The effects of intravenous anesthetics on QT interval during anesthetic induction with desflurane.

INTRODUCTION: This study aimed to determine the effects of the interaction between intravenous anesthetics and desflurane on the QT interval. METHODS: Fifty patients who underwent lumbar spine surgery were included. The patients received 3 µg/kg fentanyl and were randomly divided into two groups: group P patients received 1.5 mg/kg propofol and group T patients received 5 mg/kg thiamylal 2 min after fentanyl injection. All patients received rocuronium and desflurane (6% inhaled concentration) after loss of consciousness. Tracheal intubation was performed 3 min after rocuronium injection. Heart rate (HR), mean arterial pressure (MAP), bispectral index score (BIS), and the heart rate-corrected QT (QTc) interval on a 12-lead electrocardiograms were recorded before fentanyl injection (T1), 2 min after fentanyl injection (T2), 1 min after propofol or thiamylal injection (T3), immediately before intubation (T4), and 2 min after intubation (T5). RESULTS: There were no significant intergroup differences in patient characteristics. BIS and MAP decreased after anesthesia induction in both groups. MAP values at T3, T4, and T5 in group T were higher than those in group P. HR did not change over time or differ between the groups. The QTc intervals at T4 and T5 in group T were longer than those at T1. In group P, the QTc interval at T3 was significantly shorter than that at T1. The QTc intervals at T3, T4, and T5 in group T were significantly longer than those in group P. CONCLUSIONS: A propofol injection could counteract the QTc interval prolongation during desflurane anesthesia induction. TRIAL REGISTRATION: UMIN Clinical Trials Registry database reference number: UMIN000023707 . This study was registered on August 21, 2016.

The effects of intravenous anesthetics on QT interval during anesthetic induction with sevoflurane.

PURPOSE: Sevoflurane is known to prolong the QT interval. This study aimed to determine the effect of the interaction between intravenous anesthetics and sevoflurane on the QT interval. METHODS: The study included 48 patients who underwent lumbar spine surgery. Patients received 3 µg/kg fentanyl and were then randomly allocated to either Group T, in which they received 5 mg/kg thiamylal, or Group P, in which they received 1.5 mg/kg propofol, at 2 min after administration of fentanyl injection for anesthetic induction. Vecuronium (1.5 mg/kg) and sevoflurane (3 % inhaled concentration) were administered immediately after loss of consciousness and tracheal intubation was performed 3 min after vecuronium injection. Heart rate (HR), mean arterial pressure (MAP), bispectral index score (BIS), and the heart rate-corrected QT (QTc) interval on a 12-lead electrocardiogram were recorded immediately before fentanyl administration (T1), 2 min after fentanyl injection (T2), immediately before intubation (T3), and 2 min after intubation (T4). RESULTS: There were no significant differences between the two groups in baseline patient characteristics. BIS and MAP significantly decreased after anesthesia induction in both groups. At T3, MAP in Group T was higher than in Group P, while HR had reduced in both groups. The QTc interval was prolonged after anesthesia induction in Group T, but did not change at any time point in Group P. The QTc interval after anesthesia induction in Group T was longer than in Group P. CONCLUSION: We concluded that an injection of propofol could counteract QTc interval prolongation associated with sevoflurane anesthesia induction.

[A Case of Acetaminophen Poisoning Associated with Tramcet Overdose].

Tramcet is a mixture of tramadol and acetaminophen. Acetaminophen poisoning may be caused by excessive intake of Tramcet. A 17-year-old female took excessive quantity of Tramcet before noon. She reported it herself in the emergency room. Her main complaint was nausea and dizziness. Acetaminophen may cause liver damage with dose-dependent manner. Because there was a possibility of acetaminophen poisoning, we started oral acetylcysteine. She was discharged from hospital 5 days later without side effects of acetylecysteine and liver damage.

An observational study of the association between microalbuminuria and increased N-terminal pro-B-type natriuretic peptide in patients with subarachnoid hemorrhage.

BACKGROUND: The urinary albumin/creatinine ratio (ACR) is a significant neurologic prognostic predictor in patients with aneurysmal subarachnoid hemorrhage (SAH). B-type natriuretic peptide (BNP) plays an important role in body fluid regulation in patients with SAH. The present study was performed to determine whether ACR was independent predictor for unfavorable neurological outcome and ACR was associated with increased N-terminal pro-BNP (NT-pro-BNP) after SAH. METHODS: We studied 61 patients undergoing surgery who were admitted within 48 h after aneurysmal SAH onset between July 2008 and June 2010. Hunt and Hess grade and Fisher grade were recorded at admission. The Glasgow Coma Scale (GCS) score was calculated at admission and daily for seven postoperative days. Arterial blood was sampled at admission and for seven postoperative days to determine the PaO2/FIO2 ratio, C-reactive protein level, troponin I level, and NT-pro-BNP level. Urine was sampled at admission and daily for seven postoperative days to determine ACR and vanillylmandelic acid/creatinine ratio (VMACR). Neurological outcomes were assessed at hospital discharge by using the Glasgow Outcome Scale. Receiver operating characteristic curves were constructed for the predictive variables of unfavorable neurological outcomes, and the area under the curve (AUC) was determined. Multivariate logistic regression analyses were performed for the significant predictors of unfavorable neurological outcomes after SAH. Associations with NT-pro-BNP were evaluated by using the Spearman rank correlation test. RESULTS: Of the 61 patients, 24 had unfavorable outcomes. The prevalence rate of microalbuminuria was 85 % (52/61). The highest NT-pro-BNP levels were above the normal range in 57 of 61 patients (93 %). According to the AUC, the Hunt and Hess grade, GCS score, the highest ACR, and highest VMACR were significant predictors of neurological outcome. Multivariate logistic regression analyses showed that the highest ACR and Hunt and Hess grade are independent prognostic predictors of unfavorable neurological outcomes. The highest NT-pro-BNP significantly correlated with the highest troponin I, highest ACR, and VMACR on admission. CONCLUSIONS: The highest ACR is an independent prognostic predictor of unfavorable neurological outcomes after SAH. Moreover, plasma NT-pro-BNP elevation may be associated with the development of microalbuminuria.

[The Interaction of Low-dose Droperidol, Propofol, and Sevoflurane on QTc Prolongation].

BACKGROUND: Droperidol is an effective antiemetic, but its use is limited because of the warning of drug-induced QT prolongation. Some reports showed that low-dose droperidol does not significantly probing QT interval. This study was aimed to determine the effect of low-dose droperidol (1.25 and 2.5 mg) on QTc interval, and the interaction among droperidol, propofol and sevoflurane. METHODS: Patients received either 1.25 mg (group L : n = 25) or 2.5 mg (group H : n = 25) droperidol, and fentanyl (3 µg x kg(-1)) was administered 2.5 min later. One minute after fentanyl administration, anesthesia was induced using propofol (1.5 mg x kg(-1)) and vecuronium. One minute after propofol administration, sevoflurane (3%) was started. Tracheal intubation was performed 3 min after propofol administration, and then sevoflurane was reduced to 1%. RESULTS: Compared to baseline, the QTc interval in group L was unchanged by droperidol. In group H, the QTc interval was significantly prolonged after droperidol injection, but recovered after propofol injection. After tracheal intubation, QTc interval was significantly prolonged in both groups. CONCLUSIONS: Droperidol's effect on QTc prolongation was shown at the dose of 2.5 mg but not 1.25 mg. This prolongation effect was offset by propofol, and was unchanged by sevoflurane.

[Analysis of the Factors in Successful Helmet Non-invasive Positive Pressure Ventilation].

BACKGROUND: Non-invasive positive pressure ventilation (NPPV) reduces the incidences of ventilator-associated pneumonia, the duration of ICU stay and the mortality rate compared with conventional respiratory management of the patients with acute respiratory failure (ARF). Recently, helmet NPPV equipment became available. Because of the high tolerability, the helmet seems to be the best NPPV interface when prolonged and continuous assistance is needed. In this study, we analyzed several factors related to failure of helmet NPPV in ARF patients in intensive care unit (ICU), retrospectively. METHODS: Institutional Research Committee of Nagasaki Rosai Hospital approved this study. We studied consecutive patients with ARF who needed ventilator support in ICU from February 2012 to February 2013. We excluded the patients whose trachea had been intubated before admission to ICU and comatose patients. After admission to ICU, all ARF-patients received helmet NPPV and conventional intensive care therapy including sedation with dexmedetomidine and vasoactive agents. General clinical data including blood gas analysis were recorded at admission to ICU and during ICU stay. Patient's tracheas were intubated if they met at least one of the following criteria, as judged after they had received helmet NPPV: lack of improvement in arterial blood pH or PaCO2; changes in mental status, in patients unable to tolerate noninvasive ventilation; a decrease in SaO2 to less than 85% despite the use of a high FIO2. The final decision of endotracheal intubation was made by a staff intensivist. We defined the failure of helmet NPPV as the execution of endotracheal intubation. The data were presented as median (IQR), and statistical analysis was performed using Mann-Whitney U-test and Fisher's exact probability test at the P<0.05 level of significance. RESULTS: The subjects were 36 patients (25 males and 11 females) aged 27 to 94 years, including 6 patients with acute heart failure (AHF), 8 with pneumonia, 6 with aspiration pneumonia, 2 with hemothorax, 10 with acute respiratory distress syndrome (ARDS), 1 with asthma, and 3 with acute exacerbation of chronic obstructive pulmonary disease (COPD). NPPV was successful in 29 (19 males and 10 females), but unsuccessful in 7 patients (6 males and 1 female). There were no significant differences in demographic data and the variables before induction of NPPV between the successful and unsuccessful groups. The P/F ratio was improved from 133 (99,167) to 209 (143,274) in the successful group, and from 93 (81,157) to 188 (129,271) in the unsuccessful group after the induction of NPPV, but there was no significant difference between the two groups. In the patients with unsuccessful NPPV, expiratory positive airway pressure, inspiratory positive airway pressure, respiratory rate, body temperature and FIO2 before removing NPPV were significantly higher, and ICU stay was longer compared with the patients with successful NPPV. Furthermore, marked excretion of sputum was observed in 4 of the 7 patients with unsuccessful NPPV. CONCLUSIONS: Helmet NPPV improved oxygenation in ARF patients immediately after induction of NPPV. Although there were no significant predictable parameters of unsuccessful NPPV before induction of NPPV, a lot of excretion of sputum might be suggested as a risk factor.

Comparative efficacy of levobupivacaine and ropivacaine for epidural block in outpatients with degenerative spinal disease.

BACKGROUND: Levobupivacaine has less toxic potential on both the cardiovascular and central nervous system and has been widely used for postoperative epidural analgesia in surgical patients. However, there are few reports on the efficacy of epidural levobupivacaine in outpatients with lumbosacral radiculopathy. This study was carried out to evaluate the comparative efficacy of levobupivacaine and ropivacaine for epidural block in outpatients with degenerative spinal disease and sciatica. OBJECTIVE: We studied 32 patients (19 men and 13 women) with degenerative spinal disease and sciatica. STUDY DESIGN: The study was performed in a prospective, randomized, double blind, and crossover fashion. SETTING: Treatment room for outpatients. METHODS: The epidural block was produced with a caudal approach (0.125% levobupivacaine or 0.2% ropivacaine, 15 mL). The upper level of analgesia, lumbosacral pain, motor blockade, and hemodynamic changes were evaluated by pin prick, visual analogue scale (VAS), Bromage scale, and arterial blood pressure and heart rate at 15, 30, 60, and 90 minutes after epidural block, respectively. The recovery time to mobilization, ambulation, and spontaneous micturition were measured. RESULTS: There were no significant differences (P < 0.05) in the upper level of analgesia, VAS, and Bromage scale between 0.125% levobupivacaine and 0.2% ropivacaine throughout the time course. There were no significant differences in the recovery times to mobilization, ambulation, and spontaneous micturition between 0.125% levobupivacaine and 0.2% ropivacaine. There were no significant differences in arterial blood pressure and heart rate between the 2 trials throughout the time course. CONCLUSION: The results showed that 0.125% levobupivacaine and 0.2% ropivacaine for epidural block by a caudal approach provide similar lumbosacral pain relief, hemodynamic effects, and the degree and the recovery of motor blockade in outpatients with degenerative spinal disease and sciatica.

The interaction of antiemetic dose of droperidol with propofol on QT interval during anesthetic induction.

PURPOSE: We investigated the effect of low-dose droperidol on heart rate-corrected QT (QTc) interval and interaction with propofol. METHODS: Seventy-two patients undergoing upper limb surgery were included in this study. Patients were randomly allocated to one of three groups: group S (n = 24), which received 1 ml saline; group D1 (n = 24), which received 1.25 mg droperidol; or group D2 (n = 24), which received 2.5 mg droperidol. One minute later, fentanyl (3 µg/kg) was administered. Two minutes after fentanyl administration, anesthesia was induced using propofol (1.5 mg/kg) and vecronium. Tracheal intubation was performed 3 min after the administration of propofol. Heart rate, mean arterial pressure, bispectral index, and QTc interval were recorded at the following time points: immediately before the droperidol injection (baseline); 3 min after the saline or droperidol injection; 3 min after the propofol injection; and 2 min after tracheal intubation. RESULTS: Compared to baseline, the QTc interval in group S and group D1 was significantly shorter after propofol injection, but recovered after tracheal intubation. In group D2, the QTc interval was significantly prolonged after droperidol injection, but recovered after propofol injection, and was significantly prolonged after tracheal intubation. CONCLUSIONS: We found that saline or 1.25 mg droperidol did not prolong QTc interval, whereas 2.5 mg droperidol prolonged the QTc interval significantly, and that propofol injection counteracted the prolongation of the QTc interval induced by 2.5 mg droperidol.

Differential effects of propofol and sevoflurane on QT interval during anesthetic induction.

There have been conflicting reports on whether propofol prolongs, shortens, or does not change QT interval. The aim of this study was to determine the effect of target-controlled infusion (TCI) of propofol on heart rate-corrected QT (QTc) interval during anesthetic induction. We examined 50 patients undergoing lumbar spine surgery. Patients received 3 µg/kg of fentanyl and were randomly allocated to one of the following 2 groups. Group S patients received 5 mg/kg of thiamylal followed by sevoflurane, 5 % at the inhaled concentration. Group P patients received propofol using TCI system at 5 µg/mL for 2 min followed by 3 µg/mL. Tracheal intubation was performed after vecuronium administration. Heart rate (HR), mean arterial pressure (MAP), bispectral index score (BIS), and QTc interval in 12-lead electrocardiogram were recorded at the following time points: just before fentanyl administration (T1), 2 min after fentanyl injection (T2), 1 min after thiamylal injection or 2 min after the start of TCI (T3), just before intubation (T4), and 2 min after intubation (T5). BIS and MAP significantly decreased after anesthetic induction in both groups. HR decreased after anesthetic induction and recovered after tracheal intubation in group P, whereas it did changed in group S throughout the study period. QTc interval was shortened at T3 and T4 in group P, but prolonged at T3, T4, and T5 in group S, as compared with T1. Propofol TCI shortens QTc interval, whereas sevoflurane prolongs QTc interval during anesthetic induction.

Comparison between propofol and dexmedetomidine in postoperative sedation after extensive cervical spine surgery.

PURPOSE: Patients undergoing extensive cervical spine surgery (ECSS) occasionally require emergency reintubation due to postoperative airway complications. To avoid it, an endotracheal tube is retained in patients maintained under sedation overnight. This study was conducted to determine whether dexmedetomidine would be superior in sedative effects to propofol for postoperative sedation after ECSS. METHODS: We studied 32 consecutive patients undergoing ECSS who required prophylactic intubation postoperatively under sedation overnight. The patients were randomly divided into two groups. Group D (n = 16) received dexmedetomidine 0.1 µg/kg/min for 10 min as a loading dose, followed by a continuous infusion at 0.4 µg/kg/h. Group P (n = 16) received propofol 0.1 mg/kg/min for 10 min as a loading dose, followed by a continuous infusion at 1 mg/kg/h. All patients received analgesia with buprenorphine. Ramsay sedation scale, extremity movement, and pain intensity were recorded every 2 h. Dexmedetomidine and propofol dosages were adjusted to maintain a desired sedation level. Nursing staff adjusted dopamine to maintain systolic blood pressure >100 mmHg and administered atropine when the heart rate was <50 bpm. RESULTS: The proportions of adequate sedation level, movement, and pain status were similar between groups. In group D, heart rates were lower, frequency of atropine use was greater, and dopamine dose was higher than in group P. CONCLUSION: Both sedatives are efficacious after ECSS; however, dexmedetomidine decreased heart rate and required higher dose of dopamine.

[Relationship between magnesium concentration in cerebrospinal fluid and delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage].

BACKGROUND: The present study was conducted to determine the relationship between magnesium concentration in cerebrospinal fluid (CSF) and delayed cerebral ischemia (DCI) in patients with subarachnoid hemorrhage (SAH). METHODS: We studied 39 consecutive patients undergoing surgery after SAH. A spinal drainage catheter was inserted into the lower lumbar vertebrae before surgery. CSF was then sampled and the magnesium concentration measured. General clinical data, Hunt-Hess (H-H) grade and Fisher grade, aneurysm size and site, intracerebral and intraventricular hemorrhage, and blood glucose levels were all recorded on admission. At the same time, the Glasgow coma scale (GCS) score was calculated. Outcomes were assessed using the Glasgow outcome scale at discharge. DCI was defined as a two-point decrease in the GCS score and/or focal deficit, and was confirmed by cerebral angiography. The recorded values were expressed as the median (interquartile range). RESULTS: Of the 39 patients, 23 (59%) had DCI. The magnesium concentration in the DCI cases was 2.8 (2.7 and 2.9) mg x dl(-1), which was significantly lower than that in the non-DCI cases, i. e., 2.9 (2.8 and 3.0) mg x dl(-1) (P < 0.05). There were no significant differences in the other factors. CONCLUSIONS: The results indicate that preoperative hypomagnesemia within the CSF might play a role in the development of DCI in patients with SAH; however, further studies will be necessary to confirm this observation.

QTc interval and neurological outcomes in aneurysmal subarachnoid hemorrhage.

BACKGROUND: Prolonged heart rate-corrected QT (QTc) interval is frequently observed in subarachnoid hemorrhage (SAH). This study was conducted to determine the relationship between QTc interval and neurological outcome during the acute posthemorrhagic period after aneurysmal SAH. METHODS: We studied 71 patients undergoing surgery who were admitted within 24 h after the onset of aneurysmal SAH. Standard 12-lead electrocardiography was performed on admission (T1) and at 1 and 7 days after operation (T2 and T3). QT intervals were corrected by heart rate according to the Fridericia formula. The Glasgow Coma Scale (GCS) score was calculated over the period T1-T3. Neurological outcome was assessed using the Glasgow Outcome Scale at hospital discharge. RESULTS: Among the 71 patients, 31 had an unfavorable neurological outcome. Although QTc interval prolongation improved in patients with a good outcome, QTc interval prolongation continued in patients with an unfavorable outcome. The areas under the receiver-operator characteristic curves showed that the QTc and GCS score at T3, and the Hunt and Hess grade were significant predictors of an unfavorable neurological outcome. The threshold value, sensitivity, and specificity for the QTc at T3 were 448 ms, 73% [95% confidence interval (CI), 68-78], and 93% (95% CI, 90-96), respectively. CONCLUSION: This study confirms that QTc interval prolongation continues in the SAH patients with an unfavorable outcome but that QTc interval prolongation improves in patients with a good outcome, suggesting that a QTc interval of more than 448 ms at 7 days after operation is a predictor of neurological outcome after SAH.

Postoperative analgesic effect of preoperative intravenous flurbiprofen in arthroscopic rotator cuff repair.

PURPOSE: This study was carried out to evaluate the postoperative analgesic effects of preoperative intravenous flurbiprofen in patients undergoing arthroscopic rotator cuff repair under general anesthesia. METHODS: We studied 44 patients who underwent an elective arthroscopic rotator cuff repair in a prospective, randomized, and double-blind fashion. The patients were divided into two groups. Group A (n = 22) received lipid emulsion 0.1 ml kg(-1) as a placebo, and group B (n = 22) received flurbiprofen 1 mg kg(-1) before the surgery. Intralipid or flurbiprofen was given intravenously 5 min before the surgery. General anesthesia was maintained with sevoflurane and nitrous oxide, and 10 ml of 0.75% ropivacaine was administered intraarticularly at the end of the surgery. Postoperative analgesia was supplied with intravenous 0.1 mg buprenorphine according to the patient's demand. The effectiveness of flurbiprofen's analgesic effect was measured by a visual analog scale (VAS) and by the amount of buprenorphine consumption at 0.5, 1, 2, 4, 6, 12, and 24 h after the surgery. Time to the first analgesic was also recorded. RESULTS: VAS in group B was significantly (P < 0.01) lower than that in group A during the first 6 h postoperatively. The amount of buprenorphine consumption in group B was also significantly (P < 0.01) less than that in group A within the first 2 h postoperatively. The time to first analgesic request in group B was significantly (P < 0.01) longer than that in group A. CONCLUSION: These results show that preoperative intravenous flurbiprofen facilitates the analgesic effect in the early postoperative period after arthroscopic rotator cuff repair.

Postoperative analgesia with minidose intrathecal morphine for bipolar hip prosthesis in extremely elderly patients.

PURPOSE: It is known that an optimal dose of intrathecal morphine for analgesia after total hip arthroplasty in older patients is 0.1 mg. On the other hand, minidose intrathecal morphine (0.05 mg) is useful for analgesia after the transurethral resection of the prostate in elderly patients. We evaluated the postoperative analgesic effect of minidose intrathecal morphine after bipolar hip prosthesis in seniors (age 85 years or more) undergoing spinal anesthesia. METHODS: Twenty seniors undergoing bipolar hip prosthesis under spinal anesthesia were randomly allocated to one of two groups. Group A (n = 10) received intrathecal injection of 0.5% isobaric bupivacaine, 2.8 ml, and group B (n = 10) received intrathecal injection of 0.5% isobaric bupivacaine, 2.8 ml, plus morphine, 0.05 mg. Pain, nausea, and itching were evaluated using a numerical rating scale, ranging from 0 to 10, at 0, 4, 8, 12, and 24 h after the operation. RESULTS: The values on the numerical rating scale for pain in group B were significantly lower than those in group A at 4, 8, and 12 h after the operation. There were no significant differences between the groups in the values on the numerical rating scale for nausea or itching throughout the time course of the study. No patient in either group showed hypoxemia or respiratory depression throughout the time course. CONCLUSION: The results show that minidose intrathecal morphine provides a good analgesic effect without side effects, and it would be an effective and safe procedure for bipolar hip prosthesis in seniors.

Landiolol, a new ultra-short-acting beta1-blocker, reduces anaesthetic requirement during sevoflurane/N(2)O/fentanyl anaesthesia in surgical patients.

BACKGROUND AND OBJECTIVE: It is known that esmolol, a short-acting beta1-blocker, reduces anaesthetic requirement. In this study, we evaluated whether a low dose of landiolol, a new ultra-short-acting beta1-blocker, can reduce the sevoflurane requirement. METHODS: Twenty-five patients undergoing hip surgery were randomly divided into two groups. Group A (n = 13) received landiolol (bolus injection of 0.031 mg.kg(-1) and continuous infusion at a rate of 0.01 mg.kg(-1).min(-1)). Group B (n = 12) received physiological saline. Landiolol and physiological saline were started before the induction of anaesthesia and continued until the end of anaesthesia. Anaesthesia was maintained with sevoflurane, 60% N(2)O and fentanyl. Sevoflurane concentration was controlled to keep the bispectral index at approximately 50. The end-tidal sevoflurane concentration and haemodynamics were measured during anaesthesia. RESULTS: The average end-tidal sevoflurane concentration in group A was significantly lower than that in group B (1.2 +/- 0.30 vs. 1.8 +/- 0.3%, P < 0.01). Maximum values of systolic arterial pressure showed no difference between the groups, whereas the maximum value of heart rate in group A was significantly less than that in group B (61 +/- 10 vs. 76 +/- 14 beats min(-1), P < 0.05). CONCLUSION: The results suggest that a low dose of landiolol significantly reduces the intraoperative sevoflurane requirement during sevoflurane/N(2)O/fentanyl anaesthesia in patients undergoing hip surgery.

Age-dependent relationship between bispectral index and sedation level.

STUDY OBJECTIVE: To determine the relationship between bispectral index (BIS) and sedation. DESIGN: Prospective, observational clinical study. SETTING: Intensive care unit of a public hospital in Japan. PATIENTS: 22 ASA physical status I, II, and III middle-aged (18-65 yrs) and elderly (>65 yrs) patients receiving postoperative sedation with midazolam. INTERVENTIONS: Patients were allocated to two groups: Group M was composed of middle-aged patients (<65 yrs) and Group H elderly patients (>65 yrs). Midazolam was administered at a bolus dose of 0.1 mg/kg, followed by a continuous dose of 0.04 mg/kg per hour, which was adjusted every two hours to achieve a target level of sedation at 3-6 on the Ramsay Sedation Scale (RSS); buprenorphine was administered at a constant rate (0.625 microg kg(-1) hr(-1)). MEASUREMENTS: BIS value, RSS, midazolam dose, body temperature (BT), heart rate, dopamine dose, and mean arterial pressure were recorded every two hours by an independent nurse. Data were analyzed using Spearman rank correlation and the Mann-Whitney U test. MAIN RESULTS: BIS values decreased depending on depth of sedation; a significant correlation was noted between groups in RSS and BIS. The BIS values at levels of RSS 5 and 6 were significantly lower in Group H than Group M. CONCLUSION: BIS correlated with sedation depth, with BIS scores in group H than group M at a deep sedation depth.

Influence of low-molecular-weight hydroxyethyl starch on microvascular permeability in patients undergoing abdominal surgery: comparison with crystalloid.

PURPOSE: Adequate volume therapy is essential for stable hemodynamics and sufficient urinary output perioperatively. Hydroxyethyl starch (HES) has been reported to attenuate the microvascular hyperpermeability which occasionally occurs in surgical patients. This study was carried out to evaluate the effect of low-molecular-weight HES on the urinary microalbumin/creatinine ratio (MACR), a marker of microvascular permeability, in surgical patients. METHODS: In a prospective, controlled, and randomized clinical trial, 21 patients undergoing abdominal surgery were divided into two groups. Group HES (n = 10) received HES at 2 ml x kg(-1) x h(-1) during surgery and at 1 ml x kg(-1) x h(-1) after surgery, and additionally they received acetated Ringer's solution (AR) at a rate to keep central venous pressure (CVP) 5 mm Hg. Group AR (n = 11) received AR at a rate to keep CVP at 3-5 mmHg. MACR, soluble intercellular adhesion molecule-1 (sICAM-1), and urinary output were measured intermittently in the perioperative period. RESULTS: MACR was significantly increased during surgery in both groups. There was no significant difference in MACR between the two groups throughout the study period. The serum concentration of sICAM-1 decreased during surgery in both groups, and that in group HES was significantly lower than that in group AR at the end of surgery. Postoperative urinary output in group HES was greater than that in group AR. The intensive care unit (ICU) stay in group HES was shorter than that in group AR. CONCLUSION: Although low-molecular-weight HES does not improve microvascular hyperpermeability, the expansion of the intravascular volume by HES results in higher urinary output in the postoperative period than that seen with crystalloid solution. The lower concentration of sICAM-1 after surgery may be due to hemodilution.

Admission microalbuminuria and neurologic outcomes in intensive care unit patients with spontaneous intracerebral hemorrhage.

This study was performed to determine the prevalence and the prognostic significance of microalbuminuria in patients admitted to intensive care unit (ICU) after spontaneous intracerebral hemorrhage (ICH). From May 2004 to April 2006, we studied 59 consecutive ICH patients verified using computed tomography and admitted to our ICU within a day after stroke. General clinical, neurologic data, and Glasgow Coma Scale (GCS) were recorded at admission to ICU. Urine was collected at admission to ICU for measuring the urinary microalbumin/creatinine ratio. At hospital discharge, neurologic outcome was assessed using Glasgow Outcome Scale. Among 59 patients, 37 (63%) had unfavorable neurologic outcomes (death, persistent vegetative state, and severe disability). The prevalence rate of microalbuminuria was 85% [95% confidence interval (CI), 76-94]. The areas under the receiver operator characteristic curves showed that the urinary microalbumin/creatinine ratio [0.81 (95% CI, 0.70-0.92)] and the GCS score [0.78 (95% CI, 0.66-0.90)] at admission were significant predictors of unfavorable neurologic outcome at hospital discharge. The threshold value, sensitivity, specificity, and likelihood ratio for the urinary microalbumin/creatinine ratio were 200 mg/g, 51% (95% CI, 39-64), 96% (95% CI, 90-100), and 11.3 (95% CI, 7.9-16.0); and those for the GCS score were 11, 46% (95% CI, 36-61), 96% (95% CI, 90-100), and 10.1 (95% CI, 7.2-14.1), respectively. This study confirmed a high prevalence of microalbuminuria in ICH patients in ICU, and suggested that the urinary microalbumin/creatinine ratio >200 mg/g was comparable to the GCS score <11 at admission to the ICU with regard to its prognostic characteristics after ICH.

Comparison of oxygen consumption calculated by Fick's principle (using a central venous catheter) and measured by indirect calorimetry.

We investigated the clinical usefulness of the Fick method using central venous oxygen saturation ScvO2 and cardiac output (CO) measured by pulse dye densitometry (PDD) for monitoring oxygen consumption VO2. This prospective clinical study was performed in 28 mechanically ventilated postoperative patients after major abdominal surgery. VO2 was determined by two methods, i.e., the Fick method and indirect calorimetry. The Fick method was employed using CO measured by PDD and VO2 obtained from a central venous catheter (CVC). VO2 measured by indirect calorimetry was averaged for 15 min. Fifty-six sets of measurements were performed. VO2 values determined by the Fick method were significantly lower than those measured by indirect calorimetry (110 +/- 29 vs 148 +/- 28 ml x min(-1) x m(-2); P < 0.01). Bland and Altma analysis showed that the mean bias and precision were 33 ml x min(-1) x m(-2) and 32 ml x min(-1) x m(-2), respectively. The correlation between the two measurements of VO2 was weak (r (2) = 0.145; P = 0.0038), indicating that the Fick method using PDD and ScvO2 is not clinically acceptable for the monitoring of VO2.