Treatment of double vessel coronary artery disease by totally endoscopic bypass surgery and drug-eluting stent placement in one simultaneous hybrid session.

Hybrid coronary artery revascularization is a combination of minimally invasive coronary artery surgery and catheter-based coronary intervention. Hybrid procedures enable adequate revascularization of patients with multivessel coronary artery disease without complete opening of the chest and with the advantage of the most durable option, a left internal mammary artery (LIMA) graft is placed to the left anterior descending (LAD) artery. The hybrid concept is gaining renewed interest because totally endoscopic LIMA to LAD placement has become feasible and because drug-eluting stents in non-LAD targets may be competitive even for arterial bypass grafts. Simultaneous hybrid procedures would be desirable. We report on a case in which robotic totally endoscopic LIMA to LAD grafting using the da Vinci telemanipulation system was combined with placement of a rapamycin coated stent to the right coronary artery in one single procedure.

Evaluation of remifentanil as single drug for awake fiberoptic intubation.

BACKGROUND: Awake fiberoptic intubation is the standard of care for difficult airway management. Quality and success of this technique depend on the experience of the intubating physician and the proper preparation of the patient. The aim of this study was to compare remifentanil (R) as single agent to the combination of fentanyl (F) and midazolam (M), which have been the drugs for analgesia and sedation for this procedure. METHODS: Seventy-four adult patients requiring nasotracheal intubation were randomly assigned to one of two groups. In group I, (n=37) R was administered in incremental dosages (0.1-0.25-0.5 microg/kg/min) by an infusion pump according to comfort, level of sedation and respiratory depression. In group II, (n=37) analgesia and sedation was achieved by F 1.5 microg/kg and doses of between 1 and 10 mg M, titrated to the individual needs. Patient reactions like grimacing, movement and coughing during intubation were assessed, as well as patient recall of the procedure. Haemodynamic and respiratory parameters were continuously recorded. RESULTS: Group I patients better tolerated nasal tube passage (P<0.001) and laryngeal tube advancement (P<0.001) than group II. Remifentanil better suppressed hemodynamic response to nasal intubation (P<0.001). No significant difference in respiratory data was recorded. In group I more recall of the procedure was observed (six vs. zero patients, P<0.05). CONCLUSION: Remifentanil in high doses, as the single agent for patient preparation for awake fiberoptic intubation seems to improve intubating conditions, quality and reliability of the procedure. However, a higher incidence of recall is to be expected.

Aerosolized PGE1, PGI2 and nitroprusside protect against vascular leakage in lung ischaemia-reperfusion.

High permeability oedema is an important feature in lung injury secondary to ischaemia-reperfusion. This study investigated the influence of aerosolized prostaglandin E1 (PGE1), prostaglandin I2 (PCI2) and the nitric oxide (NO)-donor, sodium nitroprusside (SNP) on microvascular barrier function in pulmonary ischaemia-reperfusion. Buffer-perfused rabbit lungs were exposed to 180 or 210 min of warm ischaemia while maintaining anoxic ventilation and a positive intravascular pressure. Reperfusion provoked a transient, mostly precapillary elevation of vascular resistance, followed by a severe increase of the capillary filtration coefficient (Kfc) versus nonischaemic controls (3.17+/-0.34 versus 0.85+/-0.05 cm3 x s(-1) cmH2O(-1) x g(-1) x 10(-4) after 30 min of reperfusion), and progressive oedema formation. Short-term aerosolization of SNP, PGE1 or PGI2 at the beginning of ischaemia largely suppressed the Kfc increase (1.36+/-0.22, 1.32+/-0.23 and 1.32+/-0.22 cm3 x s(-1) x cmH2O(-1) x g(-1) x 10(-4), respectively) and oedema formation. In contrast, application prior to reperfusion was much less effective, with some reduction of Kfc increase by PGI2 and SNP and no effect of PGE, (1.79+/-0.31, 2.2+/-0.53 and 3.2+/-0.05 cm3 x s(-1) x cmH2O(-1) x g(-1) x 10(-4), respectively). Haemodynamics, including microvascular pressure, were only marginally affected by the chosen doses of aerosolized vasodilators. It is concluded that short-term aerosolization of prostaglandin E1, prostaglandin I2 and sodium nitroprusside at the onset of ischaemia is highly effective in maintaining endothelial barrier properties in pulmonary ischaemia-reperfusion. This effect is apparently attributable to nonvasodilatory mechanisms exerted by these agents. Alveolar deposition of prostaglandins and/or nitric oxide donors by the aerosol technique may offer pulmonary protection in ischaemia-reperfusion injury.

Protection against gas exchange abnormalities by pre-aerosolized PGE1, iloprost and nitroprusside in lung ischemia-reperfusion.

BACKGROUND: Development of severe gas exchange abnormalities and respiratory failure is a major threat in lung transplantation. METHODS: We used a model of ischemia-reperfusion injury in buffer-perfused rabbit lungs, with gas exchange conditions being analyzed in detail by the multiple inert gas elimination technique. A total of 150 min of warm ischemia was performed, and anoxic ventilation and a positive intravascular pressure were maintained throughout the ischemic period. RESULTS: Reperfusion provoked a transient, mostly precapillary pulmonary artery pressure elevation and progressive lung edema formation attributable to increased capillary permeability. Severe ventilation-perfusion mismatch with predominance of shunt flow became apparent within minutes after onset of reperfusion. 5 min-aerosolization maneuvers for alveolar deposition of prostaglandin E1, the long-acting prostacyclin analogue iloprost or the nitric oxide donor agent sodium nitroprusside were undertaken at the onset of ischemia. All preaerosolized vasodilator agents markedly reduced the pulmonary artery pressure elevation and the leakage response upon reperfusion. Most impressively, maintenance of physiological ventilation-perfusion matching was achieved by these maneuvers, and the development of shunt flow was largely suppressed. CONCLUSIONS: Preischemic alveolar deposition of PGE1, iloprost, and sodium nitroprusside by aerosol technique is highly effective in conserving normal pulmonary hemodynamics, microvascular integrity, and physiological gas exchange conditions upon reperfusion. This approach may offer as new strategy for maintenace of pulmonary function in lung transplantation.

A subanesthetic concentration of sevoflurane increases regional cerebral blood flow and regional cerebral blood volume and decreases regional mean transit time and regional cerebrovascular resistance in volunteers.

Inhaled anesthetics exert metabolically mediated effects on cerebral blood vessels both directly and indirectly. We investigated the effects of a 0.4 minimum alveolar subanesthetic concentration of sevoflurane on regional cerebral blood flow (rCBF), regional cerebral blood volume (rCBV), regional cerebrovascular resistance (rCVR), and regional mean transit time (rMTT) in volunteers by means of contrast-enhanced magnetic resonance imaging perfusion measurement. Sevoflurane increased rCBF by 16% to 55% (control, 55. 03 +/- 0.33 to 148.83 +/- 1.9 mL. 100 g(-1). min(-1); sevoflurane, 71.75 +/- 0.36 to 193.26 +/- 2.14 mL. 100 g(-1). min(-1)) and rCBV by 7% to 39% (control, 4.66 +/- 0.03 to 10.04 +/- 0.12 mL/100 g; sevoflurane, 5.04 +/- 0.03 to 13.6 +/- 0.15 mL/100 g); however, sevoflurane decreased rMTT by 7% to 18% (control, 3.75 +/- 0.04 to 5. 39 +/- 0.04 s; sevoflurane, 3.4 +/- 0.03 to 4.44 +/- 0.03 s) and rCVR by 22% to 36% (control, 0.74 +/- 0.01 to 1.9 +/- 0.2 mm Hg/[mL. 100 g(-1). min(-1)]; sevoflurane, 0.54 +/- 0.01 to 1.41 +/- 0.01 mm Hg/[mL. 100 g(-1). min(-1)]). Interhemispheric differences in rCBF, rCBV, and rCVR were markedly reduced after the administration of sevoflurane. These findings are consistent with the known direct vasodilating effect of sevoflurane. The decrease in rMTT further shows that rCBF increases more than does rCBV. Furthermore, we can show that the observed increase in rCBF during inhalation of sevoflurane is not explained by vasodilation alone.

Smoking does not alter the dose-requirements and the pharmacodynamics of rocuronium.

PURPOSE: Controversial data about the effect of smoking on the dose-requirements and the pharamcodynamics of rocuronium have been reported recently. This study was conducted to evaluate the dose-requirements and the pharmacodynamics of rocuronium in smokers using target controlled infusion. METHODS: The dose-requirements of rocuronium for 60 min relaxation, using target controlled infusion, given under intravenous anaesthesia with propofol, fentanyl and nitrous oxide was studied in 37 smokers and 37 non-smokers. Initially 450 microg x kg(-1) rocuronium were administered, neuromuscular effects were quantified by recording the single twitch response of the adductor pollicis muscle after ulnar nerve stimulation using a force transducer, and the neuromuscular block was kept at 80% by target controlled infusion throughout the procedure. RESULTS: The dose-requirements for one hour relaxation were 867 +/- 116 microg x kg(-1) x hr(-1) for smokers (S) and 839 +/- 149 microg x kg(-1) x hr(-1) for non-smokers (NS). The duration to 10% and the spontaneous recovery from 25% to 75% of the control twitch response also showed no differences between S (17.2 +/- 3.4 min, 10.6 +/- 0.9 min) and NS (18.9 +/- 4.3 min, 10.9 +/- 3.2 min), as well as maximum block, onset time and infusion rate. CONCLUSION: Smoking does not alter the dose-requirements for rocuronium and no effects on the onset time, degree of block, time to maximum block, duration 10% and spontaneous recovery index were observed.

[The effect of different priming doses on the pharmacodynamics of cisatracurium]. / Die Wirkung unterschiedlicher Primingdosierungen auf die Pharmakodynamik von Cisatracurium.

OBJECTIVE: The aim of the study was to evaluate the effect of two different priming regimen on the onset time of 100 micrograms/kg cisatracurium, when compared to bolus administration. METHODS: 51 patients were randomly assigned and received either a bolus of 100 micrograms/kg cisatracurium, or a priming dose of 10 micrograms/kg cisatracurium followed after 4 min by 90 micrograms/kg cisatracurium, or a priming dose of 15 micrograms/kg cisatracurium followed after 4 min by 85 micrograms/kg cisatracurium. The neuromuscular monitoring was performed using a mechanomyograph (Groningen II Monitor). Anaesthesia was induced with propofol and fentanyl and maintained by continuous infusion of propofol. RESULTS: The priming combination of 15 micrograms/kg cisatracurium followed after 4 min by 85 micrograms/kg cisatracurium produced a statistically significant reduction in the onset time (95% block) (180 +/- 60 s) and time to complete block (210 +/- 48 s), when compared to the bolus group (240 +/- 60 s and 288 +/- 66 s) (p < 0.05). CONCLUSION: Our data indicate that the "priming principle" is an appropriate technique to shorten the onset time of cisatracurium. To achieve a maximum effect the priming combination of 15 micrograms/kg cisatracurium followed after 4 min by 85 micrograms/kg cisatracurium is recommended.

National publication output in medical research.

OBJECTIVE: Both the total number of publications and the number of publications in high-ranking journals determine a country's reputation in scientific research. A predominance of national authors in a country's international high-ranking journals has occasionally been presumed. We therefore analysed the publication output of various countries and the proportion of national authors in international high-ranking journals. METHODS: The database EMBASE (Excerpta Medica) by means of the online service Dialog was used to analyse the national publication output of various countries during the years 1986 to 1990 and 1991 to 1995 and the proportion of national authors in The Lancet and The New England Journal of Medicine (NEJM.). RESULTS: American and British publications played the leading roles in the total number of medical publications from 1986 to 1990 (35.6% and 8.8%, respectively) and also from 1991 to 1995 (34.3% and 9.1%, respectively). A more detailed analysis revealed an unexpectedly high national publication output (publications per million inhabitants) of smaller countries, which exceeded that of larger nations during both periods studied (national publication output 1986-90 vs. 1991-95: Israel: (3386 vs. 3447), Sweden: (3303 vs. 3620), Switzerland: (2930 vs. 3722), Denmark: (2884 vs. 3167), UK: (2186 vs. 2825), USA: (2042 vs. 2388)). Furthermore, the proportion of national authors during both periods (1986-90 vs. 1991-95) studied was 41.8% vs. 34.1% in the case of The Lancet and 77.9% vs. 69.5% in the case of The New England Journal of Medicine. CONCLUSIONS: The present study found an unexpectedly high national publication output of smaller countries as well as a clearly disproportionate number of published articles from national authors in The Lancet and the NEJM during the years 1986 to 1990 and 1991 to 1995.