Continuous intracameral phenylephrine-ketorolac irrigation for miosis prevention in femtosecond laser-assisted cataract surgery: Reduction in surgical time and iris manipulation.

PURPOSE: To determine whether the addition of phenylephrine 1.0%-ketorolac 0.3% (Omidria) to the irrigation solution during femtosecond laser-assisted cataract surgery (FLACS) reduces surgical time and the need for pupil expansion devices compared with the irrigation solution containing epinephrine. SETTING: Wake Forest Baptist Eye Center, Winston-Salem, North Carolina, USA. DESIGN: Retrospective case series. METHODS: Data were collected from consecutive patients. One group had epinephrine 1 µg/mL in the irrigating solution and the other group, had phenylephrine and ketorolac 4 mL added to 500 mL irrigation solution instead of epinephrine. All patients received preoperative topical bromfenac 2 days before surgery. The same surgeon performed all procedures using the same laser (Catalys) and operative conditions. Endpoints were surgical time and the use of pupil expansion devices. RESULTS: Data were collected from 200 consecutive patients, 100 in each group. Patient demographics, including a mean baseline pupil size of 7.1 mm, were similar between the groups. Mean surgical times were significantly reduced in the phenylephrine-ketorolac group versus the epinephrine group (8.1 minutes versus 9.4 minutes) (P = .007). When eyes requiring a pupil expansion device were eliminated, there was still a significant reduction in surgical time for phenylephrine-ketorolac versus epinephrine (8.1 minutes versus 9.0 minutes) (P = .018). Two eyes (2%) in the phenylephrine-ketorolac group and 12 eyes (12%) in the epinephrine group required a pupil expansion device (P = .009). CONCLUSION: These data support the hypotheses that using phenylephrine and ketorolac reduces FLACS time and the need for pupil expansion devices.

ED50 and ED95 of intrathecal hyperbaric ropivacaine for parturients undergoing cesarean section with prophylactic infusion of phenylephrine: A Prospective dose-finding Study.

BACKGROUND: Studies have reported that the ED50 of intrathecal ropivacaine was increased when using prophylactic infusion of phenylephrine to prevent spinal-induced hypotension. However, ED95 is more meaningful to clinical practice than ED50. Therefore, we conducted this study to determine the 95% effective dose (ED95) of intrathecal hyperbaric ropivacaine for cesarean section in parturients receiving prophylactic infusion of phenylephrine to prevent spinal-induced hypotension. METHODS: A hundred of healthy parturients undergoing elective cesarean section under combined spinal-epidural anesthesia (CSEA) were enrolled in this randomized, double-blinded, dose-ranging study. Patients were randomly assigned to receive 7, 9, 11, 13 or 15 mg intrathecal hyperbaric ropivacaine respectively. The prophylactic phenylephrine infusion (50 µg/min) was initiated immediately at the same time of spinal injection. Successful spinal anesthesia was defined as a T5 sensory level achieved within 10 min after intrathecal drug administration and no epidural supplement was required during the surgery. The ED95 was calculated with Probit analysis. RESULTS: The ED95 of intrathecal ropivacaine with 5 µg sufentanil for successful anesthesia was 15.2 mg (95%CI, 13.5-18.8 mg), when receiving prophylactic infusion of phenylephrine. CONCLUSION: Under the conditions of the present study, the ED95 of intrathecal hyperbaric ropivacaine for successful spinal anesthesia for cesarean section in healthy parturient receiving prophylactic infusion of phenylephrine was 15.2 mg.

Decreased hepatic response to glucagon, adrenergic agonists, and cAMP in glycogenolysis, gluconeogenesis, and glycolysis in tumor-bearing rats.

The response to glucagon and adrenaline in cancer cachexia is poorly known. The aim of this study was to investigate the response to glucagon, adrenergic agonists (α and ß) and cyclic adenosine monophosphate (cAMP) on glycogenolysis, gluconeogenesis, and glycolysis in liver perfusion of Walker-256 tumor-bearing rats with advanced cachexia. Liver ATP content was also investigated. Rats without tumor (healthy) were used as controls. Agonists α (phenylephrine) and ß (isoproterenol) adrenergic, instead of adrenaline, and cAMP, the second messenger of glucagon and isoproterenol, were used in an attempt to identify mechanisms involved in the responses. Glucagon (1 nM) stimulated glycogenolysis and gluconeogenesis and inhibited glycolysis in the liver of healthy and tumor-bearing rats, but their effects were lower in tumor-bearing rats. Isoproterenol (20 µM) stimulated glycogenolysis, gluconeogenesis, and glycolysis in healthy rats and had virtually no effect in tumor-bearing rats. cAMP (9 µM) also stimulated glycogenolysis and gluconeogenesis and inhibited glycolysis in healthy rats but had practically no effect in tumor-bearing rats. Phenylephrine (2 µM) stimulated glycogenolysis and gluconeogenesis and inhibited glycolysis and these effects were also lower in tumor-bearing rats than in healthy. Liver ATP content was lower in tumor-bearing rats. In conclusion, tumor-bearing rats with advanced cachexia showed a decreased hepatic response to glucagon, adrenergic agonists (α and ß), and cAMP in glycogenolysis, gluconeogenesis, and glycolysis, which may be due to a reduced rate of regulatory enzyme phosphorylation caused by the low ATP levels in the liver.

AKAP-Lbc mediates protection against doxorubicin-induced cardiomyocyte toxicity.

Doxorubicin (DOX) is a chemotherapic agent that is widely used to treat hematological and solid tumors. Despite its efficacy, DOX displays significant cardiac toxicity associated with cardiomyocytes death and heart failure. Cardiac toxicity is mainly associated with the ability of DOX to alter mitochondrial function. The current lack of treatments to efficiently prevent DOX cardiotoxicity underscores the need of new therapeutic approaches. Our current findings show that stimulation of cardiomyocytes with the α1-adrenergic receptor (AR) agonist phenylephrine (PE) significantly inhibits the apoptotic effect of DOX. Importantly, our results indicate that AKAP-Lbc is critical for transducing protective signals downstream of α1-ARs. In particular, we could show that suppression of AKAP-Lbc expression by infecting primary cultures of ventricular myocytes with lentiviruses encoding AKAP-Lbc specific short hairpin (sh) RNAs strongly impairs the ability of PE to reduce DOX-induced apoptosis. AKAP-Lbc-mediated cardiomyocyte protection requires the activation of anchored protein kinase D1 (PKD1)-dependent prosurvival pathways that promote the expression of the anti-apoptotic protein Bcl2 and inhibit the translocation of the pro-apoptotic protein Bax to mitochondria. In conclusion, AKAP-Lbc emerges as a coordinator of signals that protect cardiomyocytes against the toxic effects of DOX.

Outcomes of levator advancement and Müller muscle-conjunctiva resection for the repair of upper eyelid ptosis.

Both the Müller muscle-conjunctiva resection (MMCR) and levator advancement (LA) procedures can be used to manage ptosis in patients with good levator function. The aim of this article is to evaluate the efficacy and cosmetic outcomes of the two procedures. The clinical records of 29 consecutive eyelids of 26 patients undergoing MMCR and 30 eyelids of 23 patients undergoing LA were analysed. Eleven (42%) in the LA group and 9 (39%) in the MMCR group were male. The preoperative eyelid measurements were significantly different in the LA compared to the MMCR groups, in terms of palpebral aperture (PA) (6.3 vs 7.4, p = 0.01), marginal reflex distance 1 (MRD1) (-0.1 vs 1.5, p < 0.001) and levator function (LF) (12.1 vs 13.4, p = 0.03). The MRD1 1 month post-surgery was slightly less in the LA group compared to the MMCR group (2.6 vs 3.18 mm, p = 0.047) but not significantly different at months 3 and 6. The final change in MRD1 was significantly higher in the LA group (2.93 vs 1.76, p = 0.004). The MMCR group had a lower incidence of lid contour abnormalities (0% vs 20%, p = 0.01) and overcorrection (0% vs 13%, p = 0.04). There was no statistically significant difference in the rates of undercorrection in either group. Both the MMCR as well as LA procedures are effective for mild to moderate ptosis in patients with good levator function. Patients undergoing MMCR had higher success rates, better preservation of the natural lid contour, and a lower incidence of overcorrection than patients undergoing LA.

Prophylactic phenylephrine infusion for the prevention of hypotension after spinal anesthesia in the elderly: a randomized controlled clinical trial.

STUDY OBJECTIVE: Hypotension frequently occurs during spinal anesthesia (SA), especially in the elderly. Phenylephrine is effective to prevent SA-induced hypotension during cesarean delivery. The objective of this study was to evaluate the efficacy and safety of prophylactic infusion of phenylephrine after SA for orthopedic surgery in the elderly. DESIGN: This prospective, randomized, double-blind, and placebo-controlled study included 54 patients older than 60 years undergoing elective lower limb surgery under SA (injection of 10 mg of isobaric bupivacaine with 5 µg of sufentanyl). INTERVENTION: Patients were randomized to group P (100-µg/mL solution of phenylephrine solution at 1 mL/min after placement of SA) or the control group C (0.9% isotonic sodium chloride solution). The flow of the infusion was stopped if the mean arterial blood pressure (MAP) was higher than the baseline MAP and maintained or restarted at 1 mL/min if MAP was equal to or lower than the baseline MAP. Heart rate and MAP were collected throughout the case. MEASUREMENTS: Hypotension was defined by a 20% decrease and hypertension as a 20% increase from baseline MAP. Bradycardia was defined as a heart rate lower than 50 beats per minute. MAIN RESULTS: Twenty-eight patients were randomized to group P and 26 patients to group C. MAP was higher in group P than in group C (92 ± 2 vs 82 ± 2 mm Hg, mean ± SD, P< .001). The number of hypotensive episodes per patient was higher in group C compared with group P (9 [0-39] vs 1 [0-10], median [extremes], P< .01), but the number of hypotensive patients was similar between groups (19 [73%] vs 20 [71%], P= 1). The time to onset of the first hypotension was shorter in group C (3 [1-13] vs 15 [1-95] minutes, P= .004). The proportion of patients without hypotension (cumulative survival) was better in group P (P= .04). The number of hypertensive episodes per patient and the number of bradycardic episodes per patient were similar between groups (P= not significant). CONCLUSION: Prophylactic phenylephrine infusion is an effective method of reducing SA-induced hypotension in the elderly. Compared with a control group, it delays the time to onset of hypotension and decreases the number of hypotensive episodes per patient. More data are needed to evaluate clinical outcomes of such a strategy.

Review on surgical management of ptosis and the use of phenylephrine: A national survey of British Oculoplastic Surgery Society (BOPSS) UK Consultants.

We assess current practice using topical phenylephrine by British Oculoplastic Surgery Society (BOPSS) consultants in the surgical management of ptosis. All UK consultant BOPSS members were invited to participate in a web-based survey, consisting of 8 questions relating to the surgical management of adult primary involutional ptosis with normal levator function and the use of phenylephrine in the management of ptosis. 53 BOPSS consultants (43%) completed the survey, of which 76% perform anterior approach levator advancement as first-line surgery. Then, 40% of consultants routinely use phenylephrine unilaterally in the ptotic eye, with 90% using 2.5% as opposed to 10%. Also, 77% of consultants use topical phenylephrine to illustrate the predicted outcome of surgery for the patient's benefit and 65% modify their approach on the basis of the test. If phenylephrine raises the ptotic eyelid >2 mm, those using an anterior approach reduces to 13.6%, with majority using a posterior approach (86.4%). If phenylephrine induces no improvement, then 76% use an anterior approach. If phenylephrine induces a contralateral ptosis 79% of consultants will perform simultaneous bilateral surgery. A number of interesting trends were observed amongst BOPSS consultants in their surgical approach to ptosis based on the phenylephrine test. The majority of consultants will switch from anterior to posterior approach surgery when the phenylephrine test is strongly positive and will also perform bilateral surgery when a contralateral ptosis is induced with phenylephrine.

Dynamic Analysis of Müller's Muscle Response to Phenylephrine.

PURPOSE: To characterize in vivo response of Muller's muscle to phenylephrine about time and diurnal variation. METHODS: A nonrandomized trial of adults without (n = 20, 40 eyes) and with ptosis (n = 5, 5 eyes) measured for response of marginal reflex distance-1 (MRD1) to topical phenylephrine (2.5%) every 15 seconds in the morning (6-10 AM) and evening (6-10 PM). Mean MRD1 was plotted over time, and morning and evening MRD1 were compared with the Spearman correlation coefficient (r) and paired t test. RESULTS: Regardless of the time of day, subjects with and without ptosis had maximal response to phenylephrine within 2 minutes, with persistence of response at 30 minutes. There was good correlation (r = 0.92), with no statistically significant difference in rate or amount of change of MRD1 between morning and evening time points. CONCLUSIONS: Maximal response to phenylephrine occurs within 2 minutes of instillation with persistence of response at 30 minutes; there appears to be no diurnal variation in phenylephrine testing.

Oral Midodrine Hydrochloride for Prevention of Orthostatic Hypotension during Early Mobilization after Hip Arthroplasty: A Randomized, Double-blind, Placebo-controlled Trial.

BACKGROUND: Early postoperative mobilization is essential for rapid recovery but may be impaired by orthostatic intolerance (OI) and orthostatic hypotension (OH), which are highly prevalent after major surgery. Pathogenic mechanisms include an insufficient postoperative vasopressor response. The oral α-1 agonist midodrine hydrochloride increases vascular resistance, and the authors hypothesized that midodrine would reduce the prevalence of OH during mobilization 6 h after total hip arthroplasty relative to placebo. METHODS: This double-blind, randomized trial allocated 120 patients 18 yr or older and scheduled for total hip arthroplasty under spinal anesthesia to either 5 mg midodrine hydrochloride or placebo orally 1 h before mobilization at 6 and 24 h postoperatively. The primary outcome was the prevalence of OH (decrease in systolic or diastolic arterial pressures of > 20 or 10 mmHg, respectively) during mobilization 6 h after surgery. Secondary outcomes were OI and hemodynamic responses to mobilization at 6 and 24 h. RESULTS: At 6 h, 14 (25%; 95% CI, 14 to 38%) versus 23 (39.7%; 95% CI, 27 to 53%) patients had OH in the midodrine and placebo group, respectively, relative risk 0.63 (0.36 to 1.10; P = 0.095), whereas OI was present in 15 (25.0%; 15 to 38%) versus 22 (37.3%; 25 to 51%) patients, relative risk 0.68 (0.39 to 1.18; P = 0.165). At 24 h, OI and OH prevalence did not differ between groups. CONCLUSIONS: Preemptive use of oral 5 mg midodrine did not significantly reduce the prevalence of OH during early postoperative mobilization compared with placebo. However, further studies on dose and timing are warranted since midodrine is effective in chronic OH conditions.

Potential Role of Catecholamine Response to Acute Hypoxia in the Modification of the Effects of Radioprotectors.

Involvement of hormonal response (catecholamine release) to acute hypoxia induced by radioprotectors in modification of their radioprotective properties was studied in experiments on outbred mature female albino mice, female albino rats, and dogs of both sexes. The response intensity was evaluated by the reduction of radioprotective and toxic properties of indralin (a α1-adrenoceptor agonist and a radioprotector). The radioprotective effect of indralin was measured using lethal doses of whole-body γ-irradiation ((60)Co) and its acute toxicity was assessed by LD50. It was found that repeated administration of indralin with 30-60-min intervals was followed by weakening of its radioprotective effect. Similar sensitization effect of indralin was observed after pretreatment with cystamine and epinephrine. Comparison of the severity of sensitization after administration of epinephrine and cystamine in the dose providing radioprotective effect showed that the potential aminothiol-induced release of catecholamines can provide optimal long-term radioprotective effect of epinephrine.

Palpebral position interdependence in blepharoptosis: comparison of the effect of instillation of 10% phenylephrine drop and digital lifting / Interdependência na posição palpebral em ptose palpebral: comparação do efeito de instilação de colírio de fenilefrina 10% e o teste de elevação digital da pálpebra

Purpose: To quantify and compare the effects of instillation with 10% phenylephrine and digital lifting on the contralateral upper eyelid of patients with involutional bilateral blepharoptosis. Methods: The present prospective clinical study involved patients with involutional bilateral blepharoptosis who underwent two tests: 1) digital lifting of the more ptotic eyelid and observation of the effect on the contralateral eyelid and 2) instillation of two drops of 10% phenylephrine in the more ptotic eye and observation of the effect on the contralateral eyelid. Patients were filmed before and 5, 10, and 15 min after instillation, and the resulting images were analyzed to obtain eyelid measurements. The results were tested using a linear mixed-effects model. Results: A total of 27 patients, ranging from 52 to 82 years of age (mean age 68.51 ± 8.21 years), 24 (88.88%) of whom were women, were included in the present study. In eyes that received instillation, the marginal distance reflex-1 (MDR1) values increased from baseline (1.21 ± 0.60 mm) until 10 min after instillation, then remained statistically unchanged until 15 min after instillation (2.42 ± 0.90 mm). Significant differences were observed in the contralateral eye of the group that underwent digital lifting (1.51 ± 0.53 mm - 1.63 ± 0.56 mm) and in the contralateral eye of the group that underwent 10% phenylephrine instillation (1.38 ± 0.54 mm - 1.63 ± 0.56 mm); p=0.02 and p<0.01, respectively. Conclusion: In all eyes, 10% phenylephrine elevated the upper eyelid, with improved eyelid height at 10 min after instillation. Significant differences were observed in the height of the contralateral eyelid when compared before and after each intervention in each group; however, this difference was very small and nearly undetectable by conventional clinical evaluation in the digital lifting group. However, the 10% phenylephrine eye-drop test resulted in substantial changes in MDR1 values ...

Objetivo: Quantificar e comparar o efeito da instilação do colírio de fenilefrina 10% com o levantamento manual da pálpebra superior contralateral de pacientes com ptose palpebral bilateral involucional. Métodos: Estudo clínico e prospectivo de pacientes com ptose palpebral bilateral involucional submetidos a dois testes: 1) elevação manual da pálpebra mais ptótica e observação do efeito da intervenção na pálpebra contralateral; e 2) a instilação de duas gotas de colírio de fenilefrina 10% no olho mais ptótico e observação do efeito da intervenção na pálpebra contralateral. Os pacientes foram filmados antes e 5, 10 e 15 minutos após a instilação. Os resultados foram analisados estatisticamente com o modelo linear de efeitos mistos. Resultados: O estudo incluiu 27 pacientes com idade entre 52-82 anos (68,51 ± 8,21), 24 dos quais eram do sexo feminino (88,88%). Em olhos submetidos a instilação do colírio, os valores da DMR1 (distância marginal reflexo) aumentaram da linha de base (1,21 ± 0,60 mm) até os 10 min, em seguida, manteve-se estatisticamente estável até 15 min (2,42 ± 0,90 mm). Diferenças significativas foram observadas nos olhos contralaterais, independentemente do levantamento manual da pálpebra (1,51 ± 0,53 mm - 1,63 ± 0,56 milímetros) e da instilação do colírio de fenilefrina 10% (1,38 ± 0,54 mm - 1,63 ± 0,56 mm), p=0,02 e p<0,01 respectivamente. Conclusões: Em todos os olhos, a instilação do colírio de fenilefrina 10% mostrou um aumento gradual do valor de distância marginal reflexo até os 10 min. Nos olhos contralaterais houve diminuição do valor de distância marginal reflexo, independentemente do teste realizado, porém as mudanças que ocorrem na posição da pálpebra contralateral, durante o teste da elevação manual, são muito pequenas e difíceis de serem detectadas no exame clínico convencional. Enquanto isso, o teste de colírio de fenilefrina 10% produziu mudanças substanciais nos valores distância marginal reflexo nos ...

Palpebral position interdependence in blepharoptosis: comparison of the effect of instillation of 10% phenylephrine drop and digital lifting.

PURPOSE: To quantify and compare the effects of instillation with 10% phenylephrine and digital lifting on the contralateral upper eyelid of patients with involutional bilateral blepharoptosis. METHODS: The present prospective clinical study involved patients with involutional bilateral blepharoptosis who underwent two tests: 1) digital lifting of the more ptotic eyelid and observation of the effect on the contralateral eyelid and 2) instillation of two drops of 10% phenylephrine in the more ptotic eye and observation of the effect on the contralateral eyelid. Patients were filmed before and 5, 10, and 15 min after instillation, and the resulting images were analyzed to obtain eyelid measurements. The results were tested using a linear mixed-effects model. RESULTS: A total of 27 patients, ranging from 52 to 82 years of age (mean age 68.51 ± 8.21 years), 24 (88.88%) of whom were women, were included in the present study. In eyes that received instillation, the marginal distance reflex-1 (MDR1) values increased from baseline (1.21 ± 0.60 mm) until 10 min after instillation, then remained statistically unchanged until 15 min after instillation (2.42 ± 0.90 mm). Significant differences were observed in the contralateral eye of the group that underwent digital lifting (1.51 ± 0.53 mm - 1.63 ± 0.56 mm) and in the contralateral eye of the group that underwent 10% phenylephrine instillation (1.38 ± 0.54 mm - 1.63 ± 0.56 mm); p=0.02 and p<0.01, respectively. CONCLUSION: In all eyes, 10% phenylephrine elevated the upper eyelid, with improved eyelid height at 10 min after instillation. Significant differences were observed in the height of the contralateral eyelid when compared before and after each intervention in each group; however, this difference was very small and nearly undetectable by conventional clinical evaluation in the digital lifting group. However, the 10% phenylephrine eye-drop test resulted in substantial changes in MDR1 values in the treated and contralateral eyes, indicating clinical and statistical efficiency.

[Management of intraoperative floppy iris syndrome]. / Managementul sindromului de flaciditate iriana intraoperatorie.

PURPOSE: To evaluate the incidence of IFIS in male patients whith alfa 1-AB treatment for benign prostatic hyperplasia (BPH) who underwent cataract surgery and also the pre and intraoperatory management and IFIS profilaxy. SETTING: Iasi "Sf Spiridon" Emergency Hospital and "Oftaprof" private practice METHODS: Observational retrospective study that took place over a period of 2 years (july 2009-july 2011) and reviewed 2484 eyes that underwent cataract surgery. A number of 1199 eyes were from 1049 male patients. RESULTS: Out of the 1049 male patients, 139 (13,25%) underwent treatment for BHP using the medication as follows: 119 used tamsulosin (85,6%); 18 used doxazosin, (12,94%); 2 used alfuzosin (1,43%). Out of the 139 men, 32 (23,02%) showed IFIS but only the ones treated with tamsulosin. After introducing a surgical protocol that comprised of the use of large amounts of vascoelastic material (Viscoat), intracamerular fenilefrin (Mezaton), the use of iris retractors and low faco parameters the incidence and severity of IFIS was significantly reduced. CONCLUSIONS: Correct evauation before surgery is necessary in order to anticipate the condition as its frequency and severity can be reduced by a proactive behavior which demands experience and adequate endowment.

Cell-penetrating peptides modulate the vascular action of phenylephrine.

Cell-penetrating peptides (CPP) are a family of peptides able to penetrate the cell membrane. This group of compounds has attracted consideration as potential therapeutic tools for the delivery of various substances into cells. Here, we investigated possible interactions between several CPP synthesized in our laboratory and the vascular action of phenylephrine. We used isolated rat tail artery and examined the influence of pretreatment by seven different CPP on the concentration-response curve induced by the α1 receptor agonist phenylephrine. Peptides were synthesized by solid-phase peptide synthesis (SPPS) using the 9-fluorenylmethoxycarbonyl (Fmoc) method. Among the seven different polypeptides, i.e., TP10 (transportan-10), [Lys(AAc)13]TP, [Lys(CAc)13]TP, [Lys(GAc)13]TP, [Lys(TAc)13]TP, [Lys(UAc)13]TP and [Lys(Ac)13]TP, only TP10 and [Lys(AAc)13]TP, both at a concentration of 1 µM (the lowest concentration inducing a significant change in the contraction of isolated rat stomach in our pilot study), rendered rat tail artery more sensitive to phenylephrine; the relative potency increased significantly. Conversely, [Lys(Ac)13]TP strongly decreased the efficacy of phenylephrine.

Phenylephrine tumescence in split-thickness skin graft donor sites in surgery for burn injury- a concentration finding study.

The purpose of this study is to determine the lowest concentration of subcutaneous phenylephrine (neosynephrine) required for effective vasoconstriction in skin graft donor sites. Surgery for burn injury is associated with blood loss. Tourniquet use and tumescence with epinephrine have decreased blood loss. However, absorption of epinephrine has been reported with systemic effects. Phenylephrine, an α1-adrenergic receptor agonist, has vasoconstrictive properties similar to epinephrine's without other α-adrenergic or ß-adrenergic activity. The aim of this study is to determine the lowest effective concentration of phenylephrine that will provide vasoconstriction in split-thickness graft donor sites. By using intensive care unit equivalency tables, the authors estimated a concentration of phenylephrine on the basis of current epinephrine tumescence. This concentration was titrated up or down according to an algorithm established a priori, determining the minimum concentration that achieved vasoconstriction in three consecutive patients. The primary outcome was local vasoconstriction. Secondary outcomes measured were pre-, intra-, and postoperative mean arterial pressure, systolic pressure and heart rate, graft take, and donor site healing. The subjects were six otherwise healthy adult patients (five men and one woman) with a mean age of 36 years. The average TBSA was 737.5 cm². Vasoconstriction was achieved at 5 µg/ml. No significant alterations in hemodynamic measures were observed. The optimal concentration of phenylephrine for prevention of bleeding in donor sites appears to be 5 µg/ml. Participants will be able to identify the effects of phenylephrine and epinephrine tumescence. They will also identify the concentration at which phenylephrine will be effective in donor sites.