Twenty-four hour hyperinsulinemic-euglycemic clamp improves postoperative nitrogen balance only in low insulin sensitivity patients following cardiac surgery.

BACKGROUND: Critically ill patients often suffer from a protein catabolic state. The aim of this study was to demonstrate that nitrogen balance (NB) in cardiac patients admitted to the intensive care unit (ICU) is related to their insulin sensitivity level and that supraphysiologic doses of insulin can restore anabolism. MATERIALS AND METHODS: Twenty-eight patients that were admitted to ICU in enteral and/or parenteral nutrition have been enrolled in this study. All patients received a standard nutrition protocol for at least 3 days before starting the study. These patients received either enteral or parenteral nutrition based on 1.4 kcal/kg/h and 1.1 g/kg/24 h of proteins. Participants were studied for three 24 h periods (P1 , P2 , and P3 ). Twenty-four hour NB was calculated from urinary urea nitrogen excretion, fixed protein and energy intake during each of the three periods (P1 , P2 , and P3 ). Simultaneous to P2, a 24 h hyperinsulinemic-euglycemic clamp (HEC) was performed to determine patients' insulin sensitivity (IS) or insulin resistance (IR), as well as the impact of high doses of insulin on NB. RESULTS: Nitrogen balance remained consistently positive in the IS group regardless of the clamp. In IR patients, NB was negative before the clamp and became positive during P2 and P3 . Insulin sensitivity improved during the HEC in IR patients (P < 0.001). CONCLUSIONS: A negative NB was found only in insulin resistant patients admitted to the ICU for more than 7 days. A 24-h period HEC improved NB in these patients.

Anesthetic management for right upper extremity amputation due to recidivous cutaneous carcinoma and acute postoperative pain control in patients affected by epidermolysis bullosa.

A 22-year-old male who was affected by epidermolysis bullosa (EB) and xeroderma pigmentosa (with structural and pathological changes that preclude orotracheal intubation) underwent right upper extremity amputation and ipsilateral axillary lymphadenectomy. The patient was operated without intubation, thereby assuring an optimal state of acute postoperative pain control by regional anesthesia. Intravenous administration of ketamine and remifentanil plus low-dose sevoflurane resulted in anesthesia with spontaneous breathing by the patient. Moreover, the intraoperative brachial plexus nerve block before amputation followed by positioning of an epidural catheter to deliver continuous infusion of local anesthetics close to the cut nerves during surgery obtained a very good level of acute postoperative pain control.

Physiologic role of nitric oxide in the maintenance of uterine quiescence in nonpregnant and pregnant sheep.

OBJECTIVE: This study evaluated the role of nitric oxide in the maintenance of uterine quiescence in nonpregnant and pregnant ewes. STUDY DESIGN: Sixteen ovariectomized nonpregnant and 10 pregnant (115 days' gestation) chronically instrumented ewes were studied. Uterine contractility was assessed by electromyography and intrauterine pressure recordings. Nitric oxide synthase inhibition was induced with nitro-L -arginine methyl ester or aminoguanidine (4. 5 mg/kg per hour) given during estrogen replacement with 17beta-estradiol (100 microg/d) or in late gestation. In the pregnant group we evaluated the ability of nitric oxide synthase inhibition to alter the responsiveness to oxytocin-induced uterine contractility. Blood pressure and common internal iliac artery blood flow were assessed to confirm nitric oxide synthase inhibition. In addition, the effects of the nitric oxide donor nitroglycerin and the cyclooxygenase inhibitor indomethacin were studied in nonpregnant sheep. The effect of nitric oxide in vitro on myometrial spontaneous and induced contractions was also studied. RESULTS: In nonpregnant estrogen-replaced sheep, nitric oxide synthase inhibition and nitroglycerin administration did not alter uterine contractility, despite significant changes in blood pressure. In contrast, indomethacin decreased electromyographic results to 70% of baseline after 1 hour and 47% after 2 hours. In pregnant ewes nitric oxide synthase inhibition failed to alter uterine contractility in response to oxytocin. These findings are in contrast to results of the in vitro study in which nitric oxide was shown to relax sheep myometrium. CONCLUSION: The absence of significant effects of nitric oxide synthase inhibition and nitric oxide donors on uterine contractility in vivo suggests that nitric oxide does not play a physiologic role in the regulation of uterine contractility in nonpregnant or pregnant ewes.

Nonpregnant sheep uterine type I and type III nitric oxide synthase expression is differentially regulated by estrogen.

The aim of this study was to characterize the effect of estrogen on the expression of neuronal and endothelial isoforms of nitric oxide (NO) synthase (NOS) in myometrium, endometrium, and caruncle (nonglandular endometrium) in nonpregnant sheep. Twenty sheep were castrated during synchronized estrus (Days 14-16) and 4 days after surgery treated i.v. through the jugular with 100 microg/day of estradiol-17beta for 5 (n = 6) or 8 (n = 6) days or with vehicle (n = 8). Nitric oxide synthase mRNA was measured by ribonuclease protection assay, and NOS protein mass was measured by Western immunoblotting. Data were analyzed by ANOVA and Tukey's test. The three distinct uterine compartments studied contained the mRNA and protein for the neuronal (type I NOS) and the endothelial (type III NOS) isoforms of NOS. However, no inducible NOS was detected. Estrogen exhibited a differential effect on NOS expression in a tissue compartment- and NOS isoform-specific manner. In myometrium and caruncles, but not in endometrium, type I NOS mRNA and protein mass increased significantly (p < 0.05) after 5 or 8 days of estrogen. In contrast, type III NOS increased significantly in myometrium only after 8 days, whereas in endometrium and caruncles the increase was significant in the 5-day treatment group (p < 0.05). We conclude that the expression of type I NOS and type III NOS in the uterus are differentially regulated by estrogen. This differential regulation suggests that the NO produced within the uterus serves more than one physiological role. In myometrium it may be a uterorelaxant and regulate glucose utilization, and in endometrium and myometrium it may regulate blood flow.