Anaesthetic depth control using closed loop anaesthesia delivery system vs. target controlled infusion in patients with moderate to severe left ventricular systolic dysfunction.

OBJECTIVES: To compare the efficacy of anaesthetic depth control using Closed Loop Anaesthesia Delivery System (CLADS) and Target Controlled Infusion (TCI) in patients with moderate to severe left ventricular dysfunction (LVSD). DESIGN: Randomized control trial. PATIENTS: Forty ASA III/IV adult patients with moderate to severe LVSD scheduled for open heart surgery. INTERVENTIONS: Propofol was administered using CLADS or TCI for maintaining BIS of 50. Induction and maintenance doses were controlled automatically in CLADS. Dixon's up and down method was used to estimate the plasma concentration needed for induction in TCI. MEASUREMENT: Percentage of total anaesthesia time ("valid CLADS time") for which BIS remained within ±10 of target (BIS=50). MAIN RESULTS: BIS remained within ±10 of the target for a significantly longer duration of time in CLADS group (p=0.001). Performance parameters like Median Performance Error (MDPE), p=0.024; Median Absolute Performance Error (MDAPE), p=0.0212; and global score p=0.017 were significantly better in CLADS group. Total propofol consumption was significantly less in CLADS group (p=0.014). Mean value (95% CI) of EC50 and EC95 for target plasma propofol concentration for induction was 1.62 (1.45-1.79) µgml-1 and 1.87 (1.73-2.96) µgml-1 respectively using probit analysis. CONCLUSIONS: Closed loop delivery of propofol using CLADS performed significantly better than TCI in this subset of patients. CLINICAL TRIALS REGISTRATION NO.: www.ClinicalTrials.gov-NCT02645994.

Effect of intravenous ondansetron on sensory and motor block after spinal anaesthesia with hyperbaric bupivacaine.

Ondansetron is a potent antiemetic and a competitive antagonist at serotonin receptors, which are also involved in modulation of pain. This study was designed to assess the effect of systemic ondansetron on sensory and motor block after subarachnoid anaesthesia with hyperbaric bupivacaine. Sixty patients undergoing transurethral resection of bladder tumours were randomly assigned to one of two groups. Group 1 received 2 ml (4 mg) of ondansetron whereas patients in group 2 received 2 ml of normal saline 15 minutes prior to administration of subarachnoid block with 2.5 ml of hyperbaric bupivacaine 0.5%. Time to attain peak sensory block (P = 0.27), time to two segment regression (P = 0.19) and time to regression to the S, dermatome (P = 0.84) did not significantly differ between the two groups. No differences in regression of sensory block were noted at any time. The mean duration of motor block also did not differ (P = 0.44), with similar regression of block at all time intervals except at 90 minutes. We concluded that intravenous ondansetron does not affect the intensity or duration of sensory and motor block after spinal anaesthesia with hyperbaric bupivacaine.

Magnesium sulphate for treatment of tetanus in adults.

There are reports that suggest that magnesium sulphate alone may control muscle spasms thereby avoiding sedation and mechanical ventilation in tetanus, but this has not been confirmed. We examined the efficacy and safety of intravenous magnesium sulphate for control of rigidity and spasms in adults with tetanus. A prospective clinical study of intravenous magnesium sulphate was carried out over a period of two years in a tertiary care teaching hospital. In addition to human tetanus immunoglobulin and parenteral antibiotics, patients with tetanus received magnesium sulphate 70 mg/kg intravenously followed by infusion. The infusion was increased by 0.5 g/hour every six hours until cessation of spasms or abolishment of patellar tendon jerk. The primary outcome measure was efficacy determined by control of spasms. Secondary outcomes included frequency of autonomic instability, duration of ventilatory support, hospital stay and mortality. Thirty-three patients were enrolled. At presentation, the incidence of severity of tetanus was as follows: Grade I: 5 (15%), Grade II: 13 (39%), Grade III: 14 (42%) and Grade IV: 1 (3%). Rigidity and mild spasms were controlled with magnesium therapy alone in six patients; all were Grades I or II. Additional sedatives were required in severe forms of tetanus. The average duration of ventilatory support was 18.3 +/- 16.0 days and the overall mortality was 22.9%. Asymptomatic hypocalcaemia was a universal finding. Magnesium sulphate therapy alone may not be efficacious for the treatment of severe tetanus.

Generalized pustular psoriasis complicated by acute respiratory distress syndrome.

Psoriasis has a chronic and relatively benign course. However, severe complications are possible. One rare complication is acute interstitial pneumonitis. This entity should be suspected when a patient presents with dyspnoea and high fever. Knowledge of this pathology is crucial, for although it is essential to rule out aetiologies requiring specific management such as microbial infection or drug-related syndromes, diagnosis should not be delayed as its severe clinical course is improved by corticosteroids. We report two patients with an acute respiratory distress syndrome arising during the course of pustular psoriasis. Repeated bacteriological testing in lungs and blood remained negative. In both cases lung involvement was severe, requiring artificial ventilation. Dramatic clinical resolution was obtained by using corticosteroids. Besides infectious causes and drug hypersensitivity to methotrexate or acitretin, acute respiratory distress syndrome, sometimes due to a pulmonary capillary leak syndrome, is a rare cause of pneumonitis in the course of psoriasis, and may be fatal. Its pathogenesis is unknown. However, animal models suggest a role for T-helper (Th) 1 lymphocytes, known to be activated in psoriasis, and a role for tumour necrosis factor-alpha, a major Th1 cytokine, in alveolar damage.

Epidemiological survey of melanoma in the Auvergne region (France): is there an increased incidence in Auvergne?

To assess the efficiency of melanoma screening and prevention campaigns in the Auvergne region (France), cases of melanoma have been recorded since 1st June 1998. The epidemiological follow-up of melanoma was carried out using two sentinel networks; one involving the pathologists, and the other, the dermatologists of the region. Incidence was calculated using the capture-recapture method, by cross-matching the data supplied by both dermatologists and pathologists. Between June 1st 1998 and December 31st 2000, 363 cases of melanoma were recorded. The crude incidence rate of melanoma per 100,000 person-years was 17.1 for all melanomas and 14.6 for invasive melanomas. These rates of incidence were higher than the estimated national rate of France, and were close to incidences found in countries of Northern Europe. This might be explained by an increase in screening for melanoma, by more precise estimation of the incidence due to the capture-recapture method, or by geographic factors (mountainous area). An answer may be provided by following the variation in time of incidence and thickness of melanomas; the increase in the number of thin (low Breslow index) melanomas corresponding with increased screening.