Effects of high positive end-expiratory pressure on haemodynamics and cerebral oxygenation during pneumoperitoneum in the Trendelenburg position.

We investigated the effects of 10 cmH2O positive end-expiratory pressure on cerebral haemodynamics and cerebral oxygenation in patients undergoing laparoscopic lower abdominal surgery in the 30° Trendelenburg position during desflurane anaesthesia. Twenty-six patients were enrolled in this study. After anaesthesia induction, pneumoperitoneum was applied in Trendelenburg position. Twenty minutes later, positive end-expiratory pressure was applied. There was no change in regional cerebral oxygen saturation (p = 0.376). Cerebral perfusion pressure decreased significantly over time (p < 0.001) and positive end-expiratory pressure caused a further decrease in cerebral perfusion pressure (p = 0.036). The application of 10 cmH2O positive end-expiratory pressure during pneumoperitoneum in the Trendelenburg position preserved regional cerebral oxygen saturation, but cerebral perfusion pressure decreased significantly due to its secondary haemodynamic effects.

Optimal dose of propofol for intubation after sevoflurane inhalation without neuromuscular blocking agent in children.

BACKGROUND: This study was designed to determine the optimal dose of propofol for excellent intubating conditions in children without neuromuscular blockade at various alveolar concentrations of sevoflurane. METHODS: Sixty-three children, aged 0.5-5 years, were randomized to three groups of end-tidal sevoflurane concentration (ETsevo) 3%, 3.5%, and 4%. Inhalation anesthesia was started with sevoflurane 7% in 100% oxygen. When the patients became unconscious, inspired concentration was adjusted to obtain the target ETsevo for each group. When ETsevo reached the target concentration, a predetermined dose of propofol was given and tracheal intubation was performed. The proper dose of propofol was determined using the 'up-and-down' method. RESULTS: The median dose (95% confidence intervals) of propofol for excellent tracheal intubating conditions in 50% of children were 1.25 mg/kg (0.84-1.75) at ETsevo of 3%, 0.76 mg/kg (0.35-1.21) at 3.5%, and 0.47 mg/kg (0.26-1.09) at 4%. The frequency of adverse effects was not different between groups during induction and recovery. CONCLUSION: Propofol 1.5-2 mg/kg provides excellent intubating conditions at 3-4% ETsevo in children without using any neuromuscular blocking agent.

Ketorolac or fentanyl continuous infusion for post-operative analgesia in children undergoing ureteroneocystostomy.

BACKGROUND: children undergoing ureteroneocystostomy suffer from post-operative pain due to the surgical incision and bladder spasm. A single-shot caudal block is a common technique for paediatric analgesia, but a disadvantage is the limitation of a short duration in spite of the additives co-administered. A few clinical trials have shown that ketorolac provides an effective post-operative analgesia and reduces the bladder spasms after ureteral implantation in children. We compared the efficacy of a continuous infusion of ketorolac and fentanyl in post-operative analgesia and bladder spasm in children who underwent ureteroneocystostomy. METHODS: fifty-two children were allocated to the ketorolac group (Group K, n=26) and fentanyl group (Group F, n=26). After general anaesthesia, a caudal block was performed with 1.5 ml/kg of 0.15% ropivacaine. At the beginning of surgery, an infusion was started after the bolus injection of ketorolac 0.5 mg/kg or fentanyl 1 microg/kg. An infusion device was programmed to deliver ketorolac 83.3 microg/kg/h or fentanyl 0.17 microg/kg/h for 48 h. RESULTS: two of Group F and three of Group K were excluded from the study. Post-operative pain scores were similar between the two groups. One of Group K (4%) and seven of Group F (30.4%) experienced bladder spasms. The rescue analgesic requirements were significantly less in Group K. CONCLUSIONS: a Continuous infusion of ketorolac provided effective analgesia after operation in children who underwent ureteroneocystostomy as well as a low dosage of fentanyl. Ketorolac was more effective in reducing the frequency of bladder spasms and rescue analgesic requirements.

Acid-base alterations during laparoscopic abdominal surgery: a comparison with laparotomy.

BACKGROUND: Carbon dioxide insufflation during laparoscopic surgery results in an acid-base imbalance. The purpose of this study was to investigate the effect of pneumoperitoneum on the acid-base status using Stewart's approach. METHODS: Thirty patients undergoing abdominal surgery were allocated to the laparotomy group (n=15) or the laparoscopy group (n=15). The acid-base parameters were measured 10 min after the induction (T1), 40 min after opening the peritoneum or pneumoperitoneum according to the group (T2), at the end of the surgery (T3), and 1 h after the surgery (T4). RESULTS: There were no significant differences in the standard base excess (SBE), strong ion gap, or anion gap between the two groups. In both groups, the SBE decreased at T2, T3, and T4 compared with baseline value. At T3 and T4 in the laparotomy group, the apparent strong ion difference (SIDa) and pH were decreased whereas the lactate and chloride were increased compared with their baseline values. At T2 in the laparoscopy group, the pH was decreased whereas Pa(CO(2)) was increased compared with their baseline values. CONCLUSIONS: The decrease in the pH during the pneumoperitoneum was affected by the increase in Pa(CO(2)), which promptly returned to a normal value after the desufflation. On the other hand, the decrease in the pH after laparotomy was affected by the metabolic factors, which persisted an hour after the surgery.

The relative position of ilioinguinal and iliohypogastric nerves in different age groups of pediatric patients.

BACKGROUND: Ilioinguinal nerve (IIN) and iliohypogastric nerve (IHN) blocks provide good perioperative pain relief for children undergoing inguinal procedures such as inguinal hernia repair, orchiopexy, and hydrocelectomy. The aim of this ultrasound imaging study is to compare the relative anatomical positions of IIN and IHN in different age groups of pediatrics. METHODS: Two-hundred children (aged 1-82 months, ASA I or II) undergoing day-case surgery were consecutively included in this study. Following the induction of general anesthesia, an ultrasonographic exam was performed using a high-frequency linear probe that was placed on an imaginary line connecting the anterior superior iliac spine (ASIS) to the umbilicus. RESULTS: There were significant differences in ASIS-IIN (distance from ASIS to IIN), ASIS-IHN (distance from the ASIS to the IHN), and IIN-IHN (distance between IIN and IHN) between the age groups: <12 months (n=84), 12-36 months (n=80), and >37 months (n=36). However, IIN-Peritoneum (distances from IIN to peritoneum), skin-IIN, and skin-IHN (depth of IIN and IHN relative to skin) were similar in three groups. ASIS-IIN and ASIS-IHN showed significantly positive correlations with age. CONCLUSIONS: Age should be considered when placing a needle in landmark techniques for pediatric II/IH nerve blocks. However, needle depth should be confirmed by the fascial click due to the lack of predictable physiologic factors.

Evaluation of thein vivo antithrombotic, anticoagulant and fibrinolytic activities ofLumbricus rubellus earthworm powder.

A saline suspension ofLumbricus rubellus earthworm powder (EWP) was administered to rats (1 g/kg/day) orally for 15 days to evaluate an oral effectiveness for thrombotic disorders. Blood was drawn at 2-day interval after the administration. Several parameters for antithrombotic, anticoagulant and fibrinolytic activities were measured, including platelet aggregation, clotting time, plasmin activity and the levels of FDP (fibrin/fibrinogen degradation products), D-dimer, and t-PA antigen. It did not affect platelet aggregation induced by ADP and collagen but anticoagulant activity (aPTT and TT) was gradually increased to two-folds for the first 5 days of administration and back to normal. Fibrinolytic acitivity of euglobulin fraction was highest on the 11th day after the administration. The level of FDP was elevated to be comparable to the positve control (5-10 mug/ml) after 9-day treatment. Oral administration of the EWP could also reduce the formation of venous thrombus induced with viper venom. Complete blood count (CBC) profiles were within normal ranges except for a slight increase in white blood cells after the oral administration for 15 days. These results suggested that the EWP may be valuable for the prevention and/or treatment of thrombotic diseases.

The predictors for continuous renal replacement therapy in liver transplant recipients.

BACKGROUND: Acute renal failure (ARF) after liver transplantation requiring continuous renal replacement therapy (CRRT) adversely affects patient survival. We suggested that postoperative renal failure can be predicted if a clinically simple nomogram can be developed, thus selecting potential risk factors for preventive strategy. METHODS: We retrospectively reviewed the medical records of 153 liver transplant recipients from January 2008 to December 2011 at Severance Hospital, Yonsei University Health System, in Seoul, Korea. There were 42 patients treated with CRRT (20 and 22 patients received transplants from living and deceased donors, respectively) and 115 were not. Univariate and stepwise logistic multivariate analyses were performed. A clinical nomogram to predict postoperative CRRT application was constructed and validated internally. RESULTS: Hepatic encephalopathy (HEP; odds ratio OR, 5.47), deceased donor liver donations (OR, 3.47), Model for End-Stage Liver Disease (MELD) score (OR, 1.09), intraoperative blood loss (L; OR, 1.16), and tumor (hepatocellular carcinoma) as the indication for liver transplantation (OR, 0.11) were identified as independent predictive factors for postoperative CRRT on multivariate analysis. A clinical prediction model constructed for calculating the probability of CRRT post-transplantation was 1.7000 × HEP + [-4.5427 + 1.2440 × (deceased donor) + 0.0830 × (MELD score) + 0.000149 × the amount of intraoperative bleeding (L) - 2.1785 × tumor]. The validation set discriminated well with an area under the curve (AUC) of 0.90 (95% confidence interval, 0.85-0.95). The predicted and the actual probabilities were calibrated with the clinical nomogram. CONCLUSIONS: We developed a predictive model of postoperative CRRT in liver transplantation patients. Perioperative strategies to modify these factors are needed.

Anesthetic management of a spontaneous spinal-epidural hematoma during pregnancy.

Spontaneous spinal-epidural hematoma is uncommon and rare during pregnancy. We were presented with a 31-year-old patient who developed back pain with lower extremity paralysis at 36 weeks of gestation. A magnetic resonance imaging scan demonstrated an acute spinal-epidural hematoma and therefore, an emergency cesarean delivery was performed followed by hemilaminectomy with hematoma removal. Anesthesia was initiated with a volatile-based technique which, following delivery of the baby, was changed to target-controlled infusions of propofol and remifentanil. Postoperatively, dopamine was infused to maintain the blood pressure within the high-normal range to optimize spinal cord perfusion. Successful anesthetic and postoperative management is described together with a review of the literature.

Low-dose remifentanil infusion during ventilator weaning and tracheal extubation in postoperative intensive care unit patients sedated with propofol-remifentanil: a randomised clinical trial.

Discontinuation of sedatives for ventilator weaning and extubation can be associated with hyperdynamic responses, including hypertension and tachycardia. We examined the effects of a maintained low dose of remifentanil infusion on cardiovascular responses and coughing during extubation in postoperative intensive care unit patients sedated with propofol-remifentanil. Fifty patients who required mechanical ventilation after major abdominal surgery were randomised into remifentanil group (n=25) or control group (n=25). Sedation during mechanical ventilation was maintained with remifentanil and propofol via a target-controlled infusion system. These drugs were titrated to the target sedation range, bispectral index values of 60 to 75 and Richmond Agitation Sedation Scale values of -3 to -2. When weaning was initiated, propofol was stopped in both groups. In the control group, remifentanil infusion was also stopped; in the remifentanil group, remifentanil infusion was maintained until extubation at a target effect site concentration of 1.0 ng/ml. Extubation was performed if the patient's respiratory, haemodynamic states were stable and if the patient was able to follow commands. Heart rate, mean arterial pressure and cough severity were evaluated. The mean arterial pressure, heart rate and cough severity did not differ between the two groups during extubation. The time from stopping of propofol infusion to extubation was significantly longer in the remifentanil group compared to that in the control group (P=0.020). Maintaining a low-dose remifentanil infusion during ventilator weaning, delayed tracheal extubation without any differences in haemodynamic changes or coughing in postoperative intensive care unit patients.

Extracorporeal membrane oxygenation in a patient with stress-induced cardiomyopathy after caesarean section.

Stress-induced cardiomyopathy is an acute cardiac syndrome mimicking ST-segment elevation myocardial infarction and is characterised by transient left ventricular dysfunction in the absence of obstructive coronary artery disease. Caesarean delivery is associated with intense emotional and physical stress, which may precipitate stress-induced cardiomyopathy mimicking acute myocardial infarction. We report a case of a woman who was supported with extracorporeal membrane oxygenation for acute heart failure and severe pulmonary oedema, which may have resulted from stress-induced cardiomyopathy in the early postpartum period following caesarean delivery.

A new glycosaminoglycan from the giant African snail Achatina fulica.

A new glycosaminoglycan has been isolated from the giant African snail Achatina fulica. This polysaccharide had a molecular weight of 29,000, calculated based on the viscometry, and a uniform repeating disaccharide structure of -->4)-2-acetyl,2-deoxy-alpha-D-glucopyranose (1-->4)-2-sulfo-alpha-L-idopyranosyluronic acid (1-->. This polysaccharide represents a new, previously undescribed glycosaminoglycan. It is related to the heparin and heparan sulfate families of glycosaminoglycans but is distinctly different from all known members of these classes of glycosaminoglycans. The structure of this polysaccharide, with adjacent N-acetylglucosamine and 2-sulfo-iduronic acid residues, also poses interesting questions about how it is made in light of our current understanding of the biosynthesis of heparin and heparan sulfate. This glycosaminoglycan represents 3-5% of the dry weight of this snail's soft body tissues, suggesting important biological roles for the survival of this organism, and may offer new means to control this pest. Snail glycosaminoglycan tightly binds divalent cations, such as copper(II), suggesting a primary role in metal uptake in the snail. Finally, this new polysaccharide might be applied, like the Escherichia coli K5 capsular polysaccharide, to the study of glycosaminoglycan biosynthesis and to the semisynthesis of new glycosaminoglycan analogs having important biological activities.