Evaluation of the Temple Touch Pro, a Novel Noninvasive Core-Temperature Monitoring System.

BACKGROUND: The Temple Touch Pro (TTP) is a novel system that estimates core temperature from skin over the temporal artery. We tested the hypothesis that this noninvasive system estimates core temperature to an accuracy within 0.5°C. METHODS: Core temperature was continuously monitored in 50 adult and pediatric surgical patients by positioning the sensor patch of a TTP over one temporal artery. The sensor consists of a thermistor array near the skin surface, another set of thermistors above an insulator, and a second insulator between the upper unit and the environment. The sensor measures skin temperature and heat flux, from which the monitor unit estimates core temperature from a proprietary algorithm. Reference core temperature was measured from the esophagus or nasopharynx. We conducted agreement analysis between the TTP and the reference core temperature measurements using the 95% Bland-Altman limits of agreement for repeated measurement data. The proportion of all differences that were within 0.5°C and repeat measures concordance correlation coefficient (CCC) were estimated as well. RESULTS: TTP and the reference core temperature measurements agreed well in both adults and pediatric patients. Bland-Altman plots showed no evidence of systematic bias or variability over the temperature from 35.2°C to 37.8°C. The estimated 95% lower and upper limits of agreement were -0.57°C (95% confidence interval [CI], -0.76 to -0.41) and 0.57°C (95% CI, 0.44 to 0.71), indicating good agreement between the 2 methods. Ninety-four percentage (95% CI, 87% to 99%) of the TTP temperatures were within 0.5°C of the reference temperature. Good agreement was also supported by an estimated repeated measures CCC of 0.82 (95% CI, 0.66 to 0.91). The TTP core temperature measurements also agreed well with nasopharyngeal reference temperatures. CONCLUSIONS: The noninvasive TTP system is sufficiently accurate and reliable for routine intraoperative core temperature monitoring.

Perioperative metabolic alkalemia is more frequent than metabolic acidemia in major elective abdominal surgery.

OBJECTIVE: To investigate the incidence, type and etiology of perioperative metabolic disturbances associated with major abdominal surgery. We hypothesized that metabolic alkalemia is more frequent than metabolic acidemia. METHODS: This was a prospective, observational study, performed in a university-affiliated hospital. 98 consecutive patients undergoing major abdominal surgery were included in the study. Patients were observed by serial vital signs and laboratory measurements during the preoperative, intraoperative, PACU and the first three postoperative day periods. Central venous pressure, systolic pressure variation, fluid input, urine output, temper- ature, electrolytes, and acid-base variables were recorded. The primary endpoint of the study was the incidence of metabolic alkalemia or acidemia. Metabolic alkalemia was defined as pH >7.45 and BE >+3. Metabolic acidemia was defined as pH <7.35 and BE <-3. Continuous variables were described as mean ± standard deviation. Distributions of continuous variables was assessed for normalty using the Kolmogorov-Smirnov test (cut off at P = 0.01). The frequency of metabolic acidemia or alkalemia was compared across time points using Cochran's Q test and between time points using the binomial distribution. RESULTS: Metabolic acidemia occurred only intraoperatively and in the PACU. Subjects with metabolic acidemia were older, (74 ± 9 yr. vs. 66 ± 12, P = 0.01). Intraoperative body temperature was inversely associated with PACU lactate (P = 0.035). Blood loss >500 mL was more frequent in acidemic patients (42% vs. 19%, P = 0.033). More patients with hyperphosphatemia had acidemia than subjects without hyperphosphatemia (39% vs. 17%, P = 0.019). Metabolic alkalemia occurred more frequently than metabolic acidemia (49% vs. 23%, P < 0.0001) and was correlated with hypochloremia. The incidence of metabolic alkalemia decreased from baseline to intraoperative and PACU periods (13% vs. 3%, P = 0.003) and increased from the PACU to the three postoperative days (3% vs. 45%, P = 0.007). CONCLUSIONS: Metabolic alkalemia occurred more frequently than metabolic acidemia and occurred mainly preoperatively and postoperatively, while acidemia occurred mainly during surgery and in the PACU.

Organizational prerequisites for anesthesia outside the operating room.

PURPOSE OF REVIEW: The purpose of this review is to define the responsibility and designation of anesthesia personnel to nonoperating room location anesthesia and their education in this regard. The review will also define the safety standards, guidelines, physical environment, equipment, accreditation, the quality of care and patient and procedural selection. RECENT FINDINGS: Anesthesia outside the operating room continues to be a challenging field. With the advances in surgical and anesthetic technology, there is an increasing need for research in the area of office-based anesthetic techniques and for improvement in terms of adherence to safety standards in aiming to decrease morbidity and mortality and increase patient satisfaction. SUMMARY: Complications of anesthesia outside the operating room still persist even in American Society of Anesthesiologists (ASA) status I patients and in accredited facilities with board-certified physicians. The department of anesthesiology taking care of the in-hospital office-based facility has the responsibility to define safe practice standards according to the ASA guidelines regarding education, documentation, guidelines preparation, equipment, standards monitoring, collaboration with other facilities, backup for the personnel in case of emergencies and prolongation of observation of a complicated patient in the postanesthesia care unit. Office-based facilities outside the hospital should comply with all federal, state, local laws and regulations. Such precautions will enhance safety, efficiency and reliability of office-based anesthesia inside and outside the hospital.

A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age.

OBJECTIVE: To present a concise history of tracheostomy and tracheal intubation for the approximately forty centuries from their earliest description around 2000 BC until the middle of the twentieth century, at which time a proliferation of advances marked the beginning of the modern era of anesthesiology. DATA SOURCES: Review of the literature. CONCLUSIONS: The colorful and checkered past of tracheostomy and tracheal intubation informs contemporary understanding of these procedures. Often, the decision whether to perform a life-saving tracheostomy or tracheal intubation has been as important as the technical ability to perform it. The dawn of modern airway management owes its existence to the historical development of increasingly effective airway devices and to regular contributions of research into the pathophysiology of the upper airway.

Gastroesophageal regurgitation during anesthesia and controlled ventilation with six airway devices.

STUDY OBJECTIVE: To investigate the frequency of gastroesophageal regurgitation and respiratory mechanics during positive pressure ventilation using 5 supraglottic devices or an endotracheal tube (ETT). DESIGN: Prospective, randomized study. SETTING: Operating rooms in a university-affiliated hospital. PATIENTS: 180 ASA physical status I and II patients, aged 18 to 65 years old, who underwent elective orthopedic, minor vascular, peripheral plastic, or urologic surgery during general anesthesia. INTERVENTIONS: Patients were randomly allocated to one of 6 airway device groups (n = 30 each): (1) Cobra Perilaryngeal Airway; (2) Laryngeal Mask Airway (LMA) Classic; (3) LMA Fastrach; (4) LMA ProSeal; (5) laryngeal tube; and (6) ETT (SIMS Portex, Ltd, Hythe, Kent, UK). After insertion of the designated device, the lungs of each nonparalyzed patient were mechanically ventilated. MEASUREMENTS: Hypopharyngeal pH, peak inspiratory pressures, sealing pressures, and lung compliance were measured. Hypopharyngeal pH lower than 4 was considered a regurgitation event. MAIN RESULTS: Regurgitation (episodes of pH <4) occurred in between one and 5 patients of each study group, with no statistical difference. Sealing pressures were similar among all the airway device groups. CONCLUSIONS: The frequency of gastroesophageal regurgitation in anesthetized, unparalyzed, mechanically ventilated patients was similar in patients whose lungs were ventilated with either the Cobra Perilaryngeal Airway, LMA Classic, Fastrach, ProSeal, laryngeal tube, or ETT.

The effect of intermittent versus continuous bladder catheterization on labor duration and postpartum urinary retention and infection: a randomized trial.

STUDY OBJECTIVE: To assess the effect of intermittent versus continuous bladder catheterization on labor duration and local anesthetic consumption. DESIGN: Randomized, controlled, prospective, single-blind trial. SETTING: University-affiliated hospital. PATIENTS: 209 ASA physical status I and II, primiparous parturients who received patient-controlled epidural analgesia for labor. INTERVENTIONS: Patients were randomly allocated to either the intermittent bladder catheterization group (Group IC; n = 109) or the continuous catheterization group (Group CC; n = 100). MEASUREMENTS: Duration of the second stage of labor, dose of local anesthetics given, and primary outcomes were compared by group using the t-test for independent samples. Main secondary outcomes were postpartum urinary retention and rate of postpartum urinary tract infection (UTI; asymptomatic bacteruria). MAIN RESULTS: Duration of the second stage of labor was longer in Group CC than Group IC: 105 +/- 72 vs. 75 +/- 52 min (P = 0.002). This finding was associated with increased local anesthetic dose requirement in Group CC during both stages of labor (73 +/- 25 mL vs. 63 +/- 26 mL; P = 0.005). The rate of UTI was similar (30%) in both study groups. CONCLUSION: Intermittent bladder catheterization was associated with shorter second-stage labor and less local anesthetic, but the same frequency of postpartum urinary retention and UTI was seen with both catheterization groups.

Predistention of the epidural space before catheter insertion reduces the incidence of intravascular epidural catheter insertion.

BACKGROUND: Accidental cannulation of an epidural vein is a common complication associated with epidural anesthesia or analgesia. On the basis of a pilot study and previous reports, we tested the hypothesis that predistention of the epidural space with saline before epidural catheterization would ease catheter insertion and decrease the incidence of this complication. METHODS: Two-hundred-three laboring women were randomly assigned to receive an epidural with loss of resistance technique with 2 mL (nondistention) or 5 mL saline (distention). In the distention group, the syringe plunger was held closed before epidural catheter insertion. Then in both groups, a test dose of 3 mL of 1.5% lidocaine was injected through the epidural catheter. RESULTS: There were fewer accidental intravascular catheter placements (2% vs 16%, P = 0.0001) in the distention group, and 91% of patients in this group did not have any unblocked segments versus 67% in the nondistension group (P = 0.0001). The difference in onset time of analgesia was small (5.0 +/- 2 min vs 6 +/- 3 min, P = 0.0001) and not clinically important. The quality of analgesia (visual analog scores and ropivacaine consumption) was similar between groups. CONCLUSIONS: Distention of the epidural space with 5 mL saline before epidural catheter insertion decreased the incidence of accidental venous cannulation and the number of unblocked segments.

Transient neurological symptoms after isobaric subarachnoid anesthesia with 2% lidocaine: the impact of needle type.

BACKGROUND: The reported incidence of transient neurological symptoms (TNS) after subarachnoid lidocaine administration is as high as 40%. We designed this clinical trial to determine the incidence of TNS with two different pencil-point spinal needles: one-orifice (Atraucan) and two-orifice (Eldor) spinal needles. METHODS: Ninety-nine ASA physical status I or II patients undergoing surgical procedures of the urinary bladder or prostate were prospectively allocated to receive spinal anesthesia with 40 mg, 2% isobaric lidocaine plus fentanyl injected through either a 26-gauge Atraucan (n = 52) or a 26-gauge Eldor (n = 47) spinal needle. During the first three postoperative days, patients were observed for postoperative complications, including TNS. The primary end-point for this trial was the percentage of TNS in both double- and single-orifice spinal needle procedures. RESULTS: The incidence of TNS was higher when spinal anesthesia was done through the Atraucan needle (28.8% vs 8.5%, P = 0.006). Fifty percent of the patients in the double-orifice group versus 100% of the single-orifice group developed TNS after surgery in the lithotomy position (P = 0.014). The relative risk for developing TNS with the Eldor needle was 0.29 (95% CI: 0.07-0.75) compared with the Atraucan needle. CONCLUSIONS: The use of a double-orifice spinal needle was associated with a lower incidence of TNS, which may have been due to the needle design.

Activin betaA in term placenta and its correlation with placental inflammation in parturients having epidural or systemic meperidine analgesia: a randomized study.

STUDY OBJECTIVE: To investigate the immunohistochemical localization of betaA subunit of activin A in human term placenta, as a marker for placental infection/inflammation and elevated temperature, in parturients laboring during two analgesic regimens. DESIGN: Prospective, randomized controlled study. SETTING: Delivery room. PATIENTS: 56 healthy, ASA physical status I and II primiparous women in labor. INTERVENTIONS: Parturients were assigned to receive patient-controlled epidural analgesia (PCEA) with 0.2% ropivacaine or patient-controlled intravenous analgesia PCA with meperidine. MEASUREMENTS: Histologic and immunohistochemical placental evaluation for white blood cell infiltration and activin betaA staining were made. Maternal temperature elevation above 37.6 degrees C and leukocytosis above 15,000/microL were recorded. MAIN RESULTS: Temperature was not significantly increased in parturients receiving PCEA over those who received (PCA) with meperidine (31% vs 11%, respectively; P = 0.1). There was also no association between temperature elevation during epidural analgesia and increased white blood cell count (>15,000/microL) or presence of polymorphonuclear and/or lymphocyte aggregation in the placenta. Immunohistochemical staining with antisera against the betaA subunit of activin was present mainly in the placental cytotrophoblast, syncytiotrophoblast, and vascular endothelium, and was not associated with an increase in maternal temperature. No significant difference was noted between the two analgesic techniques with regard to maternal temperature elevation. Intrapartum temperature elevation was not associated with histologic signs of placental inflammation or with expression of activin betaA in the placenta. CONCLUSION: Other mechanisms may be involved in the etiology of temperature elevation during labor.

Proper insertion depth of endotracheal tubes in adults by topographic landmarks measurements.

STUDY OBJECTIVE: To evaluate a new method of endotracheal tube (ETT) positioning relative to carina, based on external topographic landmarks. DESIGN: Prospective, randomized, crossover study. SETTING: Operating room, university hospital. PATIENTS: 200 American Society of Anesthesiologists (ASA) physical status I-II patients (100 women and 100 men) scheduled for elective surgery with general anesthesia. INTERVENTIONS: ETT insertion depth was topographically determined by adding the distance measured (in cm) from the right mouth corner to right mandibular angle to the distance measured from the right mandibular angle to a point situated on the center of a line running transversally through the middle of the sternal manubrium. This method was compared to the 21/23 cm insertion depth method. MEASUREMENTS: ETT position was assessed fiberoptically. The main end point was considered the percentage of ETT tips situated more than 25% higher or lower than a predetermined "best" tip position (4 cm above the carina). MAIN RESULTS: There were 58.5% ETT tips positioned too closely (<3 cm above the carina) to the carina with the control method and 24% with the study method (P=0.0001). No ETT tip was too high (>5 cm above the carina). The tip-carina distance was shorter in women (2.7+/-2.5 vs 3.6+/-2.2 cm in men P=0.0001) and in those aged more than 65 years (2.8+/-2.4 vs 3.4+/-2.4 cm with age less than 65 years; P=0.012) only with the 21/23 cm method. CONCLUSIONS: With our new ETT positioning method, there were fewer ETTs positioned outside the desired range of distance to carina. Our method may be especially valuable in women and in patients older than 65 years.

The importance of blood sampling site for determination of hemoglobin and biochemistry values in major abdominal and orthopedic surgery.

STUDY OBJECTIVE: To determine whether sampling of blood from different sites influences laboratory results. DESIGN: Prospective, double-blind study. SETTING: University-affiliated hospital in Israel. PATIENTS: 100 ASA physical status I, II, and III patients undergoing major orthopedic or colon surgery (total hip and revision of total hip replacement, colon resection, or radical cystectomy). MEASUREMENTS: Blood was sampled simultaneously for hemoglobin, electrolytes, glucose, pH, blood gases, and lactate from three sampling sites (peripheral vein, central vein, and radial artery) at 5 time frames (after induction of anesthesia [baseline], one hr after induction of anesthesia, at the end of surgery, after one hr in the recovery room, and 4 hrs after surgery). At the same time points, recorded rectal temperature, mean arterial pressure, heart rate, and central venous pressure were recorded. Anesthesia, monitoring, and dwell volumes before sampling were standardized. MAIN RESULTS: There were no significant differences between the results of hemoglobin, electrolytes, glucose, pH, and blood gases obtained from different sampling sites and at different time frames. Lactate level (mmol/L) was higher in peripheral venous blood than it was in either the central vein or radial artery (<0.05), and higher in central venous blood compared with arterial blood (P < 0.05; 2.04 +/- 1.16, 1.74 +/- 0.78, and 1.54 +/- 0.68, respectively). CONCLUSION: Under stable hemodynamics and in the absence of hypothermia, serum lactate level was higher in peripheral venous blood than it was in the central vein or radial artery.

Mode of ventilation during cardiopulmonary bypass does not affect immediate postbypass oxygenation in pediatric cardiac patients.

STUDY OBJECTIVE: To investigate the impact of different modes of ventilation during cardiopulmonary bypass (CPB) on immediate postbypass oxygenation in pediatric cardiac surgery. DESIGN: Prospective, randomized clinical trial. SETTING: University hospital. PATIENTS: 50 pediatric patients (18 girls, 32 boys), aged 4 months to 15 years, undergoing elective repair of congenital heart disease. INTERVENTIONS: Patients were randomized to receive one of 5 modes of ventilation during bypass. Groups 1 and 2 received high-frequency/low-volume ventilation with 100% (group 1) or 21% oxygen (group 2). Groups 3 and 4 received continuous positive airway pressure of 5 cm H(2)O with 100% (group 3) or 21% oxygen (group 4); and in group 5, each patient's airway was disconnected from the ventilator (passive deflation). MEASUREMENTS: Blood gas analysis and spirometry data were recorded 5 minutes before chest opening, 5 minutes before inducing bypass, 5 minutes after weaning from bypass, and 5 minutes after chest closure. MAIN RESULTS: There were no differences in Pao(2) values among the 5 groups studied and at the different time points. Lung compliance was higher 5 minutes before bypass in group 1 versus group 5 (34 +/- 13 mL/cm H(2)O vs 20 +/- 9 mL/cm H(2)O; P = 0.048). CONCLUSIONS: Mode of ventilation during CPB did not affect immediate postbypass oxygenation.

Respiratory events with sugammadex vs. neostigmine following laparoscopic sleeve gastrectomy: a prospective pilot study assessing neuromuscular reversal strategies.

Abdominal surgery in obese patients may be associated with pulmonary morbidity, and mortality. Some patients may arrive in the PACU with residual paralysis. The purpose of this study was to find out if there was an association between the type of muscle relaxant reversal agent and the development of postoperative respiratory events in patients undergoing laparoscopic sleeve gastrectomy surgery. METHODS: From September 2012 to February 2013, in a prospective randomized pilot study, two different muscle relaxant reversal agents were administered at the end of surgery in 57 patients undergoing laparoscopic sleeve gastrectomy: sugammadex 2 mg/kg (32 patients) vs. neostigmine 2.5 mg (25 patients). We compared the occurrence of early and late respiratory events/complications by the type of reversal agent. Postoperative respiratory rate, oxyhemoglobin saturation (SpO2), number of patients with SpO2 lower than 95% in PACU, the minimum value of SpO2 in PACU, train-of four counts (TOF) before reversal, unexpected ICU admissions, duration of hospitalization and incidence of reintubation were recorded. RESULTS: SpO2 in the PACU was significantly lower in the neostigmine group - 95.80 (± 0.014)) vs. in sugammadex group - 96.72 (± 0.011) (p < 0.01), despite a lower TOF count measured in the sugammadex group before reversal, meaning a deeper level of residual relaxation in this group before the administration of the reversal agent (2.53 ± 0.98 vs. 3.48 ± 0.58 p < 0.01). Also, the minimal SpO2 was significantly lower in the PACU in the neostigmine group: 93% vs. 94% (p = 0.01). Respiratory rates were not different. After the administration of reversal, both groups had TOF counts of 4 with no fade assessed visually. There were no postoperative respiratory events or complications. CONCLUSIONS: The use of sugammadex (as compared to neostigmine) as a reversal agent following laparoscopic sleeve gastrectomy surgery was associated with higher postoperative SpO2 despite the lower TOF count before the administration of reversal agent. Despite the statistical difference in SpO2, its clinical importance seems to be minimal. The lack of difference in the other measured variables may stem from the small number of patients studied (pilot).

Comparison of hemodynamic profiles in transurethral resection of prostate vs transurethral resection of urinary bladder tumors during spinal anesthesia: a bioimpedance study.

STUDY OBJECTIVE: Transurethral resection of prostate (TURP) is more frequently associated with perioperative fluid and electrolyte disturbances than transurethral resection of bladder tumors (TURT) because of irrigating fluid absorption. Because fluid overload may cause hypertension, we compared the patients' intraoperative hemodynamic profiles (including the incidence of hypertension) during TURP vs TURT, both performed during spinal anesthesia, by using the bioimpedance method. DESIGN: Prospective single-blind study. SETTING: University hospital. PATIENTS: 80 (40 in each group) men, ASA physical status I and II. INTERVENTIONS: Patients underwent TURP or TURT surgery with spinal anesthesia. MEASUREMENTS: Mean arterial pressure, heart rate, cardiac index, and systemic vascular resistance were compared between the 2 groups. A mean arterial pressure greater than 30% from the baseline value was considered as hypertension. Plasma sodium was measured preoperatively, intraoperatively, and postoperatively. MAIN RESULTS: Transurethral resection of prostate patients received more irrigating fluid (7900 +/- 2310 vs 5650 +/- 21560, P < 0.05) and had a higher calculated volume of fluid absorbed: 638 +/- 60 vs 303 +/- 40 mL for the TURT patients (P < 0.05). Mean arterial pressures were higher with TURP, 30 minutes after the onset of surgery and at the end of the procedure (111 +/- 15 vs 100 +/- 10 and 109 +/- 14 vs 99 +/- 14 mmHg, respectively; P < 0.05). However, there was no hypertension in either group. There were no differences in hemodynamic measurements of hyponatremic vs normonatremic patients. Plasma sodium decreased postoperatively more in the TURP group (140.4 +/- 2.6 mEq/L baseline to 134.1 +/- 3.5 mEq/L, P < 0.05) and was lower postoperatively in the TURP group compared with TURT (134.1 +/- 3.5 vs 137.2 +/- 2.9 mEq/L, P = 0.04). CONCLUSIONS: Although more irrigating fluid was absorbed in the TURP group, there were no episodes of hypertension in either group.

[Tracheostomy and endotracheal intubation: a short history].

The first descriptions of tracheostomy appear in old Hindu scripts around 2000 BC and Egyptian documents around 1500 BC. Since then, other reports in animals and humans established the tracheostomy as a life saving procedure. Vesalius in 1543 reported the first tracheal intubation in an animal. Trousseau reported 200 patients suffering from diphtheria who were saved by tracheostomy. In the early 1870's, Trendelenburg from Germany performed the first endotracheal anesthesia in man. Macewen in 1878 reported the first elective endotracheal intubation for anesthesia. He isolated the trachea by packing the hypopharynx, from leaking of blood and debris. Later, Rosenberg and Kuhn administered cocaine as local anesthetic to obtund the cough reflex during intubation. Tracheostomy and intubation have been broadly used during the First World War. Magill (1888-1986) recognized the advantages of tracheal intubation. Also, by his efforts, anesthesia has become an independent specialty. In 1913 the first anesthetic laryngoscope was invented by Jackson and modified by the Magill, Miller and Macintosh. In 1942, curare was introduced as a muscle relaxant for abdominal relaxation during general anesthesia and endotracheal intubation became routine in major abdominal and other surgeries. The article also reviews the Israeli contribution to the development of tracheostomy.

Residual Curarization and Postoperative Respiratory Complications Following Laparoscopic Sleeve Gastrectomy. The Effect of Reversal Agents: Sugammadex vs. Neostigmine.

BACKGROUND: Incomplete muscle relaxant reversal or re-curarization may be associated with postoperative respiratory complications. In this retrospective study we compared the incidence of postoperative residual curarization and respiratory complications in association with the type of muscle relaxant reversal agent, sugammadex or neostigmine, in patients undergoing laparoscopic sleeve gastrectomy. MATERIAL AND METHODS: We reviewed the charts of all patients (179) undergoing laparoscopic sleeve gastrectomy from July 2012 to July 2013 at Wolfson Medical Center. Sugammadex 1.5-2 mg/kg (112 patients) or neostigmine 2.5 mg (67 patients) were used as reversal agents. Results were compared by the type of reversal agent employed. Compared parameters included demographic and anaesthetic data, residual curarization, oxyhemoglobin saturation (SpO2) in the recovery room (PACU), episodes of SpO2 lower than 90% in PACU, unexpected intensive care (ICU) admissions, incidence of atelectasis and pneumonia, re-intubation and duration of hospitalization. RESULTS: Obstructive sleep apnea syndrome (OSAS) was more frequent in the sugammadex group (19% vs. 8%; p = 0.026). Total intravenous anesthesia (TIVA) was more frequently associated with sugammadex (33% vs. 16%; p = 0.007). There were no differences in postoperative residual curarization, SpO2 < 90% episodes, reintubation, ICU admissions, pulmonary complications and duration of hospitalization. CONCLUSION: With the inherent limitations of a retrospective study, the use of sugammadex following laparoscopic sleeve gastrectomy showed no advantage over neostigmine in terms of residual curarization and respiratory complications.

Preconditioning allows engraftment of mouse and human embryonic lung cells, enabling lung repair in mice.

Repair of injured lungs represents a longstanding therapeutic challenge. We show that human and mouse embryonic lung tissue from the canalicular stage of development (20-22 weeks of gestation for humans, and embryonic day 15-16 (E15-E16) for mouse) are enriched with progenitors residing in distinct niches. On the basis of the marked analogy to progenitor niches in bone marrow (BM), we attempted strategies similar to BM transplantation, employing sublethal radiation to vacate lung progenitor niches and to reduce stem cell competition. Intravenous infusion of a single cell suspension of canalicular lung tissue from GFP-marked mice or human fetal donors into naphthalene-injured and irradiated syngeneic or SCID mice, respectively, induced marked long-term lung chimerism. Donor type structures or 'patches' contained epithelial, mesenchymal and endothelial cells. Transplantation of differentially labeled E16 mouse lung cells indicated that these patches were probably of clonal origin from the donor. Recipients of the single cell suspension transplant exhibited marked improvement in lung compliance and tissue damping reflecting the energy dissipation in the lung tissues. Our study provides proof of concept for lung reconstitution by canalicular-stage human lung cells after preconditioning of the pulmonary niche.

Urinary function during epidural analgesia with methadone and morphine in post-cesarean section patients.

Urinary function was assessed in 120 women after cesarean section under epidural anesthesia. Postoperative analgesia was obtained by means of epidurally administered methadone (40 patients) or morphine (40 patients). In the remaining 40 women, no narcotic drugs were given and postoperative pain was treated with intramuscular or oral non-opiate analgesics and sedatives. Both methadone and morphine provided potent postoperative pain relief. Following epidural methadone, mean urine volumes of the first two postoperative voidings were increased (543 +/- 38 ml and 571 +/- 31 ml) as compared with those after epidural morphine (219 +/- 25 ml and 218 +/- 18 ml) and with those of patients receiving non-opiate analgesics (319 +/- 28 ml and 414 +/- 30 ml). The mean time interval between the end of surgery and first voiding following methadone analgesia was shorter (336 +/- 27 min) than after morphine (582 +/- 18 min) or after non-opiate (448 +/- 28 min) analgesic drugs. Difficulty in micturition and the need for bladder catheterization were also decreased in the group with epidural methadone (2.5%) in comparison with the groups receiving morphine (57.5%) or non-opiate analgesic medicaments (12.5%). The use of epidural methadone for postoperative pain relief is advocated, both in view of its analgesic potency and of the low incidence of urinary disturbances.