipulation were documented.

RESULTS: The median TTI was 41 s (interquartile range [IQR] 30-51) for the Flex-It group compared with 32 s (IQR 28-42) for the control group (P = 0.03). The median visual analog scale score for ease of intubation was 20 (IQR 11-39) for the Flex-It group compared with 15 (IQR 8-28) for the control group (P = 0.13). The overall incidence of a Cormack-Lehane Grade I or II glottic view was 100%.

CONCLUSIONS: In a group of experienced operators using the GlideScope, the FIS was less effective for orotracheal intubation than a malleable endotracheal tube stylet.

METHODS: We performed a retrospective review of a departmental database to determine whether a comprehensive program to manage difficult airways was associated with a reduced need to secure the airway surgically via cricothyrotomy or tracheostomy. The annual number of unplanned, emergency surgical airway procedures for inability to intubate and ventilate reported for the 4 yr before the program (January 1992 through December 1995) was compared with the annual number reported for the 11 yr after the program was initiated (January 1996 through December 2006).

RESULTS: The number of emergency surgical airways decreased from 6.5 ± 0.5 per year for 4 yr before program initiation to 2.2 ± 0.89 per year for the 11-yr period after program initiation (P < 0.0001). During the 4-yr period from January 1992 through December 1995, 26 surgical airways were reported, whereas only 24 surgical airways were performed in the subsequent 11-yr period (January 1996 through December 2006).

CONCLUSIONS: A comprehensive difficult airway program was associated with a reduction in the number of emergency surgical airway procedures performed for the inability of an anesthesiologist to intubate and ventilate, a reduction that was sustained over an 11-yr period. This decrease occurred despite an increase in the number of patients reported to have a difficult airway and an overall increase in the total number of patients receiving anesthesia per year.

METHODS: A prospective cohort study was conducted in an intensive care unit of the University Hospital, Montpellier, France, from December 2003 to December 2005. Thirty consecutive patients admitted for severe head trauma were subjected to sedatives, mechanical ventilation, and intraparenchymatous recording of ICP and were evaluated with Glasgow Outcome Scale score. Simultaneous 60-s recordings of ICP and arterial blood pressure (BP) signals, beginning as soon as possible after head trauma, were repeated until death or clinical stabilization, every 15 min, with physicians blinded to the patients’ data. Spectra of ICP and BP waveforms were computed with Fourier transform. Amplitudes of cardiac and respiratory harmonics were analyzed. Cardiac (or respiratory) gain was defined as the ratio of amplitudes of cardiac (or respiratory) harmonic of ICP to BP signals and referred to as Gc and Gr, respectively.

RESULTS: Twenty of the 30 enrolled patients recovered consciousness (Glasgow Outcome Scale score = 3, 4, or 5). Gr/Gc averaged over the whole recording period performed better in discriminating consciousness recovery (area under receiver operating characteristic [ROC] curve: 0.98; 95% confidence interval [CI]: 0.91–1) than ICP (0.76; 95% CI: 0.54–0.97), cerebral perfusion pressure (0.75; 95% CI: 0.53–0.97) and Gc (0.77; 95% CI: 0.57–0.99) (P < 0.001 for each comparison). When considering the recording period 30 h posttrauma (hpt), 162 hpt, a value of Gr/Gc ≥4 was always associated with consciousness recovery, and the relative risk was equal to 9 (95% CI: 1.42–57.12).

CONCLUSIONS: Gr/Gc, which characterizes the cerebrovascular transmission, better discriminates bad evolution than high values of ICP or low values of cerebral perfusion pressure in patients with severe head trauma. A reduction in Gr/Gc ratio might be an early alarm signaling worsening intracranial hemodynamic conditions.

METHODS: This was a retrospective study in the intensive care unit. Between 2006 and 2007, we identified 18 patients with acute lung injury/ARDS who received either APRV or PSV and had a helical computed tomography scan twice in 3 days.

RESULTS: Computed tomography data from the APRV and PSV groups (n = 9 each) were analyzed for 3-dimensional reconstruction and volumetry. Aerated lung regions (normally aerated, poorly aerated, nonaerated, and hyperinflated) were identified by their densities in Hounsfield units. The Pao₂/Fio₂ ratio and alveolar-arteriolar oxygen gradient after ventilation were improved in both groups (P = 0.008); however, the improvements in the APRV group exceeded those in the PSV group when delivered with equal mean airway pressure (P = 0.018 and 0.015, respectively). Atelectasis decreased significantly from 41% (range, 17%–68%) to 19% (range, 6%–40%) (P = 0.008) and normally aerated volume increased significantly from 29% (range, 13%–41%) to 43% (range, 25%–56%) (P = 0.008) in the APRV group, whereas lung volume did not change in the PSV group.

CONCLUSIONS: Spontaneous ventilation during APRV improves lung aeration by decreasing atelectasis. PSV for gas exchange is effective but not sufficient to improve lung aeration. These results indicate that APRV is more efficient than PSV as a mode of primary ventilatory support to decrease atelectasis in patients with ARDS.

METHODS: Anesthesiologists performed 4 airway access techniques on excised porcine tracheas. The techniques were 1) wire-guided (WGT), 2) trocar (TT), 3) needle cannula (NCT), and 4) surgical—scalpel with endotracheal tube (ST). Participants performed each technique at both the CTM and tracheal sites. Specimens were assessed for injury.

RESULTS: Injury was observed in 8 of 40 and 27 of 40 specimens at the CTM and tracheal sites, respectively (P < 0.001). Injury was more frequent at the tracheal site compared with the CTM in both the TT and ST groups (P = 0.02) but not for the NCT and WGT. The rank order for any injury at the tracheal site was ST (9 of 10) = TT (9 of 10) > WGT (6 of 10) > NCT (3 of 10) (P = 0.02, highest versus lowest), whereas there was no difference in injury at the CTM. The rank order for posterior injury at the tracheal site was TT (9 of 10) = ST (9 of 10) > WGT (5 of 10) > NCT (2 of 10) (P = 0.005, highest versus lowest). The rank order for penetrating injury at the tracheal site was ST (6 of 10) = TT (6 of 10) > WGT (2 of 10) > NCT (1 of 10) (P = 0.057, highest versus lowest). There was no difference in the incidence of lateral, superficial, or perforating injuries among sites and techniques. Fractures were more common at the tracheal site (15 of 40 vs 0 of 40, P < 0.001) and differed by technique. The rank order of fracture incidence at the tracheal site was ST (6 of 10) > WGT (5 of 10) > TT (4 of 10) > NCT (0 of 10) (P = 0.011, highest to lowest). Compression of >50% was seen in 10 of 40 vs 28 of 40 (P < 0.001) specimens at the CTM and tracheal sites, respectively. The rank order of compression of >50% of airway lumen for both sites was TT > ST > WGT > NCT (P = 0.03, P < 0.001, CTM and tracheal sites, respectively, highest versus lowest).

CONCLUSION: Airway injury and luminal compression were more common at the tracheal site than at the CTM. The ST and TT were associated with the highest incidence of injury. This has implications for emergency airway access in cases in which it may be difficult to accurately identify the CTM.

METHODS: The role of rFVIIa for off-label indications, including trauma, cardiac surgery, and severe postpartum hemorrhage, remains controversial. The Haemostasis Registry established by Monash University in Melbourne, Australia monitors off-label use of rFVIIa across Australia and New Zealand. The purpose of this study was to summarize Registry data for all obstetric hemorrhage patients treated with rFVIIa at participating hospitals between January 2002 and July 2008. The primary outcome measures were reduction or cessation of bleeding (positive therapeutic response), mortality, and hysterectomy rate.

RESULTS: During the study period, the Registry received data for 2128 patients. This included 110 cases of administration of rFVIIa in obstetric patients from 38 hospitals, comprising 5% of the total Registry population, 105 of whom were treated for acute hemorrhage. Women received median (interquartile range) individual doses of 92 µg/kg (73–100) of rFVIIa (median total dose 92 µg/kg [58–108]), and 78% of patients received a single dose. The positive response rate to rFVIIa was 76% with 64% responding to the first dose. Ninety-one percent of women were alive at 28 days. Forty-three women (41%) underwent hysterectomy before receiving rFVIIa and, of those remaining, 13 (21%) required hysterectomy after rFVIIa therapy. Two thromboembolic events (1 pulmonary embolism and 1 deep venous thrombosis) and 1 case of hypoxic-ischemic encephalopathy resulting from severe anoxia were reported.

CONCLUSIONS: The reported effect of rFVIIa in many, but not all, obstetric cases was positive. There was no mortality as a result of thromboembolic complications. Randomized, controlled trials are required to confirm its safety and efficacy and to assess the possibility that use at an earlier stage in treatment of severe postpartum hemorrhage may avoid the need to resort to postpartum hysterectomy for control of bleeding, thus preserving fertility.

METHODS: Sixty healthy term women scheduled for planned cesarean delivery under spinal anesthesia were recruited for this randomized, double-blind study. Baseline heart rate, systolic blood pressure (SBP), CO, and FTc were recorded in the left lateral tilt position. Patients were randomized to receive 1 of 3 fluid preload regimens given over 15 min: 1.5 L crystalloid (Hartman's solution), 0.5 L of 6% w/v hydroxyethyl starch (HES) solution (HES 0.5), or 1 L of 6% w/v HES solution (HES 1.0). Further measurements were made after fluid loading every 5 min for 30 min. After 30 min, spinal anesthesia was induced with hyperbaric bupivacaine 12.5 mg with fentanyl 15 µg and recordings were continued every 5 min for 20 min or until surgery started. The primary outcome, CO, was compared among groups. The incidence of hypotension (defined as a 20% reduction in SBP from the baseline), ephedrine use, and umbilical cord blood gases were also compared.

RESULTS: Patient characteristics, heart rate, SBP, and cord gases were similar among groups. Although CO and FTc increased after preload in all groups (P < 0.005), this was only maintained with HES 1.0 after spinal anesthesia (P < 0.005). There were no differences among groups in the incidence of hypotension (70% vs 35% vs 65% for Hartman's solution, HES 0.5, and HES 1.0, respectively; P = 0.069) or mean ephedrine dose (10.4 vs 5.7 vs 9.7 mg; P = 0.26).

CONCLUSION: Despite CO and FTc increases after fluid preload, particularly with HES 1.0 L, hypotension still occurred. The data suggest that CO increases after these preload regimens cannot compensate for reductions in arterial blood pressure after spinal anesthesia.

METHODS: Electrical field stimulation or 20-HETE was applied to rat brain slices monitored by computer-assisted microscopy. In some experiments, a Na⁺ channel antagonist tetrodotoxin, a 20-HETE synthesis inhibitor HET0016, a superoxide scavenger, Tiron, nicotinamide adenine dinucleotide phosphate (NADPH) oxidase inhibitors diphenyleneiodonium (DPI) and gp91ds-tat, or propofol was added. The superoxide level in the brain slice and the production rate in the absence of slices were evaluated by dihydroethidium fluorescence or cytochrome c reduction with a superoxide-generating system, respectively.

RESULTS: Electrical stimulation induced constriction of the cerebral parenchymal arteriole, whereas this response was abolished by tetrodotoxin, HET0016, Tiron, or DPI. 20-HETE (10^–8–10^–6 mol/L) produced arteriolar constriction, which was inhibited by Tiron or DPI. Propofol reduced the constriction induced by electrical stimulation or 20-HETE. 20-HETE induced superoxide production in the brain slice, which was reduced by Tiron, gp91ds-tat, or propofol. However, propofol did not alter the superoxide production rate in the absence of brain slices.

CONCLUSIONS: Either neuronal transmission-dependent or exogenous 20-HETE seems to induce cerebral parenchymal arteriolar constriction via superoxide production resulting from NADPH oxidase activation. Propofol is likely to prevent this constriction via inhibition of NADPH oxidase, but not by its scavenging effect on superoxide.

METHODS: The passive avoidance (PA) paradigm was used to assess memory retention. For PA training, latencies (seconds) were recorded for entry from a suspended platform into a Plexiglas tube where a shock was automatically delivered. Latencies were recorded 48 h later for a testing trial. Ninety-six Swiss-Webster mice (30–35 g, 6–8 wk), were randomized into 6 groups 1) saline (control), 2) NTG immediately after learning, 3) NTG 3 h after learning, 4) NTG and NIMO, 5) vehicle, and 6) NIMO alone. The extent of hypotension and changes in brain tissue oxygenation (PbtO₂) and in cerebral blood flow were studied in a separate group of animals.

RESULTS: All groups exhibited similar training latencies (17.0 ± 4.6 s). Mice subjected to hypotensive episodes showed a significant decrease in latency time (178 ± 156 s) compared with those injected with saline, NTG + NIMO, or delayed NTG (580 ± 81 s, 557 ± 67 s, and 493 ± 146 s, respectively). A Kruskal-Wallis 1-way analysis of variance indicated a significant difference among the 4 treatment groups (H = 15.34; P < 0.001). In a separate group of mice not subjected to behavioral studies, the same dose of NTG (n = 3) and NTG + NIMO (n = 3) caused mean arterial blood pressure to decrease from 85.9 ± 3.8 mm Hg sem to 31.6 ± 0.8 mm Hg sem and from 86.2 ± 3.7 mm Hg sem to 32.6 ± 0.2 mm Hg sem, respectively. Mean arterial blood pressure in mice treated with NIMO alone decreased from 88.1 ± 3.8 mm Hg to 80.0 ± 2.9 mm Hg. The intergroup difference was statistically significant (P < 0.05). PbtO₂ decreased from 51.7 ± 4.5 mm Hg sem to 33.8 ± 5.2 mm Hg sem in the NTG group and from 38.6 ± 6.1 mm Hg sem to 25.4 ± 2.0 mm Hg sem in the NTG + NIMO groups, respectively. There were no significant differences among groups.

CONCLUSION: In a PA retention paradigm, the injection of NTG immediately after learning produced a significant impairment of long-term associative memory in mice, whereas delayed induced hypotension had no effect. NIMO attenuated the disruption in consolidation of long-term memory caused by NTG but did not improve latency in the absence of hypotension. The observed effect of NIMO may have been attributable to the preservation of calcium homeostasis during hypotension, because there were no differences in the PbtO₂ indices among groups.

METHODS: Patients scheduled for primary nononcologic THA using standardized general anesthesia were randomized. They received IV ketamine before incision (0.5 mg/kg), and a 24-h infusion (2 µg · kg^–1 · min^–1) or a similar blinded saline bolus and infusion. Postoperative analgesia included IV acetaminophen, ketoprofen, plus morphine/droperidol patient-controlled analgesia for 48 h. Data pertaining to pain scores, morphine consumption, and need for crutches were collected for 6 mo after THA. Our primary outcome was 24-h morphine consumption.

RESULTS: One hundred fifty-four patients were included (placebo, 75; ketamine, 79). Patients and operative data were similar in both groups. Ketamine decreased morphine consumption at 24 h from 19 ± 12 mg to 14 ± 13 mg (P = 0.004). At Day 30, ketamine decreased the proportion of patients needing 2 crutches or a walking frame from 56% to 31% (P = 0.0035). From Day 30 to Day 180, ketamine decreased the proportion of patients with persistent pain at rest in the operated hip (P = 0.008). At Day 180, 21% of placebo group patients (15 of 70) experienced pain at rest in the operated hip versus 8% (6 of 72) in the ketamine group (P = 0.036, odds ratio 0.33, 95% confidence interval 0.12–0.91, risk reduction 67%).

CONCLUSIONS: Ketamine had a morphine-sparing effect after THA, even when morphine was combined with multimodal systemic analgesia. It also facilitated rehabilitation at 1 mo and decreased postoperative chronic pain up to 6 mo after surgery.

METHODS: Eligible adults with CDH received either active treatment with IV propofol infusion (n = 20) or active placebo of IV midazolam (n = 20). The main outcome measures were (a) Headache Disability Inventory (HDI) at 30 days posttreatment, (b) Headache Index, a summary measure of headache intensity over the 30-day period, and (c) analgesic consumption measured as the Medication Quantification Scale version III.

RESULTS: Propofol reduced the HDI by 9.47 points (sd 14.1) at 30 days after injection (P = 0.009), but this is a smaller reduction in headache-related disability than that which the developers of the HDI regard as clinically significant. There was no statistically significant change in HDI for the control group. There were no significant within- or between-group reductions in mean pain intensity as measured by the Headache Index or medication use as measured by the Medication Quantification Scale version III in either group.

CONCLUSIONS: A single IV infusion of propofol 2.4 mg/kg produces a statistically significant, but not clinically meaningful, reduction in disability from CDH 30 days after infusion and does not reduce pain intensity or analgesic use. This study does not support this regimen of IV propofol for clinical management of CDH.

METHODS: Thirty patients with chronic nonmalignant pain that failed to respond to multimodal analgesic regimens were evaluated using the McGill Pain Questionnaire before and at 3-, 12-, and 24-mo intervals after implantation of an IT morphine infusion pump. At each clinic visit, the patient’s level of pain was assessed using an 11-point visual analog scale, with 0 = no pain and 10 = worse pain imaginable. The mean initial morphine infusion rate was 0.23 ± 0.14 mg/day (with a range from 0.09 to 0.75 mg/day) and was subsequently adjusted to maintain their pain score at a value <50% of the initial value. Adverse side effects and complications, as well as activity levels, were recorded at each clinic visit.

RESULTS: Both evaluative and affective components of the pain assessment demonstrated a significant improvement over the 24-mo study period. The evaluative component of the McGill Pain Questionnaire improved 66%, the affective component 59%, and the sensory component 32%. The average morphine infusion rate increased to 0.44 ± 0.29, 0.66 ± 0.39, and 0.80 ± 0.45 mg/day at the 3-, 12-, and 24-mo follow-up intervals (P < 0.05). The reduced level of chronic pain leads to improved social, work, and family relationships and quality of life. Among 13 patients of working age, 12 returned to work full time, and among 17 retired patients, 14 had a reduced need for assistance.

CONCLUSIONS: IT infusion of morphine using an implantable pump was helpful in improving psychosocial function in patients with intractable pain that had failed to respond to standard multimodal analgesic therapy.

METHODS: We conducted a randomized, double-blind, prospective, placebo-controlled trial of 28 patients undergoing abdominal or pelvic surgery who required patient-controlled analgesia and an overnight hospital stay. Before anesthetic induction, a transdermal nicotine patch was applied (0, 5, 10, or 15 mg). The primary outcome variable was postoperative pain reported over the first hour and over the next 5 days using a standard numerical rating scale. Secondary outcome variables were pain medication use, hemodynamic values, nausea, and sedation.

RESULTS: Patients treated with nicotine reported higher pain scores than those treated with placebo over the first hour after surgery (P < 0.01, average numerical rating scale increase = 0.67) and there was no difference between groups in the subsequent 5 days (P > 0.05). There was no significant dose effect. Diastolic blood pressure in the first hour was higher in the placebo group compared with the nicotine-treated group (P < 0.01, average increase = 11 mm Hg). There was no difference in nausea or sedation.

CONCLUSIONS: Transdermal nicotine, 5–15 mg, failed to relieve postoperative pain or reduce opioid use in smokers.

METHODS: We tested low doses (0.5–5 mg/kg) of parenteral ketoprofen against pain-related behaviors after plantar incision in rats. To further evaluate the potential sites of action of ketoprofen in our model, a novel, sustained-release microparticle formulation of ketoprofen was placed into the wound, and tested for its effects on pain behaviors. Intrathecal ketoprofen (150 µg) was also studied. Plasma samples were assayed for drug concentrations.

RESULTS: We found that low doses of parenterally administered ketoprofen produced a modality-specific effect on pain behaviors; guarding after incision was decreased, whereas no inhibition of exaggerated responses to heat or mechanical stimuli was evident. Very low doses, 0.5 mg/kg, could produce inhibition of guarding. The locally applied sustained-release ketoprofen-eluting microparticles and intrathecally administered ketoprofen also produced a modality-specific effect on pain behaviors after incision, inhibiting only guarding. Plasma levels of ketoprofen after parenteral or local administration were in the range of therapeutic blood levels in postoperative patients.

CONCLUSIONS: This study demonstrates that ketoprofen is an effective analgesic for nonevoked guarding in rats after plantar incision. There was no effect on mechanical or heat responses, which highlights the importance of multiple-modality testing of pain behaviors for drug evaluation. We found efficacy at doses used clinically in postoperative patients.

METHODS: Male rats were randomly assigned to control, sham-operated, or ligated groups. Four hours after sciatic exposure or ligation, the animals were anesthetized and killed. Dorsal horn ipsilateral and contralateral quadrants were homogenized and centrifuged to obtain a PSD-containing LP1 fraction. Homer1 isoforms were identified in Western immunoblots. In some animals, Homer1 small interfering RNA (siRNA), nontarget siRNA, MK-801, or U01026 was injected intrathecally before surgery to assess the effects of this treatment on the levels of Homer1 isoforms and on 2 signs of injury-associated pain behavior, a shift in weight-bearing distribution and thermal hyperalgesia.

RESULTS: In ligated animals, the protein levels of Homer1a increased and those of Homer1b/c decreased in the ipsilateral LP1 fraction of the spinal dorsal horn. In contrast, no changes were detected in the contralateral LP1 fraction of ligated animals or the ipsilateral or contralateral LP1 fraction of sham-operated animals. Intrathecal injections of Homer1 siRNA, but not nontarget siRNA, 2 h before the ligation prevented the accumulation of Homer1a and loss of Homer1b/c in the ipsilateral LP1 fraction. The same pretreatment with Homer1 siRNA also alleviated both a shift in weight-bearing behavior and thermal hyperalgesia in the ligated animals. Intrathecal injections of MK-801 or U0126 15 min before the ligation similarly prevented the injury-associated changes in Homer1 protein levels and the behavioral signs of pain.

CONCLUSION: The ligation-associated changes in the protein levels of Homer1a and Homer1b/c in the ipsilateral PSD of spinal dorsal horn neurons may be an important early reflection of the injury-associated plasticity that in time leads to the development of persistent pain.

METHODS: During a 1-yr period, 273 consecutive patients requiring single-injection ISB for shoulder or proximal arm surgery were studied. Patients were examined for symptoms compatible with superficial cervical plexus injury before surgery, 24 h postoperatively, and contacted by telephone 31 days after surgery. Symptomatic patients received an additional phone call 6 mo after surgery.

RESULTS: Twenty-four hours after shoulder surgery, 21 patients (7.7%) showed symptoms consistent with superficial cervical plexus neuropathy. Symptoms consisted of hypesthesia in 1–4 cutaneous branches of the cervical plexus. Five patients (1.8%) reported symptoms that lasted for >31 days. All symptoms had entirely resolved after 6 mo.

CONCLUSIONS: Superficial cervical plexus neuropathy is not uncommon after ISB using the modified lateral approach and the possibility should be discussed with patients preprocedurally.

METHODS: The MEDLINE, EMBASE, and Cochrane databases were searched for prospective, randomized studies comparing air versus liquid as the medium for loss of resistance during epidural space identification in adults. Data were abstracted from 5 studies (4 obstetric and 1 nonobstetric) (n = 4422 patients) that met inclusion criteria and analyzed for the following 6 outcomes: difficult catheter insertion, paresthesia, intravascular catheter insertion, accidental dural puncture, postdural puncture headache, and partial block.

RESULTS: The overall risk differences for adverse outcome between the different mediums were not statistically different for the obstetric population. A small, but statistically significant, risk difference for postdural puncture headache was observed when fluid was used during epidural placement for chronic pain management.

CONCLUSION: Larger studies that overcome limitations of heterogeneity across studies and a relatively infrequent occurrence of complications are required to determine the optimal medium for loss of resistance during epidural block.

METHODS: Sixteen volunteers had deep peroneal nerve blocks in each foot. After visualization of the artery and the deep peroneal nerve with an ultrasound, the nerve was stimulated with a nerve stimulator. Evoked motor responses and/or paresthesia were noted before injection of the local anesthetic.

RESULTS: Any evoked motor response (extension of the toes or muscle contractions on the dorsum of the lateral aspect of the foot) or elicitation of paresthesia resulted in complete sensory blockade of the web between the big toe and second toe.

CONCLUSIONS: Visualization of the deep peroneal nerve with ultrasound followed by elicitation of an evoked motor response, or paresthesia, predicts successful blockade of the deep peroneal nerve.

METHODS: We prospectively studied 98 patients undergoing cataract extraction in a rural eye camp in Thailand. Patients undergoing extracapsular cataract extraction with intraocular lens implantation (ECCE/IOL) received deep topical anesthesia with subconjunctival anesthesia. Patients undergoing phacoemulsification with intraocular lens implantation (Phaco/IOL) received topical anesthesia. Pain visual analog score, operative and anesthetic complications, operative time, and additional medications were recorded.

RESULTS: A mean age of 68.7 vs 67.5 yr, an operative time of 16.1 ± 6.7 min vs 12.0 ± 4.7 min, and a median (interquartile range) pain score of 30.5 mm (12.3–54.6 mm) vs 20.0 mm (9.0–45.9 mm) were seen in the ECCE/IOL and Phaco/IOL groups, respectively. Three cases of ruptured posterior capsule occurred in the Phaco/IOL group. No additional anesthesia was needed. No anesthetic complications occurred.

CONCLUSION: In a rural eye camp, deep topical anesthesia with subconjunctival anesthesia for ECCE/IOL and topical anesthesia for Phaco/IOL provide effective anesthesia for cataract surgery.