Glucose response during craniotomy: propofol-remifentanil versus isoflurane-remifentanil.

BACKGROUND: Major surgery is associated with a stress response. The aim of this study was to compare the effects of isoflurane or propofol, both supplemented with remifentanil, on the glucose, cortisol and insulin-based stress responses prospectively. METHODS: Forty patients undergoing craniotomy randomly received either 1% isoflurane (Group I, N.=20) or propofol 6 mg kg h(-1) (Group P, N.=20) during remifentanil-based (0.125 µg kg min(-1)) anesthesia. Blood glucose was recorded preoperatively, after induction, intubation and pin placement, before and after skin incision, craniotomy, dura incision, 15th, 30th, 60th, 90th, 120th, 150th, 180th min post-dura incision, following dura and skin closure, extubation and at the 1st and 24th postoperative hours. Insulin and cortisol were measured preoperatively, after intubation, dura incision, at the 60th min, extubation and at the 1st and 24th hour postoperatively. The glucose/insulin ratio and glycemic stress index were calculated after all the measurements were obtained. RESULTS: Patient characteristics were comparable in both groups. Blood glucose significantly decreased after induction in comparison to the baseline value in both groups. Blood glucose was significantly higher in Group I than Group P before skin incision, after craniotomy and dura incision and at all measurement time points after the 60th minute following dura incision. There was a significant alteration with time in insulin values in both groups and the insulin values at the 60th min were significantly lower in Group I than in Group P. There was not any difference in the inter-group analysis of cortisol; however, there was a significant change over time in the insulin values in both groups. There was no difference in the intra-group glucose/insulin ratio, however, there was a significant difference between groups at the 60th min and at extubation. The Glycemic Stress Index was comparable between groups (Group I vs. Group P: 2.48±1.15 vs. 2.15±0.86, P=0.465). CONCLUSION: Isoflurane and propofol, both combined with remifentanil, provided clinically comparable cortisol and insulin responses to surgery in craniotomy operations, whereas propofol attenuated the increase in plasma blood glucose.

Inhalation versus total intravenous anesthesia for lumbar disc herniation: comparison of hemodynamic effects, recovery characteristics, and cost.

The clinical effects, recovery characteristics, and costs of total intravenous anesthesia (TIVA), sevoflurane, and isoflurane anesthesia have been measured in various out-patient operations, but have not been evaluated in patients undergoing laminectomy or discectomy. In the current study, the authors assessed the hemodynamic characteristics, recovery, and cost analyzes after laminectomy and discectomy operations, comparing TIVA, sevoflurane, and isoflurane anesthesia. Sixty American Society of Anesthesiologists I and II patients were randomly divided into three groups, each consisting of 20 patients. Group I received propofol-alfentanil, Group 2 received sevoflurane-N2O, and Group 3 received isoflurane-N2O. At the end of surgery, the anesthetics were discontinued, and recovery from anesthesia was assessed by measuring the time until spontaneous eye opening and the time until response to verbal commands. The drug and delivery costs were calculated in United States dollars. No significant differences were found in the demographic data. Heart rate and mean arterial pressure decreased significantly after induction of anesthesia in the TIVA group, compared to the two other groups ( P < .05 for both comparisons). The fastest recovery was seen in the TIVA group. Incidences of postoperative nausea, vomiting, and pain were significantly reduced after TIVA ( P < .05 for both comparisons). Thus, TIVA patients required fewer additional drugs and showed the lowest additional costs in the post-anesthesia care unit. However, the total cost was significantly higher in the TIVA group than in the sevoflurane and isoflurane groups (52.73 dollars, 29.99 dollars, and 24.14 dollars, respectively) ( P < .05). Total intravenous anesthesia was associated with the highest intraoperative cost but provided the most rapid recovery from anesthesia, and the least frequent postoperative side effects.

The effects of intravenous fentanyl and lidocaine infiltration on the hemodynamic response to skull pin placement.

The aim of this study was to evaluate the effects of intravenous fentanyl and local lidocaine infiltration on the hemodynamic response to Mayfield skull pin head holder (MH) placement. Forty-five patients scheduled for elective craniotomy were studied. They were randomly divided into three groups. Group F received fentanyl 2 microg/kg IV 5 min before placement of the MH, group L was administered plain lidocaine 3 ml 1% by infiltration at each pin site 1 minute before placement, and both methods were applied together in group FL. Mean blood pressure (MAP) and heart rate (HR) were recorded at 5 preset times. In group F during and after MH placement, MAP and HR were significantly higher than in the L and FL groups. In the L group, there was significantly higher MAP and HR during the placement of MH than in the FL group. In the FL group, there was no significant increase in MAP or HR at any time of the recordings. We conclude that intravenous fentanyl with local infiltration of lidocaine into the periosteum is effective in reducing the hemodynamic response to MH placement in patients undergoing craniotomy.

Seasonal variation in the effect of a fixed dose of heparin on activated clotting time in patients prepared for open-heart surgery.

We investigated the effect of an injected bolus of 5 mg kg(-1) heparin at one circadian stage (08:30 to 11:00) on blood coagulation during different months of the year. Activated clotting times (ACTs) were assessed before and 5 min after heparin dosing to ensure extracorporeal circulation during open-heart surgery. The ACT data of 1083 presumably day-active Turkish patients (816 men and 267 women, mostly older than 46 years) who underwent coronary bypass surgery between 08:30 and 11:00 in the years from 1994 to 1997 were analyzed for annual rhythmicity. The ACT values obtained just before and 5 min after heparinization were subjected to cosinor analysis using a 365.25-day period to assess seasonality in basal ACT level and heparin effect. A small-amplitude annual rhythm with a wintertime peak was documented in the morning ACT in the group of 1083 patients. Rhythms of similar magnitude and staging were also detected in heparin effect on ACT in the 1083 patients and in subgroups categorized by gender. Circannual rhythmicity in the heparin effect on ACT was also documented in the elderly (> or = 45 years old), but not young (18-45 years old) patients. The annual mean effect of heparin on the ACT was statistically significantly greater in younger than older patients. The relatively low-amplitude circannual rhythm in heparin effect on ACT (approximately 10% of the annual mean) is not viewed as being meaningful in patient preparation for bypass surgery for the 5 mg kg(-1) level of heparin dose.

The effects of intravenous fentanyl and lidocane infitration on the haemodynamic response to skull placement.

The aim of this study is to evaluate the effects of intravenous fentanyl and local lidocaine infiltration on the haemodynamic response to Mayfield skull pin head holder (MH) placement. Forty-five patients scheduled for elective craniotomy were studied. They were randomly divided into three groups. Group F received 2 microg/kg(-1) fentanyl i.v. 5 min before placement of the MH, group L was administered 3 ml 1% plain lidocaine by infiltration at each pin site 1 minute later and before placement of the MH, and both methods were applied together in group FL. Mean arterial blood pressure (MAP) and heart rate (HR) were recorded at 5 preset times. Both were significantly increased during and after MH placement in group F compared to groups L and FL. In group L, there was a significant increase in MAP and HR during the placement of MH compared to group FL. In group FL, there was no significant increase in MAP or HR at any time of the recordings. We conclude that intravenous fentanyl with local infiltration of lidocaine into the periosteum is effective in reducing the haemodynamic response to MH placement in patients undergoing craniotomy.

Serum uric acid levels in cardiovascular diseases.

OBJECTIVE: Comparison of the serum uric acid levels of healthy people (n=71) and patients with cardiovascular diseases (CVD) (n=62). SUBJECTS AND METHODS: The patients included had either experienced acute myocardial infarction (AMI) (n=31), atherosclerosis (AT) (n=23) or ischaemia (n=8). The mean values (x+/-SD) of serum uric acid levels of the control group, the patients with CVD as a whole, and patients with AMI, AT and ischaemia were 4.15+/-0.45 mg%, 5.6+/-2.06 mg%, 5.96+/-2.60 mg%, 5.38+/-1.22 mg% and 4.94+/-1.40 mg%, respectively. A statistically higher level of serum uric acid was found in the controls compared to the CVD patients (P < 0.05). CONCLUSION: The higher serum uric acid levels found in CVD patients suggests that any protective antioxidant effect which uric acid has is overwhelmed by other negative effects on pathogenesis.

Pulmonary microvascular injury following general anaesthesia with volatile anaesthetics--halothane and isoflurane: a comparative clinical and experimental study.

Pulmonary microvascular injury has become a recently studied phenomenon that may be responsible for most of the complications associated with the lungs. Thirty patients undergoing partial hemilaminectomy or discectomy due to hernia of nucleus pulposus underwent Tc-99m HMPAO lung clearance as well as Tc-99m pertechnetate lung scintigraphy pre-operatively, and following general anaesthesia with halothane and isoflurane (third, fourth and tenth post-operative days). The results were compared with conventional techniques and haemodynamic parameters during the peri-operative period. In order to demonstrate acute phase changes under general anaesthesia and to perform pathological examinations, 21 New Zealand rabbits underwent radionuclide studies with Tc-99m HMPAO or Tc-99m pertechnetate. Lung biopsies were also performed. Despite no significant differences in any of the conventional diagnostic techniques, Tc-99m pertechnetate lung scintigraphy was performed for both the halothane and isoflurane groups, and Tc-99m HMPAO lung clearance was performed for the isoflurane group pre- or post-operatively. Tc-99m HMPAO lung clearance was impaired significantly in the halothane group on the third post-operative day (half time: 6.4 +/- 1.6 pre-operative and 13.76 +/- 3.3 s, P < 0.001) decreasing to pre-operative levels on the tenth post-operative day. Acute phase exposure to halothane was characterized with extremely abnormal Tc-99m HMPAO lung clearance in rabbits with respect to isoflurane, diminishing to control levels on the third day (half time: 8.7 +/- 86 control and 28.65 +/- 4.6, P < 0.001). Pathological examinations also demonstrated endothelial damage on acute exposure in the halothane group. General anaesthesia with halothane may give rise to alveolar microvascular injury, which generally seems to be underdiagnosed and may lead to serious post-operative complications.

Serum carotenoids and uric acid levels in relation to cancer.

We studied the levels of serum total carotenoids and uric acid in newly diagnosed cancer cases. The levels of carotenoids and uric acid in serum samples from 94 subjects with cancer affecting different sites (21 breast, 26 head and neck, 13 lung, 17 genitourinary and 17 other sites) were compared with those of 92 controls who were matched for age, sex, Quetelet index and smoking history. Mean (+/- SE) levels of carotenoids were significantly lower among the cases than the controls (51.41 +/- 3.32 vs. 102.75 +/- 4.52 micrograms/dl, P < 0.001), when all the different sites were considered together. The mean (+/- SE) uric acid levels among cases and controls were 5.14 +/- 0.16 mg/dl and 4.21 +/- 0.18 mg/dl (P < 0.001), respectively. It was of interest that patients with genitourinary cancer had the lowest serum carotenoids levels, and the highest levels were found in patients with breast cancer. These results are informative but do not establish a causal link. There was no apparent association between serum urate levels and cancer site. The data presented here do not provide support for the protective antioxidant properties of uric acid in cancer.

Serum levels of vitamin E in relation to cardiovascular diseases.

Serum vitamin E levels in healthy people (n = 71) and patients with cardiovascular diseases (n = 62) were determined. The cases of cardiovascular disease comprised patients with acute myocardial infarction (AMI) (n = 31), atherosclerosis (AT) (n = 23) and myocardial ischaemia (MI) (n = 8). The mean (+/- SD) serum vitamin E levels of the control group and the group with cardiovascular disease were 1.12 +/- 0.27 mg% and 0.98 +/- 0.41 mg%, respectively. Patients with AMI, AT and MI had corresponding levels of 0.97 +/- 0.48 mg%, 1.00 +/- 0.39 mg% and 1.01 +/- 0.44 mg%, respectively. Overall serum vitamin E levels were lower in the group with cardiovascular disease than in the control group. Patients and the control group are also discussed with respect to a number of potentially confounding parameters such as age, sex, smoking status, quetelet index (kg/m2), alcohol consumption, dietary intake and serum lipids.

Serum beta-carotene, vitamin E, vitamin C and malondialdehyde levels in several types of cancer.

We measured the levels of serum carotenoids (beta-carotene), total tocopherol (vitamin E), ascorbic acid and malondialdehyde (MDA) in newly diagnosed cancer cases. Levels of the antioxidants and MDA in serum samples from 208 subjects with cancer affecting different sites (59 breast, 38 head and neck, 46 genitourinary, 12 lung, 20 gastrointestinal and 33 other sites) were compared with levels in 156 controls. Cases and controls were compared with respect to a number of potentially confounding factors: age, sex, smoking status, Quetelet index (kg/m2), diet and alcohol intake. Mean (+/- SD) levels of beta-carotene, vitamin E and vitamin C were significantly lower among the cases than the controls (49.35 +/- 36.55 micrograms/l, 0.60 +/- 0.14 mg/dl, 0.40 +/- 0.27 mg/dl and 75.31 +/- 28.59 mg/dl, 0.98 +/- 0.13 mg/dl, 0.88 +/- 0.47 mg/dl, respectively) (P < 0.05). On the other hand, mean levels of MDA were significantly higher among the cases than the controls (6.79 +/- 1.22 nmol/ml and 3.52 +/- 0.97 nmol/ml, respectively) (P < 0.05). The results obtained suggest that measurement of serum antioxidants and MDA levels may provide further useful information when evaluating cancer patients.

Evaluation of serum beta-carotene levels in patients with cardiovascular diseases.

Serum beta-carotene levels in patients with cardiovascular disease and control subjects were measured. The mean values for beta-carotene were found to be 82.2 +/- 3.5 micrograms/dl for the cases as a single group, 74.83 +/- 5.6 micrograms/dl in acute myocardial infarction (AMI) cases, 88.19 +/- 6.1 micrograms/dl in atherosclerotic cases, 85.11 +/- 6.1 micrograms/dl in others and 118.2 +/- 4.3 micrograms/dl in controls. beta-carotene levels in the cases were significantly lower than in the controls (P < 0.05). Serum beta-carotene levels in cases and controls were also compared to take account of age, sex and smoking status. Our data indicate that there are apparent associations between serum beta-carotene levels, sex and smoking status.

Subperiosteal intraorbital haematoma following minor head trauma. Case report.

Subperiosteal haematoma of the orbit following minor head trauma is extremely rare. A 5-year-old girl is presented with bilateral proptosis, chemosis, extraocular palsy, and progressive visual loss after minor head trauma. She had no evidence of fracture or abnormality of coagulation. The intraorbital haematoma resulted most probably from the oozings of a subgaleal haemorrhage which entered the subperiosteal space and then dissected over the supraorbital ridge into the orbit.