Intravenous dexketoprofen induces less injection pain than racemic ketoprofen.

WHAT IS KNOWN AND OBJECTIVE: Ketoprofen has high analgesic efficacy against inflammatory and nociceptive pain. Additionally, when ketoprofen is administered in conjunction with an opioid during pain management, it prevents the development of opioid-induced hyperalgesia. The main limitation for racemic ketoprofen IV administration is venous irritation. Dexketoprofen is the active enantiomer of racemic ketoprofen and has a similar analgesic efficacy in a dose proportion of 1 : 2, but it causes fewer adverse effects than racemic ketoprofen. It has been claimed that dexketoprofen may cause less frequent and less severe injection pain than racemic ketoprofen. In this study, we compared the injection pain of IV administered racemic ketoprofen and dexketoprofen in elective surgical patients. METHODS: The ethics committee of our institution approved this randomized, double-blinded, two-treatment, two-period, crossover clinical comparison of ketoprofen and dexketoprofen. A total of 221 ASA I-III adult patients, aged 20-75 years, were initially IV administered either 0·5 mg/kg racemic ketoprofen followed 2 h later with 0·25 mg/kg dexketoprofen (group 1) or vice versa (group 2). Both compounds were diluted in 20 mL of normal saline and were injected over 6 min. Patients reported injection pain on an 11-point numerical rating scale (NRS) (0 = no pain, 10 = most pain). RESULTS AND DISCUSSION: Significantly less injection pain was reported after dexketoprofen administration. A total of 201 of 209 patients reported pain during racemic ketoprofen injection, and 157 of 210 patients reported pain during dexketoprofen injection, respectively. Moderate or severe pain was reported by 90 (41%) patients during racemic ketoprofen administration and by 43 (20%) during dexketoprofen injection (P = 0·001). The mean of injection pain during racemic ketoprofen injection was 4·2 (SD 2·5) and was 2·5 (2·4) during dexketoprofen injection (P = 0·001). No serious or unexpected adverse events were reported. WHAT IS NEW AND CONCLUSION: Dexketoprofen causes significantly less injection pain than racemic ketoprofen; therefore, it may be a more suitable IV non-steroidal anti-inflammatory than the racemate.

Platelet transfusions in adult patients with particular reference to patients undergoing surgery.

Descriptive information on platelet (PLT) recipients, particularly during surgery, is limited. A description of the current epidemiology of PLT-transfused patients is required to optimize platelet transfusion care and to follow trends in PLT use. In 2004 and 2005, information was combined from several computerized medical systems. Participating hospitals (9 hospital districts of 21) handled approximately 64% of annual Finnish hospital admissions. A total of 6321 adult patients were transfused with 37,761 PLT products. Most PLT products (43.1%) were transfused to patients suffering from haematological malignancies. Only 1.0% of all surgical patients received PLTs (53.8% of PLT recipients and 35.8% of transfused PLTs). The most common single operation connected with PLT transfusion was coronary artery bypass while 27.1% of surgery-related PLTs were given to patients having an operation involving the digestive system or spleen. Only 36.4% of all PLT-transfused (operated and conservatively treated) patients were discharged directly home; in-hospital mortality was 9.5%. PLTs were given 40 products per 1000 hospital admissions requiring an operation in 2004, and 38 products in 2005. Perioperative PLT use is slightly decreasing in adult patients. As a single-operation type, coronary artery bypass patients receive most of the PLT products and have experienced no decline in PLT use over the years. Overall, PLT recipients have high in-hospital mortality.

Intramuscular dexmedetomidine as premedication for general anesthesia. A comparative multicenter study.

BACKGROUND: Dexmedetomidine is a new potent and selective alpha 2-agonist that might prove useful as a preanesthetic agent. METHODS: A randomized, double-blind study design was used in 192 ASA physical status 1 and 2 patients scheduled for elective abdominal hysterectomy, cholecystectomy, or intraocular surgery under general anesthesia. Intramuscular injection of 2.5 micrograms/kg dexmedetomidine administered 60 min before and intravenous saline placebo 2 min before induction of anesthesia (DEXPLA group, n = 64) was compared with a combination of 0.08 mg/kg intramuscular midazolam 60 min and 1.5 micrograms/kg intravenous fentanyl 2 min before induction (MIDFENT group, n = 64), or a combination of intramuscular dexmedetomidine and intravenous fentanyl (DEXFENT group, n = 64). After thiopental induction, anesthesia was maintained with 70% N2O/O2, and fentanyl was administered according to clinical and cardiovascular criteria. Patients undergoing cholecystectomy received additional enflurane. RESULTS: Dexmedetomidine and midazolam induced comparable preoperative sedation and anxiolysis. The DEXFENT combination blunted the increases in blood pressure and heart rate induced by tracheal intubation more efficiently when compared with the DEXPLA and MIDFENT groups, in which approximately 25 mmHg and 15 beats/min greater increases were observed. The intraoperative fentanyl requirements were greater in MIDFENT patients when compared with both dexmedetomidine groups, in which 56% (DEXFENT group) and 31% (DEXPLA group) less fentanyl, respectively, was needed. Intraoperatively, fluids or vasopressors for hypotension and glycopyrrolate for bradycardia were administered more often to patients receiving dexmedetomidine than to those who did not. Postoperatively, there were no differences in oxygen saturation, analgesic, or antiemetic requirements, but dexmedetomidine-induced blood pressure and heart rate reductions were still evident at the end of the 3-h follow-up period. Bradycardia as an adverse event was reported more frequently in dexmedetomidine patients (20% in the DEXPLA and 33% in the DEXFENT groups) than in MIDFENT patients (8%). CONCLUSIONS: The results suggest that pretreatment with a single intramuscular injection of 2.5 micrograms/kg dexmedetomidine is efficacious, but significantly increases the incidence of intraoperative hypotension and bradycardia in ASA physical status 1 or 2 patients.

Mitomycin C and lipiodol do not improve the effect of intermittent hepatic artery occlusion on liver tumour growth. An experimental study in the rat.

The effect of Mitomycin C (MMC 2.0 mg/kg bw), lipiodol (0.2 ml/kg bw) and intermittent hepatic artery occlusion on liver tumour growth, as well as their possible interrelation, were studied in 29 rats. An adenocarcinoma was inoculated in the left liver lobe. After one week, the tumour size was measured and the rats then divided into five different groups of treatment. Intermittent hepatic artery occlusion was performed during five days for 1 hour daily alone, of initially in combination with MMC and lipiodol. One group was treated with MMC and lipiodol in combination and one group with lipiodol only. The tumour growth six days later was compared between the groups and with control rats. It was found that intermittent arterial occlusion significantly reduced the tumour growth (P = 0.01). However, the retarding effect of intermittent arterial occlusion on tumour growth was not significantly improved with additional treatment of MMC and lipiodol.

Metabolic responses to intermittent hepatic dearterialization in the rat.

Hepatic dearterialization is a palliative treatment for irresectable liver tumours. In the current study, the metabolic consequences of hepatic dearterialization were examined in the rat. Liver glycogen content was reduced to an average of 84% following 60 min dearterialization and was further reduced to an average of 16% following 60 min reperfusion. Plasma concentration of beta-hydroxybutyric acid was elevated by an average of 65% following 60 min hepatic dearterialization. In contrast, hepatic dearterialization did not alter cholesterol and triglyceride plasma levels. In addition, the hepatic activity of hepatic lipase was reduced by 29% after 60 min of hepatic dearterialization, a reduction which remained after 60 min of reperfusion. Clearance of intravenously administered antipyrine, which reflects the activity of liver microsomal enzymes, was reduced by 37% after 60 min of hepatic dearterialization. In conclusion hepatic dearterialization is accompanied by marked activity in the processes related to carbohydrate, lipid and xenobiotic metabolism. These effects should be taken into account when treating patients with hepatic dearterialization.

Hepatic dearterialisation induces glucose intolerance and inhibits insulin secretion in patients with liver malignancy.

Intermittent hepatic dearterialisation is used in palliation of liver malignancy. In rats hepatic dearterialisation is accompanied by glucose intolerance and impaired insulin secretion, but it is not known if similar effects occur in man. Six patients with nonresectable liver malignancy were subjected to an intravenous glucose (50 g) challenge before dearterialisation (control challenge), during a 1-hour dearterialisation period, and in the immediate reperfusion phase after the end of 1-hour dearterialisation. Insulin secretion, as judged by the plasma levels of both insulin and C peptide, was inhibited during the 1-hour dearterialisation, while the glucose elimination rate was delayed (both p less than 0.03). Contrastingly, in the immediate reperfusion phase both insulin secretion and glucose elimination did not differ from values after the control challenge. We therefore conclude that hepatic dearterialisation in patients with liver malignancy is accompanied by inhibited insulin secretion and glucose intolerance, both readily reversible.

Intermittent hepatic arterial or portal occlusion reduces liver tumor growth.

The effect of repeated, intermittent hepatic vascular occlusion on liver tumor growth was studied in 32 rats. An adenocarcinoma was inoculated in the left liver lobe. After 8 days, the tumor size was measured and then, in three groups, the hepatic artery was occluded intermittently during 5 days for 15 min, 1 hr, or 2 hr daily, respectively. The tumor growth after 6 days in these groups was compared with that in a group where instead the portal vein was occluded intermittently during 5 days for 15 min, and with that in a group of sham-operated control rats. In the control rats, the tumor volume (mean +/- SEM) increased from 0.16 +/- 0.03 to 1.34 +/- 0.15 cm3 during the 6 days of experiment. It was found that repeated, intermittent occlusion of the hepatic artery or the portal vein, retarded the liver tumor growth to 30-60% of the growth rate in sham-operated controls (P less than or equal to 0.015). The 15-min daily hepatic artery or portal vein occlusion was found to reduce the tumor growth rate as much as daily hepatic artery occlusion for 2 hr. It is suggested that short, daily, intermittent hepatic vascular occlusions might be efficient in the palliative treatment of liver malignancy.

Effect of hepatic artery or portal vein occlusion on liver tumour blood flow.

To study the blood flow in normal liver tissue and in liver malignancies after occlusion of the hepatic artery or the portal vein, an adenocarcinoma was inoculated in the left liver lobe of 10 rats. Eight days postoperatively, blood flow in normal hepatic tissue and tumour was estimated by laser Doppler flowmetry (LDF). In both normal tissue and tumour, occlusion of the hepatic artery reduced LDF values by approximately 30%, whereas occlusion of the portal vein reduced LDF values by approximately 70%. These findings indicate that changes of hepatic blood flow can be monitored by LDF, and that the portal blood flow is dominating also in liver metastasis.

Intermittent hepatic dearterialization induces glucose intolerance: an experimental study in the rat.

Intermittent hepatic dearterialization is used in the palliative treatment of liver malignancy. However, its metabolic consequences are not established. Therefore the influences of the procedure on the plasma insulin, glucagon and glucose responses were studied in healthy rats and in rats with a tumour inoculated subcapsularly into the liver. To study the influence on stimulated islet hormone secretion we infused arginine intravenously (7 mg/min) for 30 min, because arginine is known to stimulate the secretion of both insulin and glucagon. During hepatic dearterialization, hyperglycaemia developed; mean(s.e.m.) blood glucose levels after 60 min of dearterialization were 20.2(1.3) mM versus 14.7(1.5)mM in controls (P less than 0.001). Concomitantly, compensatory hyperinsulinaemia and hypoglucagonaemia occurred. Furthermore, during both dearterialization and in the immediate reperfusion phase, the arginine-induced increase in plasma insulin levels was impaired (P less than 0.001), whereas the arginine-induced increase in plasma glucagon levels was not significantly affected. These changes were qualitatively the same in tumour-free and tumour-bearing rats. We conclude that glucose intolerance develops during selective hepatic dearterialization, which is evident both from basal hyperglycaemia and impaired insulin secretion.

Double tumours of the appendix: a rare entity. A case report.

A 73-year-old man was admitted with the suspicion of appendiceal abscess. Emergency appendectomy was done. Histology revealed two tumours, an adenocarcinoma and a carcinoid. Tumours of the appendix are seldom diagnosed preoperatively and often first at microscopic examination. All specimens should therefore be histologically examined.

Use of atropine in connection with oral midazolam premedication.

The clinical significance of intramuscular premedication with 0.01 mg/kg of atropine in a procedure involving oral benzodiazepine premedication (15 mg midazolam the evening before surgery and on the morning of surgery) was investigated in a double-blind study. As far as sedation, apprehension, excitement, dizziness, emesis, and headache were concerned, there were no significant differences between group 1 (atropine) and group 2 (placebo) patients; however, both during and after anesthesia patients in group 1 had less excessive salivary secretion (especially during extubation). As a result of sympathetic overactivity, patients in group 1 had an increased heart rate and an increased incidence of supraventricular tachycardia. In group 1 intravenous infusion proved more difficult, and in addition, the patients complained more of subjective side effects (dry mouth). There was no significant correlation between the radioimmunologically measured serum concentrations and the clinical effects of atropine measured just before the induction of anesthesia. Substantial interindividual differences were found in these serum levels. From the anesthetist's viewpoint, atropine has both beneficial effects (antisecretory) and unwanted effects (cardiovascular effects). For the patient atropine caused only subjective unwanted effects. Midazolam, a new short-acting, sedative benzodiazepine derivatives, can be used without atropine as an oral premedicant.

Antidiuretic hormone concentrations following midazolam premedication.

Midazolam given orally the night before and on the morning of operation had a distinct subjective pre-operative sedative effect as compared with placebo. Patients receiving midazolam also experienced less apprehension and excitement before surgery, but in relation to quality of sleep, the difference between the two groups was not statistically significant. Antidiuretic hormone (ADH) concentrations were determined just before induction of anaesthesia and were significantly lower in the midazolam group (2.14 pg/ml, SD 0.96) than in the placebo group (3.07 pg/ml, SD 1.73). Our results show that midazolam is a useful sedative anxiolytic oral premedicant, which appears to prevent initiation of a stress reaction before induction of anaesthesia.

Effect of different kinds of premedication on the induction properties of midazolam.

The effects of different premedication (i.m. and i.v.) on the usefulness of midazolam or thiopentone as induction agents for minor surgery was studied in 194 women undergoing either dilatation and curettage or explorative fractionate curettage. Midazolam appeared to produce light sedation which required powerful premedication (i.m. atropine + pethidine and i.v. fentanyl or fentanyl + dehydrobenzperidol) when used as an induction agent for minor surgery. The clinically useful dose of midazolam is about 0.30 mg kg-1 i.v. There was greater variability in onset and duration of action among patients receiving midazolam than among those receiving thiopentone. Midazolam caused less respiratory depression, but there were no clinically significant differences between midazolam and thiopentone with respect to cardiovascular variables. Muscular movements were found more often, and postoperative sedation lasted longer in patients receiving midazolam. Midazolam as an induction agent appears more suited for major than for minor surgery.

Fatal outcome from emergency embolization of an intrahepatic aneurysm: a case report.

A 73-year-old man with a cholangiocarcinoma obstructing the hepatic duct is described. The patient was treated with percutaneous transhepatic catheter and bile duct endoprosthesis for internal drainage. This was complicated by an aneurysm of the liver, which was treated by embolization of the hepatic arteries with Gelfoam, causing an extensive liver necrosis which proved to be fatal.

Hyperparathyroidism--a life-threatening disease in 1978. A case report.

In a patient with hyperparathyroidism (HPT) two neck explorations with identification of three normal parathyroid glands were carried out. Cervical and mediastinal vein catheterization with blood sampling for determination of parathyroid hormone (PTH) confirmed drainage of large amounts of PTH to a mediastinal vein. Two thoracic explorations were negative anterior and posterior mediastinum). The operations were performed during 1971 and 1978 and extensive, progrediating decalcification with brown tumour formation was radiologically demonstrated during that time. Diminished renal function, skeleton pain and mental depression necessitated a last exploration, at which a 2 cm large parathyroid adenoma was found in the left carotid sheath just below the left mastoid process. The adenoma was drained into mediastinal veins through long anastomotic branches.