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.

METHODS: Patients were randomly assigned to receive saline (n = 38) or a modified full-dose regimen of aprotinin (n = 37) IV during OPCAB surgery. Blood sampled perioperatively from the coronary sinus, skin wounds, and systemic circulation was analyzed to test coagulation and platelet function. Major adverse cardiovascular events were monitored by obtaining troponin I at 24 h (myocardial infarction), predischarge computed tomography angiography (vein graft thrombosis), and by clinical examination for stroke.

RESULTS: Coronary sinus blood obtained immediately after OPCAB surgery showed significantly less activation in the aprotinin group, as judged by reduced formation of platelet-leukocyte conjugates (P < 0.02) and platelet-derived microparticles (P < 0.05). The aprotinin group showed inhibition of platelet aggregation induced by thrombin (P = 0.007) but not adenosine diphosphate. Thrombin generation, defined by F1.2 levels, was significantly reduced by aprotinin in the coronary sinus but not in skin wound incisions. Major adverse cardiovascular events were significantly reduced in aprotinin-treated patients (5.4% vs 29.7%, P < 0.05). Aprotinin also demonstrated antifibrinolytic properties through diminished red blood cell transfusion (P < 0.04) and reduced blood loss postoperatively (603 ± 330 vs 810 ± 415 mL, P < 0.004).

CONCLUSION: This study demonstrates that aprotinin protects patients undergoing OPCAB surgery from a hypercoagulable state by diminishing thrombin-induced platelet activation and thrombin generation within saphenous vein grafts, while maintaining systemic hemostatic and antifibrinolytic benefits. These results support further investigation of aprotinin and other PAR-1 antagonists in OPCAB surgery.

METHODS: After surgical instrumentation, we divided male Sprague-Dawley rats into 3 sets. The first set was divided into groups, which received methadone (0.03–3 mg/kg), morphine (0.03–3 mg/kg), or water (placebo) 30 min before ischemia. Some animals of the first set also received the -opioid antagonist naltrindole (5 mg/kg) before methadone (0.3 mg/kg), morphine (0.3 mg/kg), or placebo administration. The second set of animals was divided into groups that received methadone (0.3 mg/kg) 5 min before reperfusion or 10 s after reperfusion. These 2 sets of animals were subjected to 30 min of myocardial ischemia by left anterior descending coronary artery occlusion and then 2 h of reperfusion. The third set of animals received placebo, methadone (0.3 mg/kg), or morphine (0.3 mg/kg) 5 min before reperfusion and were subjected to 45 min of ischemia by left anterior descending coronary artery occlusion with 2 h of reperfusion. Myocardial IS was assessed by staining myocardial tissue with triphenyltetrazolium chloride and expressed as a percentage of the area at risk (mean ± sem).

RESULTS: Methadone or morphine administered before ischemia reduced myocardial IS. The greatest effect was achieved at a dose of 0.3 mg/kg (methadone, 46% ± 1%, P < 0.001 and morphine, 47% ± 1%, P < 0.001 versus placebo, 61% ± 1%, respectively). Naltrindole (5 mg/kg) blocked methadone-induced (0.3 mg/kg) and morphine-induced (0.3 mg/kg) cardioprotection (naltrindole + methadone, 58% ± 1%, P < 0.001 versus methadone; and naltrindole + morphine, 58 ± 1%, P < 0.001 versus morphine). Methadone (0.3 mg/kg) reduced myocardial IS when given 5 min before reperfusion (46% ± 1%, P < 0.001 versus placebo) but not 10 s after reperfusion (60% ± 1%, P = 0.675 versus placebo). No significant myocardial IS differences were seen for placebo when comparing the 45-min ischemia group (64% ± 1%) with the 30-min ischemia group (60% ± 1%, P = 0.069). The longer ischemia time of 45 min abrogated methadone-induced IS reduction (64% ± 2%, P = 0.867 versus 45-min ischemia placebo group) and morphine-induced IS reduction (65% ± 1%, P = 0.836 versus 45-min ischemia placebo group).

CONCLUSIONS: These findings demonstrate that methadone and morphine produce similar myocardial IS-sparing effects that are -opioid receptor mediated and that are dependent on the duration of myocardial ischemia.

METHODS: A detailed cardiac history, resting echocardiography, and hemoglobin and NT-proBNP levels were obtained in 666 patients before vascular surgery. Anemia was defined as serum hemoglobin <13 g/dL for men and <12 g/dL for women. Troponin T measurements and 12-lead electrocardiograms were performed on postoperative days 1, 3, 7, and 30 and whenever clinically indicated. The primary end point of the study was the composite of 30-day postoperative cardiovascular death, nonfatal myocardial infarction, and troponin T release. Receiver operating characteristic curve analysis was used to assess the optimal cutoff value of NT-proBNP for the prediction of the composite end point. Multivariable regression analysis was used to assess the additional value of NT-proBNP for the prediction of postoperative cardiac events in nonanemic and anemic patients.

RESULTS: Anemia was present in 206 patients (31%) before surgery. Hemoglobin level was inversely related with the NT-proBNP levels (β coefficient = –2.242; P = 0.025). The optimal predictive cutoff value of NT-proBNP for predicting the composite cardiovascular outcome was 350 pg/mL. After adjustment for clinical cardiac risk factors, both anemia (odds ratio [OR] 1.53; 95% confidence interval [CI]: 1.07–2.99) and increased levels of NT-proBNP (OR 4.09; 95% CI: 2.19–7.64) remained independent predictors for postoperative cardiac events. However, increased levels of NT-proBNP were not predictive for the risk of adverse cardiac events in the subgroup of anemic patients (OR 2.16; 95% CI: 0.90–5.21).

CONCLUSIONS: Both anemia and NT-proBNP are independently associated with an increased risk for postoperative cardiac events in patients undergoing vascular surgery. NT-proBNP has less predictive value in anemic patients.

METHODS: Children (aged 5–15 yr) who underwent general anesthesia were included, and all perioperative data including anesthetic drugs were collected prospectively. Children were interviewed three times postoperatively using a semistructured questionnaire. All cases of possible or probable awareness were discussed with the child's care providers to confirm or refute the memories. Internal consensus among investigators across sites was reached, and these cases and a random selection of others were reviewed by three external reviewers. For the purpose of this study, possible/probable awareness was defined as cases with agreement between the internal consensus and at least two of the three external reviewers.

RESULTS: One thousand seven hundred eighty-four children completed at least one interview. Thirty-two cases were coded as possible or probable awareness by at least one entity (i.e., either the internal consensus or one of the external reviewers). Fourteen of these cases met the definition for possible/probable awareness, making the incidence of awareness 0.8%. Six of the 14 children with awareness (43%) remembered feeling scared during their surgery and three (21%) reported hurting. Two children in this group (14%) said they would feel worse if they had to have surgery again, which was not significantly different from reports of children with no recall (15%). None of the children with awareness required psychological follow-up. Endoscopic procedures were associated with a higher risk for awareness (relative risk = 4.5 [confidence interval 1.5–13.6]).

CONCLUSIONS: Although 0.8% of children experienced possible/probable awareness in this study, none experienced short-term psychological distress.

Our aim in this exploratory study was to first compare BIS values at 4 different stages of anesthesia between intellectually disabled children and controls. Our second aim was to investigate the discriminative properties of BIS between consciousness and unconsciousness for intellectually disabled children and for controls.

METHODS: Eighteen intellectually disabled children and 35 control children, aged 2–13 yr, were included. BIS values, landmark events, and standard monitoring values of vital functions were recorded throughout the whole procedure. The performance of BIS in distinguishing between a conscious and unconscious state was assessed from receiver operating characteristic curves.

RESULTS: Median (interquartile range) BIS values for the intellectually disabled group were significantly lower than those for controls in the awake state (72 [48–77] vs 97 [84–98], P < 0.001), during stable intraoperative anesthesia (34 [21–45] vs 43 [33–52], P = 0.02), and during return of consciousness (59 [36–68] vs 73 [64–78], P = 0.009). The discriminative properties of the BIS monitor for the state of consciousness were comparable between the 2 groups according to the receiver operating characteristic curves. Nevertheless, the optimal cutoff BIS value for discrimination between conscious and unconscious state was 28 points lower for the intellectually disabled group.

CONCLUSIONS: We advise anesthesiologists to be alert to possible lower BIS values in intellectually disabled children. There is a risk that they will inadvertently misinterpret the state of consciousness in intellectually disabled children. New multicenter studies must find the optimal manner of evaluating (un)consciousness in intellectually disabled patients with documented and confirmed specific etiologies of their intellectual disability.

METHOD: Digital audiovisual recordings of 293 children undergoing outpatient elective surgery were coded using Observer XT software and the validated Revised Perioperative Child-Adult Medical Procedure Interaction Scale. Multiple pass second-by-second data recording was used to capture children’s behaviors across phases of anesthesia induction.

RESULTS: More than 40% of children aged 2–10 yr displayed some distress behavior during induction with 17% of these children displaying significant distress and more than 30% of children resisting anesthesiologists during induction. Children’s distress and nondistress behaviors displayed four profiles over the course of anesthesia induction: Acute Distress, Anticipatory Distress, Early Regulating Behaviors, and Engagement with Procedure. Older children had higher scores on early regulating and engagement profiles whereas younger children had higher scores on Acute Distress. There were no differences across age in children’s Anticipatory Distress. Construct validity of behavior profiles was supported via correlations of profile score (overall and on the walk to the operating room) with a validated assessment of children’s anxiety at induction.

CONCLUSIONS: Children undergoing anesthesia display a range of distress and nondistress behaviors. A group of behaviors was identified that, when displayed on the walk to the operating room, is associated with less distress at anesthesia induction. These data provide the first examination of potentially regulating behaviors of children, but more detailed sequential analysis is required to validate specific functions of these behaviors.

METHODS: We included 95 patients who had suffered from postoperative vomiting (POV) after general anesthesia and 94 control patients. After DNA isolation, the entire HTR3A and HTR3B coding regions, the 5' flanking regions, and exon/intron boundaries were screened for genetic variants. Correlation of identified genetic variants with POV was determined by logistic regression.

RESULTS: We identified 16 different variants in the HTR3A gene and 19 in the HTR3B gene. By using a multivariate logistic regression model that also included classical risk factors, the HTR3A variant c1377A>G was associated with a significantly higher risk (odds ratio [OR] 2.972; 95% confidence interval [CI] 1.466–6.021; P = 0.003) and the HTR3B variants c5+201_+202delCA (OR 0.421; 95% CI 0.257–0.69; P = 0.001) and c6-137C>T (OR 0.034; 95% CI 0.003–0.332; P = 0.004) were associated with a lower risk for POV. However, all significant genetic variants were located in noncoding regions of their gene.

CONCLUSIONS: Genetic variations in the HTR3A and HTR3B gene seem to be associated with the individual risk of developing POV. How strong their influence is within the multifactorial genesis of POV needs to be investigated in additional studies with an appropriate sample size.

METHODS: Two hundred adult patients presenting for elective outpatient colonoscopy were randomized to receive propofol alone or propofol plus midazolam, and/or fentanyl for IV sedation. Baseline cognitive function was measured using the computerized CogState test battery (Cogstate^TM, Melbourne, Australia) before sedation. During the procedure, sedative drug doses, depth of sedation (via the bispectral index and observer’s assessment of alertness/sedation score), complications, and treatability were recorded. Patients were interviewed about recall immediately after emerging from sedation, and cognitive testing was repeated at hospital discharge. Recovery times, quality of recovery, and satisfaction with care were also recorded.

RESULTS: In the propofol plus adjuvants group, 84 patients received fentanyl 50 µg (25–100) (median [range]) and 57 patients received midazolam 2 mg (0.5–10). Patients’ cognitive function at discharge was worse than their performance at baseline. However, the changes in cognitive function between discharge and baseline were not significantly different between the two groups. At discharge, 18.5% of patients were cognitively impaired to an extent equivalent to a blood-alcohol concentration of 0.05%. Sedation with propofol plus midazolam and/or fentanyl produced better operating conditions than sedation with propofol alone and was associated with shorter procedure times. Recovery times, recall, dreaming, quality of recovery, and patient satisfaction with care were similar between the groups. Administration of >2 mg of midazolam was a predictor of impaired cognitive function at discharge.

CONCLUSIONS: Significant cognitive impairment was common at discharge from elective outpatient colonoscopy. However, the addition of midazolam and/or fentanyl to propofol sedation did not result in more cognitive impairment than the use of propofol alone. Furthermore, the use of adjuvants improved the ease of colonoscopy without increasing the rate of complications or prolonging early recovery times..

METHODS: In this double-blind study, 52 healthy women scheduled to undergo tubal sterilization were randomly assigned to receive either intrathecal 10 mg lidocaine 2% plus 10 µg fentanyl (Group I) or intrathecal 3 mg levobupivacaine 0.5% plus 10 µg fentanyl (Group II), each solution made to a total volume of 3 mL with sterile water. The following variables were monitored intraoperatively: anesthesia onset time, need for anesthesia-analgesia supplementation, depth of sedation, surgical conditions, and occurrence of hemodynamic events. After surgery, motor block, proprioception, vibration sense, light touch, and Romberg’s test were performed to evaluate whether the patients could bypass the postanesthesia care unit and be allowed to walk by themselves. Sensory block level was determined at 5, 10, and 15 min after anesthetic injection, and then every 15 min until resolution was complete. A difference of 25 min in sensory block resolution time was considered clinically relevant.

RESULTS: Onset time and intraoperative conditions were comparable in both groups. No patient required general anesthesia to complete surgery. All patients from both groups bypassed the postanesthesia care unit. Ambulation took place after 27 (18–45) min in Group I and 30 (18–56) min in Group II (P = 0.24). Complete regression of spinal anesthesia occurred after 93 (65–120) min in Group I and 105 (78–150) min in Group II (P = 0.019); however, no differences were observed in time for home discharge 185 (150–300) min in Group I and 188 (125–300) min in Group II (P = 0.62). Global patient satisfaction was comparable between both groups.

CONCLUSIONS: Levobupivacaine 3 mg plus 10 µg fentanyl may be used as a suitable alternative to 10 mg lidocaine plus 10 µg fentanyl for spinal anesthesia of short duration. It achieved a clinically equivalent time for resolution of sensory block, similar intraoperative conditions, and comparable patient satisfaction..

METHODS: Sixty-five female patients (ASA physical status I–II) scheduled for transabdominal hysterectomy were recruited to this randomized, placebo-controlled study. Thirty-two patients in the treatment group received IV lidocaine starting 20 min before surgery, whereas the control group (33 patients) received a matched saline infusion. Both groups received patient-controlled epidural analgesia during the postoperative period. Blood samples were collected before, 24, 48, and 72 h after surgery to measure ex vivo cytokine production of interleukin (IL)-1 receptor antagonist (IL-1ra) and IL-6, as well lymphocyte mitogenic response to phytohemagglutinin-M. A 10-cm visual analog scale was used to assess pain intensity at rest and after coughing.

RESULTS: Patients in the lidocaine + patient-controlled epidural analgesia group experienced less severe postoperative pain in the first 4 and 8 h after surgery (visual analog scale 4/3.7 at rest and 5.3/5 during coughing versus 4.5/4.2 and 6.1/5.3, respectively, in the placebo group). There was significantly less ex vivo production of IL-1ra and IL-6, whereas the lymphocyte proliferation response to phytohemagglutinin-M was better maintained than in the control group.

CONCLUSION: The present findings indicate that preoperative and intraoperative IV lidocaine improves immediate postoperative pain management and reduces surgery-induced immune alterations.

METHODS: Data from 45 patients scheduled for a radical prostatectomy were analyzed. After lumbar epidural catheterization, patients received remifentanil and propofol solely for induction of anesthesia. Thereafter, epidural analgesia was initiated, and isoflurane, sevoflurane, or desflurane (15 patients each) was added to maintain unconsciousness. At least 45 min later, end-tidal concentrations were varied between 0.5 and 2 minimum alveolar anesthetic concentration. We estimated an individual k_e0 value for each patient by optimizing the prediction probability P_K (P_K-based k_e0) or by minimizing the area within the hysteresis loop (area-based k_e0). Data are mean ± sd.

RESULTS: Both semiparametric approaches led to comparable k_e0 values with 0.18 ± 0.06 min^–1 (P_K based) and 0.15 ± 0.04 min^–1 (area based) for isoflurane and 0.17 ± 0.08 min^–1 (P_K based) and 0.16 ± 0.11 min^–1 (area based) for sevoflurane. k_e0 values for desflurane (P_K based: 0.30 ± 0.17min^–1; area based: 0.32 ± 0.25 min^–1) were significantly higher than for isoflurane and sevoflurane.

CONCLUSION: Maximizing the prediction probability P_K for estimating k_e0 seems to be a promising method that researchers could use on an exploratory basis.

METHODS: We first examined changes in blood glucose levels in rats undergoing sigmoid colostomy under sevoflurane, sevoflurane/buprenorphine, propofol, and propofol/buprenorphine anesthesia. We then examined changes in blood glucose levels after glucose administration using awake rats, rats under sevoflurane anesthesia, and rats under propofol anesthesia.

RESULTS: Blood glucose levels increased markedly after sigmoid colostomy under sevoflurane anesthesia; the marked increases could not be prevented by the coadministration of buprenorphine. Under propofol anesthesia, blood glucose levels did not change after sigmoid colostomy at the highest dose, but increased slightly at the lowest and intermediate doses; the slight increases were completely prevented by the coadministration of buprenorphine. Whereas changes in blood glucose levels after glucose administration in rats under sevoflurane anesthesia were significantly greater than those in awake rats, the changes in rats under propofol anesthesia were similar to those in awake rats.

CONCLUSIONS: During surgery, hyperglycemia was observed under sevoflurane and sevoflurane/buprenorphine anesthesia, but blood glucose levels were relatively stable under propofol and propofol/buprenorphine anesthesia. Whereas sevoflurane exaggerates glucose intolerance, propofol has no significant effects on glucose tolerance. We speculate that this feature of propofol contributes, at least in part, to the stable glucose metabolism during surgery observed in this study. The results of this study confirm the marked difference in the effects of sevoflurane and propofol on glucose metabolism.

METHODS: A reversible ATP depletion (antimycin A) followed by restoration of substrate supply in LLC-PK1 cells was used as an in vitro model of renal I-R. Cell viability was assessed by dimethylthiazol-diphenyltetrazol bromide and trypan blue dye exclusion test assays. Apoptosis was evaluated by annexin V–fluorescein isothiocyanate staining by flow cytometry and immunofluorescence. Propofol treatments were initiated at various time intervals: 1 or 24 h before ischemia, only during ischemia, or only during reperfusion. To evaluate the mechanisms of propofol protection, specific K_ATP channel inhibitors or activators were used in some experiments during propofol pretreatment.

RESULTS: Propofol attenuated I-R injury on LLC-PK1 cells when present either 1 or 24 h before initiated I-R, and also during the recovery period, but not when added only during ischemia. Propofol pretreatment significantly protected LLC-PK1 from I-R-induced apoptosis. The protective effect of propofol was prevented by glibenclamide (a sarcolemmal ATP-dependent K⁺ channel blocker) and decreased by 5-hydroxidecanoic acid (a mitochondrial ATP-dependent K⁺ channel blocker), but it was not modified by diazoxide (a selective opener of ATP-sensitive K⁺ channel).

CONCLUSION: Propofol protected cells against apoptosis induced by I-R. This protection was probably due to a preconditioning effect of propofol and was, at least in part, mediated by K_ATP channels.

METHODS: Neocortical astrocytes were exposed to OGD in an anaerobic chamber. After 6 h of OGD exposure, astrocytes were subsequently subjected to 24 h of reoxygenation. Propofol was added during the OGD phase of the model. Cell morphology was assessed by light microscopy. Astrocyte viability was assessed by measuring 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide absorbency (optical density value) and the percentage of lactate dehydrogenase released by injured astrocytes. AQP4 expression was evaluated with Western blot analysis. To investigate the possible mechanism of propofol’s effects on AQP4 expression, cultured astrocytes were pretreated for 24 h with the PKC activator, 12-O-tetradecanoylphorbol 13-acetate, before the propofol treatment/OGD 6 h/reoxygenation 24 h.

RESULTS: We found by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide testing that astrocyte viability began to decrease after about 4 h of OGD exposure and decreased to 60% after 6 h of OGD. When 6 h of OGD was followed by 24 h of reoxygenation, cell viability was further decreased. AQP4 expression was attenuated after 6 h of OGD exposure but was reversed and exceeded baseline levels after 24 h of reoxygenation. Propofol dose-dependently reduced cell death assessed by lactate dehydrogenase test (P < 0.05), and 10 µM propofol significantly down-regulated AQP4 expression in astrocytes after 6 h of OGD followed by 24 h of reoxygenation (P < 0.01). Prolonged (24 h) pretreatment with the phorbol ester, 12-O-tetradecanoylphorbol 13-acetate before OGD significantly reversed the effect of propofol on AQP4 expression (P < 0.01).

CONCLUSION: Propofol, administered during OGD, provided neuroprotective effects and down-regulated AQP4 expression in the OGD/reoxygenation model of cultured rat astrocytes. Activation of the PKC pathway may block the effects of propofol.

METHODS: We anesthetized homozygous G_i2 GS/GS and wild-type (WT) mice with isoflurane and quantified time (in seconds) to loss and resumption of righting response. During recovery from isoflurane anesthesia, breathing was quantified in a plethysmography chamber for both lines of mice.

RESULTS: G_i2 GS/GS mice required significantly less time for loss of righting and significantly more time for resumption of righting than WT mice. During recovery from isoflurane anesthesia, G_i2 GS/GS mice exhibited significantly greater respiratory depression. Poincaré analyses show that GS/GS mice have diminished respiratory variability compared with WT mice.

CONCLUSION: Modulation of G_i2 signaling by RGS proteins alters loss and resumption of wakefulness and state-dependent changes in breathing.

METHODS: Rat EAAT3 was expressed in Xenopus oocytes. l-glutamate- and l-cysteine-induced membrane currents were recorded using the 2-electrode voltage clamp technique. The peak current was quantified to reflect the amount of transported substrates because transport of substrates via EAATs is electrogenic.

RESULTS: Exposure of oocytes to 5 mM tert-butyl hydroperoxide, an organic oxidant, for 10 min reduced the V_max, but did not affect the K_m, of EAAT3 for l-cysteine. The volatile anesthetics isoflurane, sevoflurane, and desflurane at concentrations from 1% to 3% attenuated the tert-butyl hydroperoxide-reduced EAAT3 activity for l-glutamate and l-cysteine.

CONCLUSIONS: Our results suggest that volatile anesthetics preserve EAAT3 function to transport l-glutamate and l-cysteine under oxidative stress, which may be a mechanism for the neuroprotective effects of volatile anesthetics.

METHODS: We randomly allocated 66 adult obese patients with a body mass index between 30 and 50 kg/m² scheduled to undergo laparoscopic bariatric surgery into 3 groups. According to the recruitment maneuver used, the zero end-expiratory pressure (ZEEP) group (n = 22) received the vital capacity maneuver (VCM) maintained for 7–8 s applied immediately after intubation plus ZEEP; the positive end-expiratory pressure (PEEP) 5 group (n = 22) received the VCM maintained for 7–8 s applied immediately after intubation plus 5 cm H₂O of PEEP; and the PEEP 10 group (n = 22) received the VCM maintained for 7–8 s applied immediately after intubation plus 10 cm H₂O of PEEP. All other variables (e.g., anesthetic and surgical techniques) were the same for all patients. Heart rate, noninvasive mean arterial blood pressure, arterial oxygen saturation, and alveolar-arterial Pao₂ gradient (A-a Pao₂) were measured intraoperatively and postoperatively in the postanesthesia care unit (PACU). Length of stay in the PACU and the use of a nonrebreathing O₂ mask (100% Fio₂) or reintubation were also recorded. A computed tomographic scan of the chest was performed preoperatively and postoperatively after discharge from the PACU to evaluate lung atelectasis.

RESULTS: Patients in the PEEP 10 group had better oxygenation both intraoperatively and postoperatively in the PACU, lower atelectasis score on chest computed tomographic scan, and less postoperative pulmonary complications than the ZEEP and PEEP 5 groups. There was no evidence of barotrauma in any patient in the 3 study groups.

CONCLUSIONS: Intraoperative alveolar recruitment with a VCM followed by PEEP 10 cm H₂O is effective at preventing lung atelectasis and is associated with better oxygenation, shorter PACU stay, and fewer pulmonary complications in the postoperative period in obese patients undergoing laparoscopic bariatric surgery.

METHODS: In this prospective observational study conducted in a biochemistry laboratory, we analyzed 179 routine blood samples from consecutive patients over a 3-mo period using two automated blood chemistry analyzers, the LX20 (Beckman) and the Modular (Roche). Measured and calculated parameters from the two analyzers were compared.

RESULTS: Although the correlation between measured values was satisfactory, there were large differences in the limits of agreement for calculated values (SID_app: 9.6 mEq/L, SID_eff: 6.4 mEq/L, and SIG: 11.7 mEq/L) and a weak correlation (SID_app: r² = 0.54 and SIG: r² = 0.12) between the analyzers.

CONCLUSIONS: The results of the Stewart-Fencl approach for interpretation of acid-base status can vary according to the analyzer used. These differences may have important clinical and research implications..

METHODS: A syringe pump infused a saline carrier solution at a low flow rate frequently used in an intensive care unit (10 mL/h) through a multiport manifold connected to the 16-gauge lumen of a standard 16-cm triple-lumen catheter. The model drug methylene blue (3 mL/h) joined the carrier flow at the first, second, or fourth stopcock of a traditional manifold or 1 of 2 positions in a microinfusion manifold, a new device designed to minimize dead volume. Effluent samples were collected every minute for quantitative spectrophotometric analysis of delivery onset and offset.

RESULTS: Onset and offset times differed significantly among individual ports of the traditional 4-stopcock manifold. There was also a significant difference between the 2 ports of the microinfusion manifold, but this was less pronounced. Both ports of the microinfusion manifold yielded delivery dynamics that were similar to the most downstream port of the 4-stopcock manifold. There was good correlation between dynamic data and dead volume for each of the manifolds.

CONCLUSIONS: Using a traditional stopcock manifold, port selection significantly affects drug delivery dynamics for continuous infusions. The findings provide quantitative support for the concept that the most critical infusion should join the system at the manifold port closest to the patient. Port selection was less important for the microinfusion manifold and dynamics were faster compared with the second and fourth ports of the stopcock manifold. The smaller dead volumes of the microinfusion manifold minimize unwanted delays in drug delivery onset and offset allowing more precise control over drug delivery by continuous infusion.

METHODS: More than 5.6 million patients in the Nationwide Inpatient Sample who underwent principal procedures of knee arthroplasty, cholecystectomy, hip/femur surgical treatment, spinal fusion, appendectomy, colorectal resection, laminectomy without fusion, coronary artery bypass grafting, and cardiac valve procedures from 1996 to 2005 were included. Rates of POVL, defined as any discharge with an International Classification of Diseases, Ninth Revision, Clinical Modification code of ischemic optic neuropathy (ION), cortical blindness (CB), or retinal vascular occlusion (RVO), were estimated. Potential risk factors were assessed by univariate and multivariable analyses.

RESULTS: Cardiac and spinal fusion surgery had the highest rates of POVL. The national estimate in cardiac surgery was 8.64/10,000 and 3.09/10,000 in spinal fusion. By contrast, POVL after appendectomy was 0.12/10,000. Those undergoing cardiac surgery, spinal fusion, and orthopedic surgery had a significantly increased risk of developing ION, RVO, or CB. Patients younger than 18 yr had the highest risk for POVL, because of higher risk for CB, whereas those older than 50 yr were at greater risk of developing ION and RVO. Other significant positive predictors for some diagnoses of POVL were male gender, Charlson comorbidity index, anemia, and blood transfusion. There was no increased risk associated with hospital surgical volume. During the 10 yr from 1996 to 2005, there was an overall decrease in POVL in the procedures we studied.

CONCLUSIONS: The results confirm the clinical suspicion that the risk of POVL is higher in cardiac and spine fusion surgery and show for the first time a higher risk of this complication in patients undergoing lower extremity joint replacement surgery. The prevalence of POVL in the eight most commonly performed surgical operations in the United States has decreased between 1996 and 2005. Increased odds of POVL with male gender and comorbidity index indicate that some risk factors for POVL may not presently be modifiable. The conclusions of this study are limited by factors affecting data accuracy, such as lack of data on the intraoperative course and inability to confirm the diagnostic coding of any of the discharges in the database.

METHODS: Twenty-four nonsedated adult volunteers underwent neck magnetic resonance imaging with and without CP. Measurements were made of the postcricoid hypopharynx, airway compression, and lateral displacement of the cricoid ring during the application of CP. The relevant anatomy was reviewed.

RESULTS: The hypopharynx, not the esophagus, is what lies behind the cricoid ring and is compressed by CP. The distal hypopharynx, the portion of the alimentary canal at the cricoid level, was fixed with respect to the cricoid ring and not mobile. With CP, the mean anterioposterior diameter of the hypopharynx was reduced by 35% and the lumen likely obliterated, and this compression was maintained even when the cricoid ring was lateral to the vertebral body.

CONCLUSIONS: The location and movement of the esophagus is irrelevant to the efficiency of the Sellick’s maneuver (CP) in regard to prevention of gastric regurgitation into the pharynx. The hypopharynx and cricoid ring move together as an anatomic unit. This relationship is essential to the efficacy and reliability of Sellick’s maneuver. The magnetic resonance images show that compression of the alimentary tract occurs with midline and lateral displacement of the cricoid cartilage relative to the underlying vertebral body.

METHODS: In this prospective, observational study, we interviewed 600 patients during the preoperative visit in a tertiary referral educational hospital in northwest Iran. The definition of substance abuse and dependence was according to DSM-IV criteria. Postoperative complications and in-hospital mortality of patients with substance (cigarette, opium, and alcohol) dependence and abuse were compared with those in control patients who did not use these substances.

RESULTS: In 600 studied patients, the prevalence of cigarette smoking was 42.1% (ex-smokers 26.0% and current smokers 16.1%), prevalence of opium use was 12.0% (opium abuse 7.0% and opium dependence 5.0%), and alcohol consumption was 8.1% (alcohol abuse 7.4% and alcohol dependence 0.7%). The prevalence of cigarette smoking was 58.9% in men and 7.6% in women (P = 0.001). Postoperative cardiac complications in current smokers (21.5%) and ex-smokers (20.5%) were not significantly different from the control group (28.2%). Also, pulmonary complications were not different in current smokers (24.7%) and ex-smokers (17.9%) from the control group (26.8%; P = 0.196). However, in men, pulmonary complications in current smokers were more prevalent than in the control group (P = 0.044). In opium and alcohol dependents and abusers, postoperative complications were not statistically different from the control group (all P values >0.05). No increase was observed regarding in-hospital mortality in patients with substance use.

CONCLUSIONS: In cardiac surgery patients in northwest Iran, the prevalence of cigarette smoking is relatively low (very low in women), as is alcohol use, compared with Western countries; however, opium use is twice as prevalent. We found higher pulmonary complication rates in men who smoked, but no increase in postoperative cardiopulmonary complications and in-hospital mortality rates in patients who abused opium and consumed alcohol.

METHODS: One hundred fifty consecutive adult morbidly obese patients (body mass index >35 kg/m²) were randomly selected to receive one of 3 VLSs: GlideScope®, Storz® V-Mac^TM, and McGrath®. Direct laryngoscopy scored the best possible view of the glottis; subsequently, the respective VLS was used, and the patient's trachea was intubated. Common preprocedural (e.g., Mallampati grade) and intraprocedural (Cormack-Lehane grade) metrics of intubation difficulty were measured, as well as the dependent variables of intubation time, number of attempts, and subjective difficulty.

RESULTS: All 3 VLSs tested offered an equal or better view of the glottis compared with traditional direct laryngoscopy. The number of attempts necessary to intubate the trachea differed significantly among VLSs (average 2.6 ± 1.0 attempts for the GlideScope, 1.4 ± 0.7 for the Storz, and 2.9 ± 0.9 for the McGrath VLS). The average intubation times were 33 ± 18 s for the GlideScope, 17 ± 9 s for the Storz, and 41 ± 25 s for the McGrath VLS.

CONCLUSIONS: In this study, the VLS with the Macintosh blade (Storz VLS) had a better overall satisfaction score, intubation time, number of intubation attempts, and necessity of extra adjuncts, compared with the 2 other tested devices.

METHODS: In 16 anesthetized pigs (31.4 ± 3.4 kg), a jugular vein, a carotid artery, the pulmonary artery (thermodilution), the portal vein, and a hepatic vein were cannulated for hemodynamic monitoring and blood sampling. Ultrasonic flowprobes were placed around the portal vein, the hepatic artery, and the superior mesenteric artery (SMA). In addition to 30 mL/kg of dextran 70 given before baseline, all animals received 10 mL · kg^–1 · h^–1 of IV fluids throughout the experiment. An endotoxin infusion (2 µg · kg^–1 · h^–1) was given for 300 min; 100 min after the start of endotoxin, the pigs were randomized to receive levosimendan (50 µg · kg^–1 · h^–1, n = 8) or placebo (n = 8). To evaluate the isolated effects of endotoxemia, all data before randomization were pooled into one group. Data were analyzed by analysis of variance and presented as mean ± sem.

RESULTS: Endotoxemia (t = 90 min, pooled data) decreased systemic vascular resistance (SVR, 2526 ± 203 to 1946 ± 122 dyn · s · cm^–5, P = 0.003) and mean arterial blood pressure (MAP, 109 ± 6 to 84 ± 3 mm Hg, P < 0.05), whereas heart rate (66 ± 4 to 98 ± 8 bpm), and mean pulmonary arterial pressure (MPAP, 20 ± 1 to 38 ± 2 mm Hg) increased (P < 0.001). Cardiac output (CO, 3.4 ± 0.2 L/min) and systemic oxygen delivery (414 ± 33 mL/min) were unchanged, but blood flows in the SMA (575 ± 34 to 392 ± 38 mL/min) and the portal vein (881 ± 62 to 568 ± 39 mL/min) decreased (P < 0.001). Although hepatic arterial blood flows increased (36 ± 8 to 219 ± 38 mL/min), gut (114 ± 11 to 84 ± 7 mL/min) and hepatic (94 ± 11 to 67 ± 8 mL/min) oxygen deliveries decreased (P < 0.05). At t = 300 min, the levosimendan group showed lower MPAP (39 ± 3 vs 49 ± 2 mm Hg, P = 0.025), lower SVR (2158 ± 186 vs 3069 ± 370 dyn · s · cm^–5, P = 0.052), and lower MAP (55 ± 9 vs 87 ± 9 mm Hg, P < 0.001) than the control group. In both groups, CO, portal vein, and hepatic arterial blood flows decreased (P < 0.001); the mean values for the levosimendan group at t = 300 min were 2.0 ± 0.4 L/min, 390 ± 83 mL/min, and 36 ± 12 mL/min, respectively. SMA blood flow decreased only in the levosimendan group (432 ± 40 to 320 ± 78 mL/min, P < 0.001), whereas gut oxygen delivery decreased in the levosimendan (85 ± 12 to 63 ± 12 mL/min, P < 0.001) and in the control (83 ± 6 to 59 ± 3 mL/min, P = 0.03) groups.

CONCLUSION: Levosimendan administered after the establishment of endotoxemic shock to pigs receiving moderate fluid resuscitation prevented further increases in MPAP and maintained a low SVR. There were, however, no improvements in CO, MAP decreased, and levosimendan neither prevented the development of circulatory shock nor improved hepatosplanchnic perfusion.

METHODS: Twenty anesthetized pigs (26.8 ± 0.5 kg) were instrumented with flow probes and catheters to monitor systemic and regional perfusion as described in our companion article in this issue of the journal. Two animals were excluded because of surgical complications. Oxygen consumption (VO₂) was measured by indirect calorimetry. Starting 1 h after instrumentation, an endotoxin infusion (Escherichia coli lipopolysaccharide, 2 µg · kg^–1 · h^–1) was administered for 300 min. Sixty minutes after the start of endotoxin, the animals were fluid resuscitated (20 mL/kg dextran 70); at 120 min, they were randomized into three groups of six animals each: levosimendan (25–50 µg · kg^–1 · h^–1), dobutamine (10–20 µg · kg^–1 · min^–1), and control. In the first two groups, norepinephrine (0.5–2 µg · kg^–1 · min^–1) was added when mean arterial blood pressure (MAP) ≤ 65 mm Hg. Crystalloids were given to maintain filling pressures ≥ baseline. The data were divided into two subsets: before (0–120 min, all animals) and after (120–300 min, three groups) randomization, and analyzed by analysis of variance. P < 0.05 was considered significant.

RESULTS: At 120 min, cardiac output was 15% higher (P < 0.001), systemic vascular resistance was 30% lower (P < 0.001), and MAP decreased 12.5% (P = 0.004); blood flow in the hepatic artery, superior mesenteric artery, and portal vein had increased by 100% (P = 0.004), 60% (P < 0.001), and 20% (P < 0.001), respectively. Between 120 and 300 min, cardiac output and systemic oxygen delivery decreased 50% in control animals (P < 0.05), remained unchanged in the levosimendan group, and increased 60% with dobutamine (P = 0.05). MAP (P = 0.043) and VO₂ (P = 0.001) decreased 20% in the control group. Portal vein flow decreased in the control (50%) and levosimendan (30%) groups (P < 0.001) and was therefore higher in the dobutamine group (P = 0.003) at 300 min. Hepatic and gut oxygen deliveries decreased in the levosimendan (50%, and 30%, respectively, P < 0.001) and control groups (70% and 45%, respectively, P < 0.05); thus, regional oxygen deliveries were greater in the dobutamine group (P < 0.05). In this group, mixed venous and hepatic vein oxygen saturation were maintained; the latter variable was higher than in the other groups (P < 0.05). Although unchanged with dobutamine, arterial (P = 0.020), portal (P = 0.020), and hepatic vein (P = 0.034) lactate concentrations increased twofold with levosimendan.

CONCLUSION: In volume-resuscitated endotoxemic pigs, the association of either levosimendan or dobutamine with norepinephrine preserved systemic blood flow, oxygen delivery, and VO₂. However, only dobutamine-norepinephrine maintained portal blood flow, which was associated with preservation of splanchnic and hepatic oxygen homeostasis and stable lactate concentrations.

METHODS: We performed a prospective observational cohort study in a 21-bed polyvalent intensive care unit in a university hospital.

RESULTS: Three hundred sixty-one intubated adult patients with a duration of mechanical ventilation (MV) of 6 days or more were admitted over a 28-mo period. Late-onset VAP was confirmed in 76 patients (21%) by the presence of at least one microorganism at a concentration ≥10⁴ colony-forming units/mL on the bronchoalveolar lavage. Gram-negative bacilli represented 75% and Staphylococcus aureus 21% of recovered organisms. Factors independently associated with late-onset VAP by multivariate analysis included a high simplified acute physiology score II score (odds ratio: 1.021; 95% confidence interval [CI]: 1.005–1.038; P = 0.01), development of acute respiratory distress syndrome during the first 5 days of MV (odds ratio: 1.98; 95% CI: 1.05–3.67; P = 0.04), and size of the endotracheal tube ≥7.5 (odds ratio: 2.06; 95% CI: 1.88–3.90; P = 0.03). EN started within 48 h of MV onset was not associated with a higher risk for late-onset VAP.

CONCLUSION: In our nontrauma patient population, early EN was not associated with development of late-onset VAP. In this population, severity of the disease during the first 5 days of MV seemed to be associated with late-onset VAP. In addition, our results suggest that the risk of late-onset VAP is higher in patients with a tube size ≥7.5 than in patients with a tube size <7.5.

METHODS: Male Sprague-Dawley rats weighing 250-300 g were randomly assigned to 1 of 4 groups: sham rats (injected intraperitoneally [IP] with saline) pretreated with vehicle (100% O₂) (sham-vehicle); sham rats pretreated with isoflurane (sham-ISO); LPS rats (injected IP with LPS) pretreated with vehicle (vehicle-LPS); and LPS rats pretreated with isoflurane (ISO-LPS). Endotoxemia was induced by IP injection of LPS. Isoflurane 1.4% was administered 30 min before LPS injection. The animals were then observed for 6 h. We monitored arterial blood pressure, heart rate, and blood gas. The extent of ALI was evaluated by lung wet/dry ratio, Evans blue dye extravasation, and histologic examination. We also measured pulmonary nitric oxide (NO), tumor necrosis factor (TNF)-, interleukin (IL)-1β, and IL-6 levels. In addition, survival statistics and pulmonary inducible NO synthase (iNOS) gene expression were also determined.

RESULTS: LPS caused systemic hypotension and severe ALI, as evidenced by the increases in the extent of ALI, impairment of pulmonary functions, and increases in pulmonary NO, TNF-, IL-1β, and IL-6. Isoflurane preconditioning mitigated systemic hypotension and the development of ALI. Isoflurane preconditioning also attenuated the LPS-induced increases in pulmonary nitrate/nitrite and proinflammatory cytokine release and improved survival of rats with severe sepsis. The expression of iNOS was upregulated by LPS and reduced by isoflurane pretreatment.

CONCLUSIONS: Isoflurane preconditioning can attenuate pulmonary proinflammatory cytokine release and decrease the mortality induced by severe sepsis. Early protection seems to be mediated partly through inhibition of iNOS-NO pathway activation.

METHODS: Sixty women presenting for elective cesarean delivery were randomly assigned to one of the 3 groups. Group 7 received intrathecal hyperbaric bupivacaine 7 mg, Group 8 received 8 mg, and Group 9 received 9 mg. Women in all 3 groups received intrathecal morphine 100 µg and IV hydroxyethyl starch 15 mL/kg at the time of initiation of combined spinal-epidural anesthesia. Surgery began when a sensory level of T4 was achieved. Patients were monitored for block characteristics and side effects by a blinded observer. Our primary outcome was the maximum cephalad sensory block height.

RESULTS: There was a difference in the maximum extent of cephalad sensory block among groups (Group 7: median T2 [interquartile range T2–T3]; Group 8: median T2 [T1–T2]; Group 9: median T1 [C8–T2]; P = 0.02). However, the time taken to reach T4 was similar in all 3 groups. The incidence of hypotension requiring vasopressors was different among groups (30% in Group 7, 55% in Group 8, and 70% in Group 9; P = 0.04). No patient had inadequate anesthesia. Neonatal outcomes were similar in all 3 groups.

CONCLUSION: The lowest dose of hyperbaric bupivacaine (7 mg) provided equally rapid onset and effective anesthesia for cesarean delivery while reducing the incidence of hypotension compared with 8 and 9 mg. However, because of its shorter duration of anesthesia, it may be feasible only when the block can be reinforced using a functional epidural catheter.

METHODS: Two hundred eight parturients who developed moderate to severe pruritus after the administration of intrathecal morphine were randomly allocated to 2 groups: IV pentazocine 15 mg (n = 104) and IV ondansetron 4 mg (n = 104). The successful treatment of pruritus (no or mild pruritus) and other adverse effects were determined 15 min after study drug administration, and patients were observed for recurrence of pruritus for 4 h.

RESULTS: The treatment success rate at 15 min was higher in the pentazocine group (96.1%) than in the ondansetron group (80.8%) (95% confidence interval of difference: 7.0%, 23.8%; P = 0.001). The recurrence rate of moderate to severe pruritus within 4 h after treatment in the pentazocine group (12.0%) was lower than in the ondansetron group (32.1%) (P = 0.001). There were no significant differences between groups in nausea/vomiting, sedation, shivering, pain scores, and pain at injection site. No respiratory depression was observed.

CONCLUSIONS: Pentazocine 15 mg is superior to ondansetron 4 mg for the treatment of intrathecal morphine-induced pruritus and has a lower recurrence rate. The side effects after treatment are mild.

METHODS: The setting is the preanesthesia evaluation clinic (PAC) of a university hospital, where patients consult several medical professionals, either by walk-in or appointment. Queuing theory was used to model the initial set-up of the clinic, and later to model possible alternative designs. With the queuing model, possible improvements in efficiency could be investigated. Inputs to the model were patient arrival rates and expected service times with clinic employees, collected from the clinic's logging system and by observation. The performance measures calculated with the model were patient length of stay and employee utilization rate. Supported by the model outcomes, a working group consisting of representatives of all clinic employees decided whether the initial design should be maintained or an intervention was needed.

RESULTS: The queuing model predicted that 3 of the proposed alternatives would result in better performance. Key points in the intervention were the rescheduling of appointments and the reallocation of tasks. The intervention resulted in a shortening of the time the anesthesiologist needed to decide upon approving the patient for surgery. Patient arrivals increased sharply over 1 yr by more than 16%; however, patient length of stay at the clinic remained essentially unchanged. If the initial set-up of the clinic would have been maintained, the patient length of stay would have increased dramatically.

CONCLUSIONS: Queuing theory provides robust methods to evaluate alternative designs for the organization of PACs. In this article, we show that queuing modeling is an adequate approach for redesigning processes in PACs.

METHODS: Three hundred forty-seven fasting patients had a preoperative glucose measurement determined from blood residue left on the IV needle, measured with an Accu-Chek glucometer (Roche Diagnostics, Indianapolis, IN).

RESULTS: After excluding patients with a diabetes history, 4.0% had a glucose measurement between 100 and 125 mg/dL, at a cost of $14.22 per identification, and 1.2% had a glucose measurement more than 125 mg/dL, at a cost of $32.00 per identification.

CONCLUSIONS: This preoperative blood glucose screening test was implemented at a cost of approximately one-tenth of current methods.

METHODS: Eighty patients undergoing craniotomy for supratentorial tumor resection were randomly assigned into two groups. Patients in Group G (n = 40) received oral gabapentin (3 x 400 mg), and patients in Group P (n = 40) received oral phenytoin (3 x 100 mg) for 7 days before the operation and postoperatively. An identical anesthesia protocol was performed for both the groups. Anesthesia was maintained with propofol and remifentanil infusion. Patient-controlled analgesia with morphine was used, and pain levels were measured. The antiepileptic-related side effects, anesthetic consumption, duration of anesthesia and surgery, tracheal extubation time, postoperative pain scores, morphine consumption, and sedation scores were recorded.

RESULTS: Thirty-seven patients in Group G and 38 patients in Group P completed the study. During the preoperative period in Group G, one patient had severe fatigue, one had severe dizziness, and one patient’s surgical procedure was changed. The median plasma levels of gabapentin were 34 µmol/mL (range, 23-51 µmol/mL) in 34 patients. In Group P, one patient withdrew from the study preoperatively and one developed transient neurological symptoms postoperatively.

The demographic data and mean duration of anesthesia and surgery were similar in both the groups. The total propofol and remifentanil consumption in Group G (1847 ± 548 mg/3034 ± 1334 µg) was significantly less than that of Group P (2293 ± 580 mg/4287 ± 1282 µg) (P = 0.01). However, tracheal extubation could be done earlier in Group P (4.5 ± 2 min) than in Group G (16.6 ± 22 min) (P < 0.001). Pain scores were significantly higher in Group P at 15 min, 30 min, and 1 h (P < 0.001). The total morphine consumption was also significantly higher in Group P (33 ± 17 mg vs 24 ± 19 mg) (P = 0.01). The postoperative sedation scores were significantly higher in Group G at 15 min, 30 min, 1 h, and 2 h (P < 0.001).

CONCLUSIONS: The administration of gabapentin to patients undergoing craniotomy for supratentorial tumor resection was effective for acute postoperative pain. It also decreased analgesic consumption after surgery. However, it may lead to side effects such as delayed tracheal extubation and increased sedation postoperatively.

METHODS: Seventy male sevoflurane-anesthetized Sprague Dawley rats were randomly assigned to the following treatment groups: normothermic ischemia, intraischemic hypothermia, and postischemic hypothermia with corresponding sham-operated controls. Fifteen naïve rats were investigated as reference for natural neurogenesis. Forebrain ischemia was induced by bilateral common carotid artery occlusion and hemorrhagic hypotension. In normothermic groups, the pericranial temperature was maintained at 37.5°C. Animals in the hypothermic groups were cooled to a pericranial temperature of 33°C for 45 min. All animals received 5-bromo-2-deoxyuridine for 7 days. Histopathological damage and 5-bromo-2-deoxyuridine-positive neurons of the hippocampus were analyzed after 28 days.

RESULTS: Hypothermia had no impact on natural neurogenesis. Cerebral ischemia increased the number of new neurons regardless of pericranial temperature. Forty-five minutes of hypothermia beginning before ischemia diminished hippocampal injury to <10% in the CA1 and CA3 regions, whereas 45 min of postischemic hypothermia beginning after reperfusion did not reduce neuronal injury compared with normothermia.

CONCLUSIONS: Neither intraischemic nor postischemic hypothermia affected the ischemia-induced increase in endogenous neurogenesis. Intraischemic hypothermia reduced hippocampal damage, whereas postischemic hypothermia as applied here did not prevent formation of histopathological injury. This indicates that, 28 days after cerebral ischemia, postischemic neurogenesis is not significantly increased by mild peri-ischemic hypothermia and not affected by the severity of histopathological damage.

METHODS: Sixty patients undergoing abdominal hysterectomy were randomly assigned to 1 of the following 3 groups: control group received oral placebo capsules and bolus plus infusion of saline; ketamine group received oral placebo capsules and, before incision, 0.3 mg/kg IV bolus and 0.05 mg·kg^–1·h^–1 infusion of ketamine until the end of surgery; and gabapentin group received oral gabapentin 1.2 g and bolus plus infusion of saline. The anesthetic technique was standardized, and the postoperative assessments included verbal rating scales for pain and sedation, IV morphine usage, quality of recovery assessment, recovery of bowel function, resumption of normal activities, and patient satisfaction with their pain management. Patients were questioned at 1, 3, and 6 mo after surgery for chronic postoperative pain.

RESULTS: Postoperative pain scores were significantly lower in the gabapentin group compared with the ketamine and control groups, and patient-controlled analgesia morphine use was significantly reduced in both treatment groups (versus control group) (P < 0.001). Total patient-controlled analgesia morphine use was decreased by 35% and 42% in the ketamine and gabapentin groups, respectively, compared with the control group (P < 0.001). Patient satisfaction with pain treatment was significantly improved in the ketamine and gabapentin groups compared with the control group (P < 0.001).

The incidence of incisional pain and related pain scores at the 1-, 3-, and 6-mo follow-up were significantly lower in the gabapentin group compared with the ketamine and control groups (P < 0.001).

CONCLUSION: Gabapentin and ketamine are similar in improving early pain control and in decreasing opioid consumption; however, gabapentin also prevented chronic pain in the first 6 postoperative months.

METHODS: One hundred thirty-two patients with acute herpes zoster diagnosed 1–7 days after the onset of the rash were randomly assigned to receive either standard therapy (oral antivirals and analgesics) or standard therapy with additional repetitive paravertebral injections of a mixture of 10 mL 0.25% bupivacaine and 40 mg methylprednisolone acetate every 48 h for a week. Efficacy was evaluated at 1, 3, 6, and 12 mo after the end of the treatments. The primary end point was the proportion of patients with zoster-associated pain and/or allodynia 1 mo after inclusion. Statistical analysis was performed based on the intent-to-treat population.

RESULTS: One hundred thirteen patients completed the 1-yr follow-up. At 1 mo posttherapy, 13% of patients in the paravertebral group reported zoster-related pain, compared with 45% in the standard group (P < 0.001). At 3, 6, and 12 mo posttherapy, the incidence of PHN was still significantly lower in the paravertebral group than in the standard group. The quality of life improved in both groups at each follow-up time point with no significant difference between groups.

CONCLUSION: Repetitive paravertebral anesthetic block in combination with steroids plus standard treatment with acyclovir and analgesics significantly reduced the incidence of PHN than the standard treatment alone.

METHODS: Therefore, a spinal block was administered in male Wistar rats by administering a local anesthetic (bupivacaine) through an intrathecal catheter at the mid-thoracic level. This thoracic spinal block completely suppressed the noxious stimulation-induced withdrawal reflex that is normally elicited by electrical stimulus. Fos immunoreactivity (Fos-IR) was quantified in all laminae of the L4 segment of the spinal cord.

RESULTS: Noxious stimulation resulted in a general and strong increase in Fos-IR in the ipsilateral dorsal horn, mainly in Laminae I, II, and V. Thoracic spinal block caused a remarkable increase in the amount of Fos-IR in Lamina V, but had no significant effect on the Fos-IR in Laminae I and II.

CONCLUSIONS: The increase in Fos-IR in Lamina V may have resulted from the interruption of a pain-modulating descending mechanism from the brain. A known modulating descending mechanism is the serotonergic system, controlled by the periaqueductal gray. This system inhibits the neurons in the superficial laminae. Another nonserotonergic system originates in the anterior pretectal nucleus. The latter facilitates neurons in the superficial laminae, while neurons in Lamina V are inhibited. We conclude that both systems are probably involved in the observed effects of the peripheral noxious stimulation given in the present model.

METHODS: Rats were divided into four groups (n = 24 each): control, trauma, trauma (T) + sham EA, and T + EA. EA was applied to Zusanli (ST36) and Lanwei (Extra37) acupoints at 20 min after surgery for 30 min, and then performed once a day on postoperative days 1–5. Splenic T cells were isolated and the production and mRNA expression of interleukin (IL)-2, interferon-, IL-4, and IL-10 were assayed. The activation of mitogen-activated protein kinase and the DNA binding activity of nuclear factor (NF)-B and activator protein (AP)-1 were examined.

RESULTS: Paw withdrawal threshold and paw withdrawal latency were significantly increased in the T + EA group compared with the trauma group from postoperative day 1 (paw withdrawal threshold: 5.8 ± 0.7 vs 3.0 ± 0.7 g; paw withdrawal latency: 7.0 ± 0.8 vs 4.5 ± 0.5 s; P < 0.001) to day 5 (9.0 ± 0.6 vs 5.5 ± 0.6 g; 12.0 ± 1.3 vs 7.0 ± 0.8 s; P < 0.001). Th1 cytokine (IL-2 and interferon-) production and mRNA expression in splenic T cells of traumatized rats were significantly decreased on postoperative day 3 (P < 0.001, trauma group versus control group), whereas Th2 cytokine (IL-4 and IL-10) production and mRNA expression were increased (P < 0.001). This was accompanied with a significant depression in the activity of extracellular-regulated protein kinase (ERK)1/2, p38, NF-B, and AP-1 (P < 0.001, trauma group versus control group). EA administration increased Th1 cytokine protein and mRNA expression, suppressed Th2 cytokine protein and mRNA expression (P < 0.05, T + EA group versus trauma group), and increased the activity of ERK1/2, p38, NF-B, and AP-1 (P < 0.001, T + EA group versus trauma group).

CONCLUSIONS: EA regulates a balance between Th1 and Th2 cytokines at protein and mRNA levels in splenic T cells, and, at least in part, involves the signaling pathways of ERK1/2, p38, NF-B, and AP-1. The findings suggest that EA may improve immune suppression after surgical trauma.

METHODS: After premedication and single-injection femoral nerve block, 60 patients undergoing knee arthroscopy were randomly allocated to receive a sciatic nerve block with either NS (n = 30) or US (n = 30). In the US group, the sciatic nerve was localized between the ischial tuberosity and the greater trochanter. In the NS group, the appropriate muscular response (foot plantar flexion or inversion) was elicited (1.5 mA, 2 Hz, 0.1 ms) and maintained to ≤0.5 mA. The volume of the injected local anesthetic was varied for consecutive patients based on an up-and-down method, according to the response of the previous patient. The initial volume was 12 mL. An independent observer evaluated the occurrence of complete loss of pinprick sensation and motor block: positive or negative responses within 20 min after the injection determined a 2-mL decrease or increase for the next patient, respectively.

RESULTS: The mean MEAV₅₀ for sciatic nerve block was 12 mL (95% confidence interval [CI], 10–23 mL) in Group US and 19 mL (95% CI, 15–23 mL) in Group NS (P < 0.001). The effective dose in 95% of cases was 14 mL (95% CI, 12–17 mL) in Group US and 29 mL (95% CI, 25–40 mL) in Group NS (P = 0.008).

CONCLUSIONS: US provided a 37% reduction in the MEAV₅₀ of 1.5% mepivacaine required to block the sciatic nerve compared with NS.

METHODS: One hundred twelve patients scheduled for elective forearm surgery under axillary brachial plexus block were randomly allocated to receive 34 mL lidocaine 1.5% with 3 mL of isotonic saline chloride (control group, n = 28), 34 mL lidocaine 1.5% with 2 mL (100 µg) of fentanyl and 1 mL of isotonic saline chloride (fentanyl group, n = 28), 34 mL lidocaine 1.5% with 2 mL saline chloride and 100 ng (1 mL) naloxone (naloxone group, n = 28), or 34 mL lidocaine 1.5% with 2 mL (100 µg) of fentanyl and 100 ng (1 mL) naloxone (naloxone + fentanyl group, n = 28). A multiple stimulation technique was used in all patients. After performing the block, sensory and motor blockades of radial, median, musculocutaneous, and ulnar nerves were recorded at 5, 15, and 30 min. The onset time of the sensory and motor blockades was defined as the time between the last injection and the total abolition of the pinprick response and complete paralysis, respectively. The duration of sensory and motor blocks was considered as the time interval between the complete block and the first postoperative pain and complete recovery of motor functions.

RESULTS: Sensory and motor onset times were longer in the naloxone (sensory onset time: 15 ± 3, and motor onset time: 21 ± 4) and naloxone + fentanyl group than control or fentanyl groups (sensory onset time: 10 ± 3 min in control group, 10 ± 4 min in fentanyl group, and 17 ± 3 min in naloxone + fentanyl group, motor onset time: 15 ± 5 min in control group, 14 ± 7 min in fentanyl group, and 17.3 ± 3.4 min in naloxone + fentanyl group) (P < 0.001). The duration of time to first postoperative pain and motor blockade was significantly longer in the naloxone (92 ± 10 and 115 ± 10 min) and naloxone + fentanyl groups (98 ± 12 and 122 ± 16 min) than control (68 ± 7 and 89 ± 11 min) and fentanyl groups (68 ± 11 and 90 ± 12 min) (P < 0.001). The time to first postoperative pain was significantly longer in the naloxone and naloxone + fentanyl groups than in the control or fentanyl groups (P < 0.001).

CONCLUSIONS: The addition of an ultra-low dose of naloxone to lidocaine 1.5% solution with or without fentanyl solution in axillary brachial plexus block prolongs the time to first postoperative pain and motor blockade but also lengthens the onset time.

METHODS: Fifty male patients undergoing transurethral surgery received either 8 mg oral ondansetron the evening before surgery plus IV 8 mg ondansetron 15 min before subarachnoid anesthesia or placebo. All patients received 2.2 mL of 0.75% plain ropivacaine intrathecally. Sensory and motor block were assessed 30 min after the intrathecal injection and every 30 min thereafter until recovery from the motor block.

RESULTS: Thirty minutes after spinal injection of ropivacaine, we first measured, in both groups, the time to maximum block for both sensory and motor modalities. The maximum level of the sensory block, defined as decreased sensation, was T8 in the control and T6 in the ondansetron group, and absence of sensation was defined as T11 and T9 for the control and the ondansetron groups, respectively. Regarding block duration, 180 min after spinal injection, sensory block was detected in 11 of 22 and 16 of 24 patients and motor block in 1 of 22 and 0 of 24 in the control and ondansetron groups, respectively. Sensory and motor block did not differ between groups at any measured time point.

CONCLUSIONS: Ondansetron had no effect on the subarachnoid sensory or motor block produced by ropivacaine.

METHODS: Two hundred twenty-seven patients were enrolled in this prospective cohort study. Fifty-nine patients underwent CABG surgery with CPB and 168 underwent off-pump surgery. Cerebral microemboli were measured continuously with bilateral transcranial Doppler ultrasonography of the middle cerebral arteries. A neuropsychological test battery that included seven tests with nine subscales was administered at baseline, as well as at 1 wk and 3 mo after surgery. POCD was defined using the international study of POCD1 definition.

RESULTS: The median total number of cerebral microemboli for the case was 430 (range: 155–2088) in patients undergoing surgery with CPB and 2 (0–66) in the off-pump patients (P < 0.001). There were no differences in the incidence of POCD between the patients having surgery with or without CPB either at 1 wk (55.2% or 32 of 58 patients [95% confidence interval: 41.5%–68.3%] vs 47.0% or 78 of 166 patients [39.2%–54.9%], P = 0.283) or 3 mo (6.4% or 3 of 47 patients [1.3%–17.5%] vs 13.1% or 16 of 122 of patients [7.7%–20.4%], P = 0.214) after surgery. Increasing age and shorter duration of postoperative hospital stay were independently associated with cognitive dysfunction at 1 wk after surgery. Increasing age and a history of diabetes mellitus were independently associated with cognitive dysfunction 3 mo after surgery. CPB or cerebral microemboli were not significantly related to the occurrence of POCD.

CONCLUSIONS: In Chinese population, avoidance of CPB during CABG surgery significantly decreased the number of cerebral microemboli, but it did not decrease the incidence of POCD at either 1 wk or 3 mo after CABG. Neither CPB nor cerebral microemboli was independently associated with the risk of POCD.

METHODS: Normal whole blood was incubated with increasing amounts of a nonspecific antibody, an anti-GPIIb/IIIa antibody, or a neutralizing anti-factor XIII antibody; samples were analyzed with a tissue factor-activated and platelet-inhibited whole blood thrombelastographic assay. Clotting time, clot formation time, maximum clot firmness, and clot lysis at 60 min were evaluated in triplicate. Also, 25 whole blood routine samples were evaluated for factor XIII deficiency using a new thrombelastographic assay incorporating a factor XIII antibody and using a standard factor XIII assay for comparison.

RESULTS: Although GPIIb/IIIa inhibition did not alter the results of the platelet-inhibited whole blood thrombelastography, factor XIII inhibition significantly reduced maximum clot firmness (P = 0.020) and increased clot formation time (P = 0.025) and clot lysis (P = 0.007), leaving clotting time unchanged; a ceiling effect seemed to be present with increasing antibody concentrations in whole blood (but not plasma). The thrombelastographic assay for factor XIII deficiency (<70% activity) had a 90% sensitivity and negative predictive value (area under receiver operating characteristic curve 0.803, P = 0.0015); for a deficiency <60%, sensitivity and negative predictive value were 100% (area under receiver operating characteristic curve 0.84, P = 0.0037).

CONCLUSION: Factor XIII has significant impact on platelet-inhibited activated whole blood thrombelastography. This phenomenon should be considered when interpreting thrombelastographic results in the bleeding patient, especially when the results trigger procoagulant therapy. Antibody-mediated factor XIII inhibition can be used to establish thrombelastography-based assays to detect factor XIII deficiency.

METHODS: A literature search was undertaken using multiple search engines and the appropriate articles were reviewed by the authors to determine anesthetic-associated complications in patients with muscular dystrophy. Of all the types of muscular dystrophy, Duchenne muscular dystrophy (DMD) and Becker dystrophy (BD) represent nearly all the anesthesia-related reports.

RESULTS: Anesthetic complications in patients with DMD and BD include intraoperative heart failure, inhaled anesthetic-related rhabdomyolysis (absence of succinylcholine), and succinylcholine-induced rhabdomyolysis and hyperkalemia.

CONCLUSION: We did not find an increased risk of malignant hyperthermia susceptibility in patients with DMD or BD compared with the general population. However, dystrophic patients who are exposed to inhaled anesthetics may develop disease-related cardiac complications, or rarely, a malignant hyperthermia-like syndrome characterized by rhabdomyolysis. This latter complication may also occur postoperatively. Succinylcholine administration is associated with life-threatening hyperkalemia and should be avoided in patients with DMD and BD.

METHODS: We performed this study in a prospective, randomized, observer-blind manner. Children aged 1–5 yr received a constant dose of 2.25 mg/kg of ropivacaine prepared as either 1.0 mL/kg of 0.225% (low volume/high concentration [LVHC], n = 37) or 1.5 mL/kg of 0.15% solution (high volume/low concentration [HVLC], n = 36). Both solutions contained radiopaque dye.

RESULTS: The median spread levels with ranges in the HVLC group (confirmed by fluoroscopic examination) were significantly higher (T6, T3-11) than in the LVHC group (T11, T8-L2). There were no significant differences in recovery times, postoperative pain scores, or side effects between the two groups. After discharge, fewer children in the HVLC group required rescue oral acetaminophen compared with the LVHC group (50.0% vs 75.7%). First oral acetaminophen time was found to be significantly longer with HVLC patients than LVHC patients (363.0 min vs 554.5 min).

CONCLUSIONS: We confirmed (with fluoroscopy) that a caudal block with 1 mL/kg ropivacaine spreads to T11 and to T6 with 1.5 mL/kg. If the total dose is fixed, caudal analgesia with a larger volume of diluted ropivacaine (0.15%) provides better quality and longer duration after discharge than a smaller volume of more concentrated ropivacaine (0.225%) in children undergoing day-case orchiopexy. The spread level of ropivacaine correlated significantly with the first oral acetaminophen time after discharge.

METHODS: From January 2007 to December 2008, 384 children younger than 5-yr-of-age subjected to rigid bronchoscopy for FB removal were included in the study. The detailed clinical information and perioperative adverse events were recorded. Surgical outcomes and incidence of perioperative adverse events were compared among different ventilation modes (spontaneous ventilation, manual intermittent positive pressure ventilation, and manual jet ventilation) and different anesthetic techniques (total IV anesthesia and inhaled anesthesia). An amalgamated dataset was used for the analysis of factors that correlated with perioperative hypoxemia.

RESULTS: In children who received total IV anesthesia with spontaneous ventilation during rigid bronchoscopy, we observed more intraoperative body movement and breath holding, significantly longer duration of emergence from anesthesia, lower percentage of successful FB removal, and more postoperative laryngospasm. Children in the manual jet ventilation group had the least occurrence of intraoperative hypoxemia. Five factors strongly correlated with intraoperative hypoxemia. Younger age, plant seed as the type of FB, longer surgical duration, pneumonia before the procedure, and spontaneous ventilation mode significantly increased the risk of intraoperative hypoxemia, whereas manual jet ventilation mode decreased it. Two factors were associated with postoperative hypoxemia: plant seed as a FB and prolonged duration of emergence from anesthesia.

CONCLUSION: We identified risk factors associated with intraoperative or with postoperative hypoxemia in rigid bronchoscopy which included patient age, type of FB, duration of surgical procedure, pneumonia before the procedure, ventilation mode, and duration of emergence from anesthesia. These results provide evidence that will help clinicians to reduce the incidence of hypoxemia in high-risk children.

METHODS: As a first step, we developed an instrument based on a qualitative study conducted with children in Great Britain, input from a focus group, and input from school children. On the day of surgery, 143 children aged 7–17 yr completed a 40-item assessment of desired surgical information and a measure of anxiety (State-Trait Anxiety Inventory for Children). Parents completed a measure assessing their child’s temperament (Emotionality, Activity, Sociability, and Impulsivity Survey) and a measure of their own anxiety (State-Trait Anxiety Inventory).

RESULTS: Results indicated that the vast majority of children had a desire for comprehensive information about their surgery, including information about pain and anesthesia, and procedural information and information about potential complications. The most highly endorsed items by children involved information about pain. Children who were more anxious endorsed a stronger desire for pain information and lesser tendency to avoid information. Younger children wanted to know what the perioperative environment would look like more than adolescent children.

CONCLUSIONS: We conclude that the majority of children aged 7–17 yr who undergo surgery want to be given comprehensive perioperative information and health care providers should ensure adequate information regarding postoperative pain is provided.

METHODS: Two hundred eighteen patients were randomized to have either an i-gel or La Premiere® LM airway placed for airway management. Patients were interviewed postoperatively for throat and neck complaints at 1, 24, and 48 h. Interviewers and patients were blinded to the device used.

RESULTS: One hundred nine patients had an i-gel and 103 had a La Premiere supraglottic device inserted. The incidence of sore throat was significantly lower with the i-gel than with LM at 1 (6 vs 32), 24 (7 vs 48), and 48 h (5 vs 25). Similar results were seen for dysphagia. The incidence of neck pain was also lower for the i-gel at 24 (1 vs 7) and 48 h (1 vs 7).

CONCLUSION: In this randomized study, the i-gel supraglottic device resulted in a lower incidence of throat and neck complaints than the La Premiere LM airway.

METHODS: The effect of NMB on the median effective end-tidal concentration of desflurane (EtDes₅₀, or MAC_tetanus) for immobility was estimated using the up-and-down method and isolated forearm technique in 24 healthy volunteers. Each volunteer sequentially received saline, mivacurium, and succinylcholine in a randomized order, while EtDes concentration during each of the treatments was determined based on the movement response of the previous volunteer on the same treatment. Nonlinear mixed-effects modeling was used to evaluate the effect of NMB on BIS versus EtDes concentration relationship at baseline and after noxious stimulation, while the frontal electromyogram (EMG_BIS) effect on BIS was also modeled as a covariate. Cardiovascular responses to noxious stimulation were compared across treatments.

RESULTS: Succinylcholine and mivacurium significantly reduced MAC_tetanus (95% confidence interval) from 5.00% (4.85%–5.13%), during saline, to 4.05% (3.81%–4.29%) and 3.84% (3.60%–4.08%), respectively. Noxious stimulation significantly, although minimally, increased BIS response during all treatments. Succinylcholine increased BIS independently of an effect on EMG_BIS. Succinylcholine administration increased cardiovascular activity. Interestingly, although cardiovascular reaction to the noxious event was ablated by mivacurium, cortical response, as determined by BIS, was retained.

CONCLUSIONS: Both succinylcholine and mivacurium enhanced immobility during near-MAC anesthesia. All treatments were associated with a small, although significant, BIS increase in response to noxious stimulation, whereas succinylcholine increased BIS independently of noxious stimulation or EMG_BIS. Mivacurium suppressed autonomic response to a noxious event.

METHODS: Demographic and intraoperative data were recorded retrospectively from the anesthesia records of patients who underwent elective spine surgery longer than 8 h. Propofol patients were matched 1:2 to VA patients, based on anesthesia time (AT) (±30 min) and blood loss (BL) (±500 mL).

RESULTS: Of 246 patients identified, 50 received propofol (AT = 10 ± 2 h, BL = 1955 ± 1409 mL) and were matched to 100 VA cases (AT = 10 ± 1 h, BL = 1801 ± 1543 mL), and of those, 40 and 72 patients, respectively, had complete lactate data at baseline and at 8 h after anesthesia and were included in the main analysis. The propofol group received 8.8 ± 2 mg · kg^–1 · h^–1 of propofol. The VA group age was older than the propofol group (58 ± 12 vs 51 ± 15 yr, respectively, P = 0.002), but there was no difference between the groups in gender, ASA grade, intraoperative hemodynamic variables, and use of vasopressors. After 8 h, the VA group had a larger increase in arterial lactate from baseline compared with the propofol group (change from baseline: propofol, 0.48 ± 0.72 mmol/L; VA, 1.2 ± 1.2 mmol/L, P = 0.001).

CONCLUSIONS: During prolonged spine surgery >8 h, VA was associated with higher serum lactate, when compared with propofol infusion. Prospective studies are needed to elucidate the exact mechanisms and clinical implications of this finding.

METHODS: We determined tailflick latency (TFL) and hindpaw withdrawal latency (HPL) under 70% N₂O, N₂O MAC, and isoflurane MAC before and after intracerebroventricular injections of anti-dopamine-β hydroxylase conjugated to saporin (SAP-DBH; n = 7), or a control antibody conjugated to saporin (n = 5). In a separate group of naive rats (n = 8), N₂O MAC was determined at 25–45 min after initiation of N₂O exposure (during peak analgesia) and again at 120–140 min (after TFL and HPL returned to baseline).

RESULTS: After 30 min of N₂O exposure, TFL and HPL increased significantly but declined back to baseline within 120 min. N₂O did not produce analgesia in rats that received SAP-DBH. However, N₂O and isoflurane MAC were not significantly different between SAP-DBH and control-injected animals (Mean ± sd for N₂O: 1.7 ± 0.1 atm vs 1.7 ± 0.2 atm; isofurane: 1.6 ± 0.2% vs 1.7 ± 0.2%). In naïve animals, N₂O MAC was not different at the 30 min period compared with the 120 min period (1.8 ± 0.1 atm vs 1.8 ± 0.2 atm).

CONCLUSIONS: Destroying brainstem noradrenergic neurons or prolonged exposure to N₂O removes its analgesic effects, but does not change MAC. The immobilizing mechanism of N₂O is independent from its analgesic effects.

METHODS: In an in vitro model, mononuclear cells isolated from peripheral blood of healthy donors were preconditioned with sevoflurane (3 times 30 min at 2 vol% interspersed by 30 min of air). Colony-forming units were determined after 9 days in culture and compared with time-matched untreated control. Using magnetic cell sorting, CD133+/CD34+ endothelial progenitors were enriched from human umbilical cord blood, and vascular endothelial growth factor (VEGF), VEGFR2 (KDR), granulocyte colony-stimulating factor (G-CSF), STAT3, c-kit, and CXCR4 expressions were determined in sevoflurane-treated and untreated cells by real-time reverse transcriptase polymerase chain reaction. In a volunteer study with crossover design, we tested whether sevoflurane inhalation (<1 vol% end-tidal concentration) would mobilize endothelial progenitor cells from the bone marrow niche into the circulation using flow cytometry of peripheral blood samples. VEGF and G-CSF plasma levels were also measured.

RESULTS: In vitro sevoflurane exposure of mononuclear cells enhanced colony-forming capacity and increased VEGF mRNA levels in CD133+/CD34+ cord blood cells (P = 0.017). Sevoflurane inhalation in healthy volunteers did not alter the number of CD133+/CD34+ or KDR+/CD34+ endothelial progenitors in the circulation, but increased the number of colony-forming units (P = 0.034), whereas VEGF and G-CSF plasma levels remained unchanged.

CONCLUSIONS: Sevoflurane preconditioning promotes growth and proliferation of stem cell-like human endothelial progenitors. Hence, it may be used to promote perioperative vascular healing and to support cell replacement therapies.

METHODS: SH-SY5Y cells, a human neuroblastoma cell line, were cultured. Cells were depolarized with KCl and the phosphorylation of CREB examined by Western blotting, enzyme-linked immunosorbant assay, and immunocytochemistry. The translocation of CaM from the cytosol to the nucleus was also examined after depolarization. Cells were depolarized and lysed and fractionated by centrifugation to determine the amount of CaM translocated to the nucleus. CaM was localized by immunocytochemistry and quantitated by Western blotting and imaging. Before and during KCl depolarization, cells were exposed to isoflurane, isoflurane plus Bay K 8644, nitrendipine, and -conotoxin GVIa, respectively.

RESULTS: P-CREB increased after KCl depolarization. The increase of P-CREB peaked at depolarization duration of 30 s. The increase in P-CREB formation was inhibited by nitrendipine, but not -conotoxin, and by isoflurane in a concentration-dependent fashion. Pretreatment with the L-type Ca²⁺ channel agonist, Bay K 8644, attenuated the inhibition of P-CREB formation by isoflurane. CaM presence in the nucleus occurred after KCl depolarization. CaM translocation was inhibited by nitrendipine and attenuated by isoflurane. Bay K 8644 pretreatment decreased the isoflurane inhibition of CaM translocation to the nucleus.

CONCLUSIONS: Our data demonstrate that isoflurane inhibits CaM translocation and P-CREB formation. This most likely occurs through isoflurane inhibition of Ca²⁺entry through L-type Ca²⁺ channels.

METHODS: Experiment 1 investigated whether wearing a HMD would affect how quickly anesthesiologists detect events, and whether the focus setting of the HMD (near or far) makes any difference. Twelve anesthesiologists provided anesthesia in three naturalistic scenarios within a simulated operating theater environment. There were 24 different events that occurred either on the patient monitor or in the operating room. Experiment 2 investigated whether anesthesiologists physically constrained by performing a procedure would detect patient-related events faster with a HMD than without. Twelve anesthesiologists performed a complex simulated clinical task on a part-task endoscopic dexterity trainer while monitoring the simulated patient’s vital signs. All participants experienced four different events within each of two scenarios.

RESULTS: Experiment 1 showed that neither wearing the HMD nor adjusting the focus setting reduced participants’ ability to detect events (the number of events detected and time to detect events). In general, participants spent more time looking toward the patient and less time toward the anesthesia machine when they wore the HMD than when they used standard monitoring alone. Participants reported that they preferred the near focus setting. Experiment 2 showed that participants detected two of four events faster with the HMD, but one event more slowly with the HMD. Participants turned to look toward the anesthesia machine significantly less often when using the HMD. When using the HMD, participants reported that they were less busy, monitoring was easier, and they believed they were faster at detecting abnormal changes.

CONCLUSIONS: The HMD helped anesthesiologists detect events when physically constrained, but not when physically unconstrained. Although there was no conclusive evidence of worsened inattentional blindness, found in aviation, the perceptual properties of the HMD display appear to influence whether events are detected. Anesthesiologists wearing HMDs should self-adjust the focus to minimize eyestrain and should be aware that some changes may not attract their attention. Future areas of research include developing principles for the design of HMDs, evaluating other types of HMDs, and evaluating the HMD in clinical contexts.

METHODS: Infusion sets differing in length, dead space volume, and presence of an ARV were assessed. Three drugs were infused simultaneously through different access points, and their concentrations were obtained using UV spectrophotometric analysis of the effluent. Different infusion configurations were compared by assessing (1) the amount of drug delivered to the patient per unit of time, (2) the mean amount of drug delivered to the patient per unit of time during the steady-state infusion (mass flow rate plateau), and (3) flow change efficiency calculated from the ratio of the area under the experimental instant mass flow rate curve to the area corresponding to theoretical instant mass flow rate curve.

RESULTS: Infusion sets with lower dead space volumes offered significantly higher flow change efficiency (53.0% ± 15.4% with a dead space volume equal to 0.046 mL 5 min after the start of infusion) than infusion sets with higher dead space volume (5.6% ± 8.2% with a dead space volume equal to 6.16 mL), whatever the flow rate changes. Even in case of large dead space volumes, the presence of an ARV significantly increased the mass flow rate plateau (from 92.4% to 99.3% of the theoretical plateau without and with the presence of an ARV, respectively).

CONCLUSIONS: Multi-infusion therapy induces perturbation in drug delivery. These perturbations (lag time, backflow, and bolus) could be reduced by using infusion sets including very low dead space volume and an ARV.

METHODS: We evaluated drug delivery via a standard pediatric 8-cm, 4-F double-lumen catheter. One syringe pump infused normal saline as the carrier fluid through a limb of a Y-piece connected to the catheter’s 22-gauge distal lumen. Through the other limb of the Y-piece, a second syringe pump infused methylene blue, the model drug, at a constant rate of 0.5 mL/h. The volume delivered was collected every minute for quantitative analysis. We compared 2 mL/h and 12 mL/h total flow rates to mimic volume delivery to a 3-kg infant, and priming of the Y-piece with the model drug, to mimic resumption of a stopped drug infusion, versus no priming, to mimic a new infusion. Drug pump system start-up performance was measured to estimate this factor’s contribution to infusion onset profiles.

RESULTS: When initiating a new infusion of the model drug, the time to steady-state delivery at the catheter’s end varied significantly among the studied scenarios as measured by the time to reach half of the targeted dose (t₅₀). Onset of delivery with a low total flow was much slower (t₅₀ = 23.5 ± 2.1 min) than with the high flow rate (t₅₀ = 15.7 ± 2.9 min). Priming the drug limb of the connecting Y-piece with methylene blue substantially shortened the time to steady state (low flow t₅₀ = 12.7 ± 0.6 min, high flow t₅₀ = 5.2 ± 0.8 min). Time to cessation of drug delivery to the end of the catheter after stopping the drug pump was substantially shorter using the high carrier flow rate (t₅₀ = 3 ± 0.5 min) compared with the low carrier flow rate (t₅₀ = 11.6 ± 0.8 min). Drug pump system start-up performance contributed to onset delay.

CONCLUSIONS: Current infusion techniques in the pediatric care setting can result in significant, unrecognized, and potentially hazardous delays in achieving delivery of intended drug doses to the patient. Total flow rate, priming of the infusion system, the dead volume of the fluid path, and the start-up performance of the infusion pump system contribute to delays in achieving targeted rates of drug delivery.

METHODS: Using New York hospital discharge data for the years 2001 through 2005, we identified all patients with a diagnosis of MH due to anesthesia using International Classification of Diseases, Ninth Revision, Clinical Modification code 995.86. MH prevalence was evaluated by demographic and clinical characteristics.

RESULTS: Of the 12,749,125 discharges from New York hospitals during the study period, 73 patients had a recorded diagnosis of MH due to anesthesia. Nearly three quarters of the MH patients were male and 71% were patients from emergency/urgent admissions. The estimated prevalence rate of MH was 0.96 (95% confidence interval [CI] 0.67–1.24) per 100,000 surgical discharges and 1.08 (95% CI 0.75–1.41) per 100,000 discharges in which there was any indication of exposure to anesthesia. The estimated prevalence of MH for males was 2.5 to 4.5 times the rate for females.

CONCLUSION: The prevalence of MH due to anesthesia in surgical patients treated in New York State hospitals is approximately 1 per 100,000. MH risk in males is significantly higher than in females.

METHODS: Using the Healthcare Cost and Utilization Project State Inpatient Databases files, we identified all discharge records for labor and delivery from New York hospitals between 2002 and 2005. We then identified women who experienced any recorded anesthesia-related complication during labor and delivery as determined by International Classification of Diseases, Ninth Revision, Clinical Modification codes. The incidence of anesthesia-related complications was calculated by demographic and clinical characteristics. Multivariate logistic regression was performed to assess risk factors of anesthesia-related complications.

RESULTS: Of the 957,471 deliveries studied, 4438 (0.46%) had at least one anesthesia-related complication. The majority (55%) of anesthesia-related events occurring during labor and delivery were spinal complications, followed by systemic complications (43%) and overdose or adverse effects (2%). Multivariate logistic regression revealed five risk factors of anesthesia-related complications: cesarean delivery (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.36-2.68), rural area (OR 1.33, 95% CI 1.21-1.46), Charlson-Deyo Comorbidity Index ≥1 (OR 1.47, 95% CI 1.28-1.69), Caucasian race (OR 1.37, 95% CI 1.24-1.52), and scheduled admission (OR 1.10, 95% CI 1.03-1.18). Anesthesia-related complications were associated with about a one-day increase in the average length of stay (3.89 ± 3.69 [mean ± sd] days vs 2.92 ± 2.38 days for deliveries without anesthesia-related complications, P < 0.0001) and a 22-fold increased risk of maternal mortality (OR 22.26, 95% CI 11.20-44.24).

CONCLUSION: The incidence of anesthesia-related complications during labor and delivery seems to be low but remains a cause of concern, particularly in women undergoing cesarean delivery, living in rural areas, or having preexisting medical conditions.

METHODS: All sequentially enrolled MO patients underwent preoperative polysomnography. Severity of OSA was quantified using AHI and the American Society of Anesthesiologists’ OSA severity scale. All patients had a standardized anesthetic that included positioning in the "ramped position" for direct laryngoscopy.

RESULTS: One hundred eighty consecutive patients were recruited, 140 women and 40 men. The incidence of OSA was 68%. The mean BMI was 49.4 kg/m². The mean AHI was 31.3 (range, 0-135). All the patients’ tracheas were intubated successfully without the aid of rescue airways by anesthesiology residents. Six patients required three or more intubation attempts, a difficult intubation rate of 3.3%. There was an 8.3% incidence of difficult laryngoscopy, defined as a Cormack and Lehane Grade 3 or 4 view. There was no relationship between NC and difficult intubation (odds ratio 1.02, 95% confidence interval 0.93-1.1), between the diagnosis of OSA and difficult intubation (P = 0.09), or between BMI and difficult intubation (odds ratio 0.99, 95% confidence interval 0.92-1.06, P = 0.8). There was no relationship between number of intubation attempts and BMI (P = 0.8), AHI (P = 0.82), or NC (P = 0.3). Mallampati Grade III or more predicted difficult intubation (P = 0.02), as did male gender (P = 0.02). Finally, there was no relationship between Cormack and Lehane grade and BMI (P = 0.88), AHI (P = 0.93), or OSA (P = 0.6). Increasing NC was associated with difficult laryngoscopy but not difficult intubation (P = 0.02).

CONCLUSIONS: In MO patients undergoing bariatric surgery in the "ramped position," there was no relationship between the presence and severity of OSA, BMI, or NC and difficulty of intubation or laryngoscopy grade. Only a Mallampati score of 3 or 4 or male gender predicted difficult intubation.

METHODS: Initially, the release of sevoflurane from the surgical site was measured during 35 tumorectomies starting from opening to closure of the dura. Volatile anesthetic absorbers were placed at three detection sites: 1) the surgeon’s breathing zone, 2) the anesthesiologist’s breathing zone, and 3) the farthest corner of the operation room. In the second sampling series that included 16 patients, the detector that had been in the corner of the operating room in the first series was now placed in the vicinity of the patient’s mouth (within 5 cm). Sevoflurane captured by the absorbers was quantified by an independent chemist using chromatography.

RESULTS: Absorbers in the surgeon’s breathing zone (0.24 ± 0.04 ppm) captured a significantly lower amount of sevoflurane compared with absorbers in the anesthesiologist’s breathing zone (1.40 ± 0.37 ppm) and comparable with that in the farthest corner of the operation room (0.25 ± 0.07 ppm). There was no correlation between the amount of absorbed sevoflurane and the size of craniotomy window, even when adjusting for the variation in duration of surgery. In the second series of sampling, absorbers in the proximity of the patient’s mouth captured the highest amount of sevoflurane (1.54 ± 0.55 ppm), followed by the anesthesiologist’s (1.14 ± 0.43 ppm) and the surgeon’s (0.15 ± 0.05 ppm) breathing zones.

CONCLUSIONS: The close proximity of the surgeon’s breathing zone to the craniotomy window does not appear to be a source of increased exposure to sevoflurane. The observed higher exposure of the anesthesiologist to sevoflurane in the operating room environment warrants further exploration.

METHODS: In this post hoc analysis, we assessed predictive parameters for neurological recovery after successful CPR. The original study was designed as a blinded, randomized, prospective, controlled, multicenter clinical trial.

RESULTS: We identified 1166 prehospital cardiac arrest patients being treated with advanced cardiac life support. Seven hundred eighty-six of 1166 patients (67.4%) died at the scene and 380 of 1166 (32.6%) were brought to the hospital. Two hundred sixty-five of 1166 patients (22.7%) died in the hospital. One hundred fifteen of 1166 (9.8%) were discharged from the hospital and 92 of the 115 patients (80%) could be followed-up. Good cerebral performance was regained by 54% of discharged patients (50 of 92 patients). In 46% of patients (42/92), unconsciousness or severe disability remained. Ventricular fibrillation was more likely to have occurred in patients with good neurological recovery (42/50 = 84.0%), whereas asystole was more likely in patients with poor neurological recovery (9/42 = 21.4%). A score was developed to predict the probability of death using logistic regression analysis. Predicting death in the hospital revealed a sensitivity of 99.8% (953/955), but only a specificity of 2.9% (3/104; threshold 0.5). Predicting survival until discharge from the hospital revealed a sensitivity of 99% (103/104), but only a specificity of 8% (72/955; threshold 0.99). A receiver operating characteristic curve yielded an area under the curve of 0.795 (0.751-0.839) at a confidence interval of 95%.

CONCLUSION: For out-of-hospital patients with cardiac arrest, parameters documented in the field did not allow accurate prediction of hospital survival.

METHODS: Anesthetized Sprague-Dawley rats were exposed to 1 min of asphyxial cardiac arrest. Resuscitation was standardized and consisted of chest compressions, oxygen (Fio₂ 1.0), and IV epinephrine 30 µg/kg (Series 1) and 10 µg/kg (Series 2). Left ventricular function was assessed by echocardiography (Series 1), and animals were randomized to receive either 5 cm H₂O PEEP or zero PEEP at commencement of CPR and throughout resuscitation. Survival was defined as the presence of a spontaneous circulation 60 or 120 min (Series 2) after initial resuscitation.

RESULTS: There were no baseline differences between the groups. In Series 1, administration of 5 cm H₂O PEEP (Fio₂ 1.0 and 0.21) was associated with improved survival compared with zero PEEP (7/9 and 6/6 vs 0/9, P < 0.01 and <0.001, respectively). Application of 5 cm H₂O PEEP (Fio₂ 1.0) increased left ventricular end-diastolic area, systemic oxygenation, and functional residual capacity. Use of PEEP during CPR did not adversely affect left ventricular systolic function or arterial blood pressure. The outcome differences were not due to increased oxygenation because the rank order of survival was 5 cm H₂O PEEP (Fio₂ 1.0) 5 cm H₂O PEEP (Fio₂ 0.21) > zero PEEP (Fio₂ 1.0), whereas the rank order of Pao₂ was 5 cm H₂O PEEP (Fio₂ 1.0) > 5 cm H₂O PEEP (Fio₂ 0.21) zero PEEP (Fio₂ 1.0). In an additional series in which epinephrine 10 µg/kg was used (Series 2), the survival was 100% with no beneficial effects of PEEP.

CONCLUSION: In asphyxial cardiac arrest in a small rodent model, continuous application of PEEP (5 cm H₂O) during and after CPR had beneficial effects on survival that were independent of oxygenation and without adverse cardiovascular effects.

METHOD: Thirty-two subjects (14 men and 18 women) were studied. We constructed pressure-flow relationships to evaluate P_CRIT and R_US during midazolam anesthesia. The midazolam anesthesia was induced with an initial dose of midazolam (0.07–0.08 mg/kg bolus) and maintained by midazolam infusion (0.3–0.4 µg · kg^–1 · min^–1), and the level of anesthesia was assessed by Ramsay score (Level 5) and Observer’s Assessment of Alertness/Sedation score (Level 2). Polysomnographic and hemodynamic variables were monitored while nasal pressure (via mask), inspiratory air flow (via pneumotachograph), and genioglossal electromyograph (EMG_GG) were recorded. P_CRIT was obtained in both the passive condition, under conditions of decreased EMG_GG (passive P_CRIT), and in an active condition, whereas EMG_GG was increased (active P_CRIT). The difference between the active P_CRIT and passive P_CRIT (P_{CRIT P – A}) was calculated in each subject to determine the compensatory neuromuscular response.

RESULTS: The difference between the active P_CRIT and passive P_CRIT (P_{CRIT A – P}) was significantly greater in women than in men (4.6 ± 2.8 cm H₂O and 2.2 ± 1.7 cm H₂O, respectively; P < 0.01), suggesting greater compensatory neuromuscular response to upper airway obstruction independent of arousal.

CONCLUSION: We demonstrate that the arousal-independent compensatory neuromuscular responses to upper airway obstruction during midazolam anesthesia were partially maintained in women, and that gender may be a major determinant of the strength of compensatory responses during anesthesia.

METHODS: In this double-blind study, 178 patients were randomly assigned to receive a preload of 500 mL of hydroxyethyl starch over a period of 15–20 min before initiation of spinal anesthesia (n = 90) or an identical fluid bolus of hydroxyethyl starch starting at the time of identification of cerebrospinal fluid (n = 88). Vasopressors (ephedrine or phenylephrine) were administered if systolic arterial blood pressure decreased less than 80% of the baseline pressure and <100 mm Hg, or with smaller decreases in blood pressure if accompanied by nausea, vomiting, or dizziness. The primary outcome was the incidence of hypotension (defined as the administration of at least one dose of vasopressor).

RESULTS: There was no significant difference between the groups in the incidence of hypotension (68% in preload group and 75% in coload group, 95% confidence interval of difference –6%–20%; P = 0.28), doses of ephedrine and phenylephrine, and number of vasopressor unit doses. The incidence of severe hypotension (systolic blood pressure <80 mm Hg) was 16% in the preload group and 22% in the coload group (P = 0.30). There were no differences in the incidence of nausea and/or vomiting, or neonatal outcome between the groups.

CONCLUSION: There was no difference in the incidence of hypotension in women who received colloid administration before the initiation of spinal anesthesia compared with at the time of initiation of anesthesia. Both modalities are inefficient as single interventions to prevent hypotension.

METHODS: Using a prospective, observational format, pregnant patients were examined for multiple potential risk factors for neuraxial technique difficulty, including current body mass index, ability to palpate spinous processes, maximum back flexion, scoliosis, and experience of the practitioner. Neuraxial technique difficulty was then assessed using two measures: 1) the number of needle passes needed to reach the desired space, and 2) the placement time from skin infiltration to either spinal injection or epidural catheter threading. Predictors of total needle passes were determined by fitting the data to a generalized linear model with negative binomial error. Predictors of neuraxial anesthetic time were determined by fitting a linear model to the log of neuraxial anesthetic placement time. A survival model was used to account for bias introduced when attending physicians intervened in resident physician procedures.

RESULTS: Neuraxial procedures in 427 pregnant patients were studied. For both the number of needle passes and the neuraxial anesthetic placement time, the significant predictors of difficulty were the practitioner’s ability to palpate the patient’s bony landmarks and the patient’s ability to flex her back. Obesity, as measured by body mass index, was not an independent predictor of either end point. Obesity did, however, strongly predict both the ability to palpate landmarks and flex the back.

CONCLUSIONS: Despite concerns that obesity may cause difficulty with neuraxial technique, some obese patients have surprisingly easy neuraxial block placements. When approaching any neuraxial anesthetic in a pregnant patient, and especially in the obese parturient, back flexion and landmark palpation predict neuraxial technique difficulty.

METHODS: We retrospectively reviewed all recorded surgical cases of 2 large European teaching hospitals from 2005 to 2008, involving 85,312 cases and 92,099 h in total. Surgical times tended to be skewed and bounded by some minimally required time. We compared the fit of the normal distribution with that of 2- and 3-parameter lognormal distributions for case durations of a range of Current Procedural Terminology (CPT)-anesthesia combinations, including possible surgeon effects. For cases with very few observations, we investigated whether supplementing the data information with surgeons’ prior guesses helps to obtain better duration estimates. Finally, we used best fitting duration distributions to simulate the potential efficiency gains in OR scheduling.

RESULTS: The 3-parameter lognormal distribution provides the best results for the case durations of CPT-anesthesia (surgeon) combinations, with an acceptable fit for almost 90% of the CPTs when segmented by the factor surgeon. The fit is best for surgical times and somewhat less for total procedure times. Surgeons’ prior guesses are helpful for OR management to improve duration estimates of CPTs with very few (<10) observations. Compared with the standard way of case scheduling using the mean of the 3-parameter lognormal distribution for case scheduling reduces the mean overreserved OR time per case up to 11.9 (11.8–12.0) min (55.6%) and the mean underreserved OR time per case up to 16.7 (16.5–16.8) min (53.1%). When scheduling cases using the 4-parameter lognormal model the mean overutilized OR time is up to 20.0 (19.7–20.3) min per OR per day lower than for the standard method and 11.6 (11.3–12.0) min per OR per day lower as compared with the biased corrected mean.

CONCLUSIONS: OR case scheduling can be improved by using the 3-parameter lognormal model with surgeon effects and by using surgeons’ prior guesses for rarely observed CPTs. Using the 3-parameter lognormal model for case-duration prediction and scheduling significantly reduces both the prediction error and OR inefficiency.

METHODS: (A) Three years of operating room (OR) information system data were analyzed. Dependent variables were the earliest times when the numbers of ORs running were always ≤6 ORs, ≤4 ORs, and ≤2 ORs. We progressively built linear regression models for each of the three dependent variables using day of the week, scheduled number of cases, scheduled hours of cases (including turnovers), and linear time trend. Calculations were repeated after excluding residuals. Calculations were repeated using regression trees. (B) Anesthesiologists were surveyed about their perceptions of the mean and 80th percentiles.

RESULTS: (A) For the three thresholds and two end points (mean and 80th percentile), differences among days of the week were as large as 45 min. Differences between end points for the same weekdays were as large as 245 min. Comparatively, additional knowledge about the number or hours of cases provided in the late afternoon on the working day before surgery reduced the mean absolute error by only 4.1–6.0 min. Results were insensitive to a variety of analytic methods. Information available more days before the day of surgery (e.g., 1 wk) would have had even less incremental predictive value. (B) The mean absolute error of anesthesiologists’ estimates for 80th percentiles was 60 min, principally because of underestimation of the 80th percentiles. More than half (69%, P = 0.0003) of anesthesiologists’ estimates for 80th percentiles had error >30 min, whereas errors of this magnitude were less for the mean (44%, P = 0.0004).

CONCLUSIONS: Historical data from OR or anesthesia information management systems, or from anesthesia billing systems, can be used months before staff scheduling to provide insight to anesthesia providers on respective calls. The data are useful because experience provides limited intuition. Updates on scheduled workload available closer to the day of surgery provided only marginal increases in knowledge over the use of historical data.

METHODS: After implantation of a high-density 8 x 8 electrode array in the visual cortex, the patterns of LFP and multiunit spike activity were recorded in rats during 0.5, 1.0, 1.5, and 2.0 minimum alveolar anesthetic concentration (MAC) enflurane anesthesia. These recordings were compared with computer simulations from a mean field model of neocortical dynamics. The neuronal effect of increasing enflurane concentration was simulated by prolonging the decay time constant of the inhibitory postsynaptic potential (IPSP). The amplitude of the excitatory postsynaptic potential (EPSP) was modulated, inverse to the neocortical firing rate.

RESULTS: In the anesthetized rats, increasing enflurane concentrations consistently caused the appearance of suppression pattern (>1.5 MAC) in the LFP recordings. The mean rate of multiunit spike activity decreased from 2.54/s (0.5 MAC) to 0.19/s (2.0 MAC). At high MAC, the majority of the multiunit action potential events became synchronous with the PED. In the theoretical model, prolongation of the IPSP decay time and activity-dependent EPSP modulation resulted in output that was similar in morphology to that obtained from the experimental data. The propensity for rhythmic seizure-like activity in the model could be determined by analysis of the eigenvalues of the equations.

CONCLUSION: It is possible to use a mean field theory of neocortical dynamics to replicate the PED pattern observed in LFPs in rats under enflurane anesthesia. This pattern requires a combination of a moderately increased total area under the IPSP, prolonged IPSP decay time, and also activity-dependent modulation of EPSP amplitude.

METHODS: To test whether preconditioning with sevoflurane induces rapid ischemic tolerance, New Zealand White male rabbits were randomly assigned to three groups. Animals in the Sev group received preconditioning with 3.7% sevoflurane (1.0 minimum alveolar anesthetic concentration) in 96% oxygen for 30 min, whereas animals in the O₂ group serving as controls inhaled only 96% oxygen for 30 min. The Sham group received the same anesthesia and surgical preparation but no preconditioning or spinal cord I/R. To evaluate the role of ERK activation in sevoflurane preconditioning, rabbits were randomly assigned to four groups. U0126, an ERK inhibitor, was administered IV 20 min before the beginning of preconditioning in the U0126 + O₂ and U0126 + Sev groups. Dimethylsulfoxide was administered IV at the same time in the vehicle + O₂ and vehicle + Sev groups. At 1 h after preconditioning, the animals were subjected to spinal cord I/R induced by infrarenal aorta occlusion. All animals were assessed at 48 h after reperfusion with modified Tarlov criteria, and the spinal cord segments (L5) were harvested for histopathological examination, TUNEL staining, and Western blot of phosphor-ERK1/2.

RESULTS: The animals in the Sev group had higher neurological scores and more normal motor neurons than those in the O₂ group (P < 0.01 for each comparison). Compared with vehicle + Sev group, the U0126 + Sev group had worse neurological outcomes, fewer viable neurons, more apoptotic neurons, and significantly decreased ERK1/2 phosphorylation (P ≤ 0.01 for each comparison). There were no significant differences in the outcomes among vehicle + O₂, U0126 + O₂, and U0126 + Sev groups.

CONCLUSIONS: This study demonstrates that sevoflurane preconditioning induces rapid tolerance to spinal cord I/R in rabbits, and the tolerance is possibly mediated through the activation of ERK. These data suggest that sevoflurane preconditioning might provide a new practical method for protecting perioperative spinal cord I/R.

METHODS: Nineteen exons covering major hotspots were chosen for the primary screening by polymerase chain reaction, denaturing high performance liquid chromatography, and confirmed by direct sequencing.

RESULTS: Three novel variants involving amino acid changes were identified in two unrelated families as Met2698Arg, Glu2724Lys in exon 51 and Leu2785Val in exon 53.

CONCLUSIONS: Three novel ryanodine receptor isoform 1 variants located either near or within the central domain might predispose carriers to MH.

METHODS: Ninety-one women received IV oxycodone or morphine before the end of laparoscopic hysterectomy and then continued with patient-controlled analgesia for 24 h postoperatively.

RESULTS: The accumulated oxycodone consumption was less (13.3 ± 10.4 mg vs 22.0 ± 13.1 mg, P = 0.001) than morphine. With oxycodone, the visual analog scale scores were significantly lower in the first hour postoperatively and sedation was less during the 24-h postoperative period, P = 0.006.

CONCLUSIONS: Oxycodone was more potent than morphine for visceral pain relief but not for sedation.

METHODS: We studied IVD degenerative changes with pain development after a 10-µL CFA injection into the L5-6 IVD of adult rats using behavioral, histologic, and biochemical studies. Serial histologic changes were analyzed to detect degenerative changes. Expression of calcitonin gene-related peptide (CGRP), prostaglandin E (PGE), and inducible nitric oxide synthase (iNOS) were determined using immunohistochemistry or real-time polymerase chain reaction as support data for pain development. In addition, CGRP immunoreactivity (ir) at the IVD was considered indirect evidence of neural ingrowth into the IVD.

RESULTS: There was a significant increase of the hindpaw withdrawal response in the CFA group until 7 wk postoperatively (P < 0.05). Histologic analyses revealed progressive degenerative changes of the disks without any damage in adjacent structures, including nerve roots. In the CGRP-ir staining study, the bilateral dorsal horns and IVD had positive ir after intradiscal CFA injection. CGRP mRNA expression was increased in the dorsal root ganglion (DRG) at 2 and 4 wk, whereas PGE and iNOS mRNAs were markedly increased at 2 wk. The increment of CGRP expression was higher in allodynic rats compared with nonallodynic rats.

CONCLUSION: Intradiscal CFA injection led to chronic disk degeneration with allodynia, which was suggested by pain behavior and expression of pain-related mediators. The increment of CGRP, PGE, and iNOS also suggest pain-related signal processing between the IVD and the neural pathway in this animal model. This animal model may be useful for future research related to the pathophysiology and development of novel treatment for spine-related pain.

METHODS: Mechanical hypersensitivity was produced by injection of carrageenan (300 µg/20 µL) into the tibiotarsal joint of the right hind leg. The mechanical pain threshold was assessed by von Frey filaments (0.064-110 g). EM1 (30, 100, and 200 µg), KYNA (30, 100, 200, and 400 µg), and their combinations in a fixed-dose ratio (1:1) were injected into the inflamed joint, and the pain threshold was determined repeatedly for 75 min after the drug administrations.

RESULTS: Neither EM1 nor KYNA administered to the inflamed joint influenced the pain threshold at the noninflamed side. Both ligands produced dose-dependent antihyperalgesia, and the highest doses caused a prolonged effect. EM1 had higher potency (30% effective dose [ED₃₀] and 50% effective dose [ED₅₀] values were 112 µg [confidence interval {CI}: 80-146] and 167 µg [CI: 135-220], respectively) compared with KYNA (ED₃₀ and ED₅₀ values were 204 µg [CI: 160-251] and 330 µg [CI: 280-407], respectively). The antinociceptive effect of EM1 was prevented by subcutaneous naltrexone pretreatment. The coadministration of EM1 with KYNA caused an enhanced and/or prolonged antinociceptive effect. The ED₃₀ and ED₅₀ values of the combination were 141 µg [CI: 83-182] and 231 µg [CI: 190-293], respectively, which did not differ significantly from the theoretically additive values (ED₃₀ and ED₅₀ values were 145 µg [CI: 68-237] and 220 µg [CI: 144-230], respectively), thus the interaction between these ligands is additive. None of the treatments caused any sign of side effects.

CONCLUSION: Peripherally administered endogenous opioid agonist and NMDA receptor antagonist ligands might be beneficial in inflammatory pain. Because both drugs barely cross the blood-brain barrier, their local administration causes no central side effects.

METHODS: Mice received PSL; pERK1/2 (p44/42) in sciatic nerve was measured by both Western blotting and immunohistochemistry. U0126 (an ERK kinase inhibitor) was injected twice, an intraneural injection (20 nmol/2 µL) 30 min before PSL, and a perineural injection (20 nmol/10 µL) on Day 1 after PSL. Thermal hyperalgesia and tactile allodynia induced by PSL were evaluated by the thermal paw withdrawal test and the von Frey test, respectively.

RESULTS: As measured by Western blotting, in sham-operated mice, the levels of pERK1/2 in sciatic nerve were constant and the same as those in naive mice across Days 1-14. In PSL-operated mice, a significant increase in pERK1/2 was observed on Day 1 after PSL and persisted until Day 3. As measured by immunohistochemistry, immunoreactivity of pERK1/2 in PSL-operated sciatic nerve was markedly increased in comparison with that in sham-operated sciatic nerve on Day 1 after PSL. In the sciatic nerve on Day 1 after PSL, as indicated by double immunostaining, the increased immunoreactivity of pERK1/2 was colocalized with glial fibrillary acidic protein (GFAP), a marker of Schwann cells, but not F4/80, a marker of macrophages. PSL-induced thermal hyperalgesia was significantly attenuated by treatment with U0126 on Days 3, 7, and 14 after PSL. The PSL-induced tactile allodynia was also significantly attenuated by treatment with U0126 on Days 7 and 14 after PSL.

CONCLUSION: Activation of ERK in Schwann cells of the injured peripheral nervous system may play an important role in the development of neuropathic pain. Our results suggest that pERK itself and ERK-related mediators are potential therapeutic targets for the treatment of neuropathic pain.

METHODS: Male Wistar rats were anesthetized with sevoflurane and administered morphine and antidepressant drugs, or saline, through intrathecal injection. The antinociceptive effect was evaluated using the thermal withdrawal test before and after drug administration. The time for the withdrawal reaction was expressed as percentage of maximum possible effect (MPE). Animals were also pretreated with yohimbine (a nonselective alpha2-adrenergic antagonist) and naloxone (a nonselective opioid antagonist) for mechanism of action studies. Pharmacologic interaction was evaluated using isobolographic analysis of simultaneous administration of fixed proportions of maprotiline and morphine.

RESULTS: Single intrathecal administration of morphine (2 µg), amitriptiline (125 µg), citalopram (144 µg), and maprotiline (1.25 µg) produced 51.6% ± 8.9%, 10.3% ± 3.2%, 33.8% ± 5.2%, and 48.5% ± 9.2% MPE, respectively. The antinociceptive effect of morphine was increased when combined with amitriptyline (91.3% ± 4.6% MPE) and maprotiline (86.9% ± 9.2% MPE) but not with citalopram (40.6% ± 4.6% MPE). Coadministration of maprotiline increased the antinociceptive duration of morphine by 4-fold (from 120 to 480 min), which was reversed by pretreatment with the -2 adrenoceptor inhibitor, yohimbine, and the mu-type opioid receptor antagonist, naloxone. Isobolographic analysis demonstrated a synergistic interaction between morphine and maprotiline.

CONCLUSIONS: Selective norepinephrine reuptake inhibitors can significantly increase the intensity and duration of morphine antinociceptive activity via both ₂-adrenergic and opioid receptors. This interaction was not observed with the selective serotonin inhibitor, citalopram.

METHODS: Twenty-four adult male rats were divided into four groups: control, formalin test, restricted control, and restricted formalin test. Ten percent formalin was injected subcutaneously into the left rear paw of the formalin test and restricted formalin test groups. The control and formalin test group rats were kept in a clear plastic chamber, whereas the restricted control and restricted formalin test group rats were kept in a modified-restraint, pipe-shaped chamber. All rats were killed after 25 min. Twelve sections of the lumbar spinal cord were processed for p-ERK immunohistochemistry using the avidin-biotin peroxidase method.

RESULTS: The number of p-ERK positive cells in the restricted formalin test group was significantly higher than in the other three groups in the ipsilateral-side superficial dorsal horn (P < 0.05). However, there was no significant difference between the formalin test group and the two control groups in pERK expression.

CONCLUSION: Licking decreased pERK of the spinal cord of the formalin test group. The findings suggested that licking attenuated the pain of the formalin test.

METHODS: In the isolated rat heart, cardiac arrest was induced by administration of equipotent doses of bupivacaine, ropivacaine, and mepivacaine, respectively, followed by cardiac perfusion with or without lipid emulsion (0.25 mL · kg^–1 · min^–1). Subsequently, the times from the start of perfusion to return of first heart activity and to recovery of heart rate and rate-pressure product (to 90% of baseline values) were assessed.

RESULTS: In all groups, lipid infusion had no effects on the time to the return of any cardiac activity. However, recovery times of heart rate and rate-pressure product (to 90% of baseline values) were significantly shorter with the administration of lipids in bupivacaine-induced cardiac toxicity, but not in ropivacaine- or mepivacaine-induced cardiac toxicity.

CONCLUSIONS: These data show that the effects of lipid infusion on LA-induced cardiac arrest are strongly dependent on the administered LAs itself. We conclude that lipophilicity of LAs has a marked impact on the efficacy of lipid infusions to treat cardiac arrest induced by these drugs.

METHODS: Sixty patients undergoing hand surgery were randomly and blindly divided into three groups. All groups received IVRA lidocaine (3 mg/kg) diluted with saline to a total volume of 40 mL. Group 1 received IVRA lidocaine plus IV saline, Group 2 received IVRA lidocaine and paracetamol (300 mg) admixture plus IV saline, and Group 3 received IVRA lidocaine plus IV paracetamol (300 mg). Sensory and motor block onset time, tourniquet pain, and analgesic use were assessed during operation. After tourniquet deflation, visual analog scale (VAS) scores at 1, 2, 4, 6, 12, and 24 h, the time to first analgesic requirement, total analgesic consumption in first 24 h, and side effects were noted.

RESULTS: Onset of motor block was shorter and recovery of motor and sensory block was significantly longer in Group 2 (P < 0.05). Intraoperative VAS scores at intraoperative 20, 30, and 40 min were significantly lower in Group 2 (P < 0.05). Intraoperative fentanyl consumption (78 ± 12, 58 ± 14, 78 ± 11 µg, respectively) and the number of patients who required fentanyl for tourniquet pain (13 patients, 3 patients, 9 patients, respectively) were significantly less in Group 2 (P < 0.05). Time to postoperative fentanyl administration was also prolonged (15 ± 6, 25 ± 5, 15 ± 4 min, respectively) in Group 2 (P < 0.05). The quality of surgical anesthesia was better in Group 2 (P < 0.05). Postoperative VAS scores and time of initial analgesic requirement were similar among groups; however, the total amount of diclophenac use was less in Group 2 (P < 0.05).

CONCLUSION: The addition of paracetamol during IVRA with lidocaine decreased tourniquet pain, increased anesthesia quality, and decreased postoperative analgesic consumption.

METHODS: Seventy-five patients scheduled for lower limb surgery under combined spinal-epidural anesthesia were randomly allocated to one of three groups receiving intrathecal bupivacaine, levobupivacaine, or ropivacaine. The dose of local anesthetic was varied using up-down sequential allocation technique. The dose for the first patient in each group was 8 mg, and the dosing increment was set at 1 mg. Subsequent doses in each group were determined by the outcome in the previous patient using success or failure of the spinal anesthesia as the primary end point. A success was recorded if a bilateral T12 sensory block to cold was attained within 20 min after intrathecal injection, and the surgery proceeded successfully until at least 50 min after the intrathecal injection without supplementary epidural injection. The ED₅₀ was calculated using the method of Dixon and Massey.

RESULTS: The ED₅₀s were 5.50 mg for bupivacaine (95% confidence interval [CI]: 4.90–6.10 mg), 5.68 mg for levobupivacaine (95% CI: 4.92–6.44 mg), and 8.41 mg for ropivacaine (95% CI: 7.15–9.67 mg) in intrathecal anesthesia. The relative anesthetic potency ratios are 0.97 (95% CI: 0.81–1.17) for levobupivacaine/bupivacaine, 0.65 (95% CI: 0.54–0.80) for ropivacaine/bupivacaine, and 0.68 (95% CI: 0.55–0.84) for ropivacaine/levobupivacaine.

CONCLUSION: This study suggests that in intrathecal anesthesia for lower limb surgery, ropivacaine is less potent than levobupivacaine and bupivacaine, whereas the potency is similar between levobupivacaine and bupivacaine.

METHODS: Sixteen young, healthy volunteers entered the study. Spectral analysis of heart rate and systolic blood pressure variability was performed before and 30, 60, 90, and 120 min after either right or left stellate ganglion block, separated by a 1 to 11/2-mo interval, with 6 mL of 1% mepivacaine. Shortly after each spectral analysis, baroreflex sensitivity was assessed with the head-up tilt test.

RESULTS: Baroreflex sensitivity, assessed by the head-up tilt test, was significantly attenuated at 30 min after either right or left stellate ganglion block (1.26 ± 0.18 to 0.46 ± 0.08 bpm/mm Hg, P < 0.05 and 1.17 ± 0.35 to 0.51 ± 0.13 bpm/min, P < 0.01, respectively). Fractal slopes reflecting the degree of self-similarity of fluctuations were significantly increased at 30 min after either right or left stellate ganglion block (right stellate ganglion block—heart rate; –1.08 ± 0.30 to –1.62 ± 0.22, P < 0.01; right stellate ganglion block—systolic blood pressure; –1.30 ± 0.80 to –2.40 ± 0.80, P < 0.05; left stellate ganglion block—systolic blood pressure; –1.20 ± 0.40 to –2.13 ± 0.50, P < 0.05). Fractal slope did not change after left stellate ganglion block with heart rate variability analysis.

CONCLUSIONS: Loss of complexity (status of being complex behavior) of both heart rate and systolic blood pressure variability, indicated by increased fractal slopes, is one mechanism in attenuating baroreflex sensitivity after stellate ganglion block.

Postoperative quadriparesis, although infrequent, can occur through different causes and mechanisms. Central progression of an interscalene block can produce acute or subacute quadriparesis depending on technical factors of the placement of the local anesthetic and its subsequent spread. The symptomatology and the imaging enabled us to refine the differential diagnoses and to exclude other causes of neurologic compromise.

METHODS: We performed a prospective, controlled, randomized animal study (male Lewis rats n = 44). The interventions we used were intraperitoneal injection of Escherichia coli LPS (10 mg/kg) or vehicle followed by either DA (25 µg/kg) or vehicle (four experimental groups). Blood and reticulocyte counts and variables of iron metabolism were measured at baseline and 3 and 14 days after interventions.

RESULTS: Animals treated with DA alone showed an eightfold increase in reticulocyte count from baseline on Day 3, whereas no increase was seen in animals administered LPS or LPS/DA. On Day 14, the red blood cell count and hemoglobin concentration had increased by approximately 10% from baseline (P < 0.001) in the DA group but had decreased after LPS on Days 3 and 14 (P < 0.05) and in animals administered LPS/DA. Consumption of iron was seen on Day 3 in the DA group but not after LPS or LPS/DA combined. Values of ferritin and transferrin did not change between groups.

CONCLUSION: LPS abolishes erythropoiesis and iron use evoked by DA and this is accompanied by a decrease in hemoglobin concentration and red blood cell concentration. Accordingly, endotoxin suppresses DAs ability to increase erythropoiesis.

METHODS: We compared the anticoagulant effect of 10 concentrations of fondaparinux added to plasma samples with normal range (n = 25, antithrombin 95.4% ± 9.2%) and low antithrombin (n = 22, antithrombin 45.5% ± 13.2%) levels, using the Heptest coagulation assay.

RESULTS: Heptest clotting time was shorter at any given fondaparinux concentration in the antithrombin-deficient samples, indicating less anticoagulant effect than in the group with normal antithrombin levels. At a high fondaparinux concentration, a saturation effect is observed with no further increase in Heptest clotting time. Addition of antithrombin concentrates results in a shift of the dose-response curve. When antithrombin concentrate was added, Heptest clotting time increased up to a fondaparinux concentration of 10 µg/mL.

CONCLUSIONS: In the conventional prophylactic and therapeutic dose range, not only treatment with antithrombin concentrates but also an increase in fondaparinux dose normalizes the anticoagulant effect. A saturation effect is observed at high fondaparinux concentrations. Higher levels of antithrombin lead to an exaggerated effect of fondaparinux on Heptest.

METHODS: Demographics, medical history, height, and weight were recorded for 1000 consecutive day surgery patients aged 2–12 yr. In addition, 1000 day surgery patients (age 2–12 yr) undergoing general endotracheal anesthesia were enrolled. After tracheal intubation, a 14–18F orogastric tube was inserted and gastric contents evacuated. Medications, fasting interval, GFV, pH, and emetic episodes were documented. Age- and gender-specific Center for Disease Control and Prevention growth charts (2000) were used to determine ideal body weight (IBW = 50th percentile) and to classify patients as lean/normal (BMI 25th–75th percentile), overweight (BMI ≥85th to <95th percentile), or obese (BMI ≥ 95th percentile).

RESULTS: Of all day surgery patients, 14.0% were overweight and 13.3% were obese. Obese children had lower GFV per total body weight (P < 0.001). When corrected for IBW, however, volumes GFV(IBW) were identical across all BMI categories (mean 0.96 mL/kg, sd 0.71; median 0.86 mL/kg, IQR 0.96). Preoperative acetaminophen and midazolam contributed to increased GFV(IBW) (P = 0.025 and P = 0.001). Lower GFV(IBW) was associated with ASA physical status III (P = 0.024), male gender (P = 0.012), gastroesophageal reflux disease (P = 0.049), and proton pump inhibitor administration (P = 0.018). GFV(IBW) did not correlate with fasting duration or age. Decreased gastric fluid acidity was associated with younger age (P = 0.005), increased BMI percentile (P = 0.036), and African American race (P = 0.033). Emesis on induction occurred in eight patients (50% of whom were obese, P = 0.052, and 75% of whom had obstructive sleep apnea, P = 0.061). Emesis was associated with increased ASA physical status (P = 0.006) but not with fasting duration. There were no pulmonary aspiration events.

CONCLUSIONS: Twenty-seven percent of pediatric day surgery patients are overweight/obese. These children may be allowed clear liquids 2 h before surgery as GFV(IBW) averages 1 mL/kg regardless of BMI and fasting interval. Rare emetic episodes were not associated with shortened fasting intervals in this population.

METHODS: One hundred children scheduled for elective surgery and general anesthesia were included. VAS-anxiety was measured at four timepoints and compared with both versions of State Spielbergers’ questionnaires (State-Trait Anxiety Inventory for Youth [STAIY] and State-Trait Anxiety Inventory for Children [STAIC]) and the modified Yale Preoperative Anxiety Scale. Children’s pain, parents’ anxiety, and parents’ proxy report of children’s anxiety were evaluated using VAS.

RESULTS: The correlation between STAIC and VAS-anxiety was significant on the day of discharge. Moreover, changes over time were not significant with STAIC, whereas VAS-anxiety was significantly sensitive to changes over time in the two groups of age (7–11 yr and 12–16 yr). A receiver operating characteristic curve, using modified Yale Preoperative Anxiety Scale as reference, determined a VAS-anxiety cutoff at 30 to identify high-anxiety groups. Pain levels were significantly higher when children were anxious (VAS ≥30) in the postoperative period. Moreover, children’s anxiety and pain were higher when parents were anxious.

CONCLUSION: VAS-anxiety is a useful and valid tool to assess perioperative anxiety in children aged 7–16 yr. The influence of children’s and parents’ anxiety on children’s postoperative pain suggests that VAS-anxiety should be recommended routinely for postoperative clinical practice to optimize anxiety and pain management.</