Hemodynamic and hormonal stress responses to endotracheal tube and ProSeal Laryngeal Mask Airway™ for laparoscopic gastric banding.

BACKGROUND: The stress responses from tracheal intubation are potentially dangerous in patients with higher cardiovascular risk, such as obese patients. The primary outcome objective of this study was to test whether, in comparison with the endotracheal tube (ETT), the Proseal™ Laryngeal Mask Airway (PLMA™) (Laryngeal Mask Airway Company, Jersey, United Kingdom) reduces blood pressure and norepinephrine responses and the amounts of muscle relaxants needed in obese patients. METHODS: We assessed hemodynamic and hormonal stress responses, ventilation, and postoperative recovery in 75 morbidly obese patients randomized to receive standardized anesthesia with either an ETT or the PLMA™ for laparoscopic gastric banding. RESULTS: In repeated-measures ANOVA, mean arterial blood pressure and plasma norepinephrine were significantly higher in the ETT group than in the PLMA™ group. In individual pairwise comparisons, blood pressure rose higher in ETT than PLMA™ patients after insertion and removal of airway devices, and after recovery. In ETT compared with PLMA™ patients, plasma norepinephrine was higher after induction of carboperitoneum (mean ± SD, 534 ± 198 and 368 ± 147 and pg/ml, P = 0.001), after airway device removal (578 ± 285 and 329 ± 128 pg/ml, P < 0.0001), and after recovery in postanesthesia care unit (380 ± 167 and 262 ± 95 and pg/ml, P = 0.003). Compared with use of the ETT, the PLMA™ reduced cisatracurium requirement, oxygen desaturation, and time to discharge from both the postanesthesia care unit and the hospital. CONCLUSIONS: PLMA™ reduces stress responses and postoperative complaints after laparoscopic gastric banding.

Vertebral fractures assessed with dual-energy X-ray absorptiometry in patients with Addison's disease on glucocorticoid and mineralocorticoid replacement therapy.

PURPOSE: to assess bone damage and metabolic abnormalities in patients with Addison's disease given replacement doses of glucocorticoids and mineralocorticoids. METHODS: A total of 87 patients and 81 age-matched and sex-matched healthy controls were studied. The following parameters were measured: urinary cortisol, serum calcium, phosphorus, creatinine, 24-h urinary calcium excretion, bone alkaline phosphatase, parathyroid hormone, serum CrossLaps, 25 hydroxyvitamin D, and 1,25 dihydroxyvitamin D. Clear vertebral images were obtained with dual-energy X-ray absorptiometry in 61 Addison's disease patients and 47 controls and assessed using Genant's classification. RESULTS: Nineteen Addison's disease patients (31.1%) had at least one morphometric vertebral fracture, as opposed to six controls (12.8%, odds ratio 3.09, 95% confidence interval 1.12-8.52). There were no significant differences in bone mineral density parameters at any site between patients and controls. In Addison's disease patients, there was a positive correlation between urinary cortisol and urinary calcium excretion. Patients with fractures had a longer history of disease than those without fractures. Patients taking fludrocortisone had a higher bone mineral density than untreated patients at all sites except the lumbar spine. CONCLUSIONS: Addison's disease patients have more fragile bones irrespective of any decrease in bone mineral density. Supra-physiological doses of glucocorticoids and longer-standing disease (with a consequently higher glucocorticoid intake) might be the main causes behind patients' increased bone fragility. Associated mineralocorticoid treatment seems to have a protective effect on bone mineral density.