Effects of coenzyme Q10 in a propofol infusion syndrome model of rabbits.

Background: Coenzyme Q (CoQ) might be the main site of interaction with propofol on the mitochondrial respiratory chain in the propofol infusion syndrome (PRIS) because of the structural similarity between coenzyme Q10 (CoQ10) and propofol. Aim: To investigate the effects of CoQ10 on survival and organ injury in a PRIS model in rabbits. Methods: Sixteen male New Zealand white rabbits were divided into 4 groups: (1) propofol infusion group, (2) propofol infusion and CoQ10, 100 mg/kg was administered intravenously, (3) sevoflurane inhalation was administered, and (4) sevoflurane inhalation and CoQ10, 100 mg/kg intravenously, was administered. Arterial blood gas and biochemical analyses were repeated every 2 h and every 12 h, respectively. Animals that were alive on the 24th hour after anesthesia induction were euthanized. The organ damages were investigated under light and transmission electron microscopy (TEM). Results: The propofol infusion group had the highest troponin T levels when compared with the other three groups at the 12th hour. The propofol + CoQ10 group had lower troponin T levels when compared with the propofol and sevoflurane groups (P < 0.05). Administration of CoQ10 decreased total liver injury scores and total organ injury scores both in the propofol and sevoflurane groups. The propofol and sevoflurane organ toxicities were attenuated with CoQ10 in liver, gallbladder, urinary bladder, and spleen. Conclusion: The addition of CoQ10 to propofol and sevoflurane anesthesia prevented the propofol-associated increase in troponin T levels at the 12th hour of infusion and decreased anesthetic-induced total liver and organ injury scores.

The effect of pneumoperitoneum and Trendelenburg position on optic nerve sheath diameter in patients undergoing laparoscopic hysterectomy.

BACKGROUND AND AIM: Laparoscopic hysterectomy (LH) have been frequently used because of low complication rates and short duration of hospital stay. Elevated intracranial pressure (ICP), a disadvantage of laparoscopic surgery, is caused by the Trendelenburg position (TP) and CO2 pneumoperitoneum (PP). This study aimed to evaluate TP and PP associated changes in ICP by ONSD measurements during LH. The intra-and inter-observer consistency and reliability of ONSD measurements were also investigated. METHODS: Sixty patients with were enrolled into this prospective study. ONSD for each patient was measured by three anesthesiologists at T0, T1, T2, and T3 time points. ONSD, mean arterial pressure (MAP), end tidal CO2 (EtCO2 ), and arterial blood CO2 partial pressure values (PaCO2 ) were measured at T0: baseline, T1: 10 min after introducing 20 mmHg PP, T2: 10 min after placing the patient in TP and 15 mmHg PP and, T3: 10 min after PP deflation. RESULTS: The ONSD measured at T1 (5.97 ± 0.49 cm) and T2 (5.95 ± 0.57 cm) were higher than T0 (5.63 ± 0.53 cm) and T3 (5.72 ± 0.47 cm) (p < 0.05). There were no correlations between MAP and ONSD, and also between PaCO2 , EtCO2 , and ONSD measurements at any time points. Inter-observer intraclass correlation coefficient (ICC) values of ONSD measurements by all examiners had moderate (at T1) to good (at T0, T2, T3) reliability. Intra-observer agreements were reasonable for each observer. CONCLUSION: ONSD measurements increase with CO2 PP and TP in patients undergoing LH. Transorbital sonography is a reliable method to monitor intraoperative changes in ONSDs. This study underlines the need for careful training and the importance of standardization in order to obtain reliable results in the examination technique of ONSD measurements.

The effects of sevoflurane anesthesia and cardiopulmonary bypass on renal function in cyanotic and acyanotic children undergoing cardiac surgery.

BACKGROUND: There are few data on the effects of anesthesia and cardiopulmonary bypass (CPB) on perioperative renal function in children with cyanotic congenital heart disease undergoing open heart surgery. This study aims to investigate the perioperative renal function in cyanotic versus acyanotic children undergoing sevoflurane anesthesia for open heart surgery. METHODS: After receiving ethical committee approval, 12 acyanotic patients (preoperative oxygen saturation: SaO(2) > 85%) and 12 cyanotic children (SaO(2) < 85%) were included. Sevoflurane was administered at concentration levels of 2% before CPB and 1-2% during CPB after standard anesthesia induction. Inorganic fluoride, electrolytes, creatinine, urea nitrogen in serum and urine samples, and N-acetyl-ß-d-glucosaminidase (NAG) in urine samples were measured before induction, before CPB, during CPB, after CPB, at the end of surgery, and at 24th h postoperatively. RESULTS: The levels of serum uric acid levels were higher in the cyanotic group (p < 0.05). There were no differences in the levels of serum creatinine and urine creatinine, urea nitrogen, and electrolytes between the two groups. Serum inorganic fluoride levels were always higher in the acyanotic group than in the cyanotic group, but these differences between the groups reached statistical significance at two measurement times (before CPB and end of surgery) (p < 0.05). Urinary inorganic fluoride levels increased with time in both groups. Although urinary NAG increased significantly after the CPB in the cyanotic group, the differences between the two groups did not reach statistical significance. CONCLUSIONS: We have concluded that renal function was not affected during open heart surgery with sevoflurane anesthesia, in both cyanotic and acyanotic children.

Comparison of propofol-fentanyl with propofol-fentanyl-ketamine combination in pediatric patients undergoing interventional radiology procedures.

BACKGROUND: With an increase in the frequency of interventional radiology procedures in pediatrics, there has been a corresponding increase in demand for procedural sedation to facilitate them. The purpose of our study was to compare the frequency of adverse effects, sedation level, patient recovery characteristics in pediatric patients receiving intravenous propofol fentanyl combination with or without ketamine for interventional radiology procedures. Our main hypothesis was that the addition of ketamine would decrease propofol/fentanyl associated desaturation. METHODS AND MATERIALS: Sixty consenting American Society of Anesthesia physical status I-III pediatric patients undergoing interventional radiology procedures under sedation were studied according to a randomized, double-blinded, institutional review board approved protocol. Group 1 received propofol 0.5 mg.kg(-1) + fentanyl 1 microg.kg(-1) + ketamine 0.5 mg.kg(-1), and group 2 received propofol 0.5 mg.kg(-1) + fentanyl 1 microg.kg(-1) + same volume of %0.9 NaCl intravenously. RESULTS: While apnea was not observed in any of the groups, there were three cases (10%) in group 1, and nine cases (30%) in group 2 with oxygen desaturation (P = 0.052). In group 1, 12 (40%) patients and, in group 2, 21 (70%) patients required supplemental propofol during the procedure (P = 0.021). There was no evidence for difference between groups in terms of other side effects except nystagmus. CONCLUSIONS: In conclusion, addition of low dose ketamine to propofol-fentanyl combination decreased the risk of desaturation and it also decreased the need for supplemental propofol dosage in pediatric patients at interventional radiology procedures.

Comparative assessment of induction efficacy of propofol preparations.

OBJECTIVE: To compare the hypnotic effects (using Bispectral Index [BIS]), hemodynamic parameters, injection pain and quality of anesthesia during induction of anesthesia of the 3 commercial propofol preparations (Abbott Propofol, Abbott Laboratories), Pofol (Dongkook Pharm. Co. Ltd.), and Propofol 1% Fresenius (Fresenius Kabi). METHODS: After Ethics Committee Approval, a prospective, randomized, double-blind study was designed in Hacettepe University Hospitals Operating Theaters in 2005. The patients aged 18-65 years, American Society of Anesthesiologists (ASA) grades I and II scheduled for elective surgery under general anesthesia with orotracheal intubation. Ninety patients were randomized into 3 groups with 30 patients in each group. Propofol infusion rate was 2.5 mg. seconds(-1). Induction time and doses to reach BIS level of 50+/-10, injection pain, BIS values and hemodynamic parameters were recorded every minutes for the first 7 minutes and than every 2 minutes for 15 minutes. We used a special chart to assess the induction quality. RESULTS: Demographical parameters and ASA Physical status were similar in all groups. There were no significant differences in induction quality, induction time and doses, injection pain, BIS values and hemodynamic parameters. CONCLUSION: Abbott Propofol, Pofol and Propofol 1% Fresenius have similar effects on anesthesia induction quality and the cost should be taken into consideration when choosing the type of commercial formulation propofol emulsions.

Effect of neostigmine on organ injury in murine endotoxemia: missing facts about the cholinergic antiinflammatory pathway.

Electrical and pharmacologic stimulation of the efferent cholinergic antiinflammatory pathway suppress the systemic inflammatory response and can prevent lethal endotoxemia. Neostigmine, a cholinergic agent, has not been tested to determine if it can prevent histopathologic organ injury in endotoxemia. In the present study, the effects of neostigmine treatment on the histopathologic organ injury inflicted by Escherichia coli endotoxin in a mouse model of septic shock was investigated. Endotoxemia in mice caused weight loss and increased spleen, liver, and lung weight. When the organs were examined for histopathologic injury, endotoxemia increased interstitial inflammation in the lungs, liver injury, and organ injury in general terms; neostigmine, at a dose of 0.1 mg/kg, failed to attenuate these effects. Although the simultaneous administration of neostigmine at a dose of 0.3 mg/kg and endotoxin decreased interstitial inflammation in the lungs, vacuolar degeneration in the liver, and total liver injury, mortality was increased with this dose in the presence of endotoxemia. We conclude that neostigmine at a dose of 0.1 mg/kg was not protective against histopathologic organ injury in mice with endotoxemia, and a higher dose (0.3 mg/kg) was not tolerated probably owing to nonspecific parasympathetic action including cardiovascular effects. Further studies are required to determine the contribution of sites in the cholinergic antiinflammatory pathway.

Analgesic effect of intra-articular tramadol compared with morphine after arthroscopic knee surgery.

PURPOSE: The aim of the study was to compare the analgesic effect of 5 mg intra-articular (IA) morphine with 50 mg IA tramadol. TYPE OF STUDY: Prospective double-blind randomized trial. METHODS: Seventy-five patients having elective arthroscopic surgery of the knee were randomized to receive IA tramadol 50 mg (tramadol group), IA morphine 5 mg (morphine group), or IA normal saline (control group), in equivalent volumes (20 mL). The tourniquet was released 10 minutes after analgesic administration. Verbal pain rating score between 0 and 10 (VRS), supplemental analgesic requirements, and incidence of side effects were recorded postoperatively. RESULTS: Results are given as (median [5-95 percentiles]). The control group had a significantly shorter time to first analgesic request (25 min [15-55]) than morphine group, (34 min [15-158], P < .008) and the tramadol group, (33 min [17-728], P < .008). The patients in the control group complained of more severe pain (VRS 7 [4-10]) when they arrived at the postanesthesia care unit compared with the morphine group (VRS 1 [0-9], P = .002) and with the tramadol group (VRS 0 [0-9], P = .002). These treatment benefits were especially prominent in the patients who had meniscectomy or in the subgroup of patients with more than 6 months of preoperative pain. There was no statistical difference between the tramadol and morphine groups in the time to first analgesia, postoperative pain scores after arrival at the postanesthesia care unit, consumption of rescue analgesic, or side effects. CONCLUSIONS: We conclude that 50 mg IA tramadol provides analgesia equivalent to 5 mg IA morphine. LEVEL OF EVIDENCE: Level II, randomized controlled trial that shows no significant difference and lacks narrow confidence intervals.

Magnesium sulfate pretreatment reduces myoclonus after etomidate.

Myoclonic movements and pain on injection are common problems during induction of anesthesia with etomidate. We investigated the influence of pretreatment with magnesium and two doses of ketamine on the incidence of etomidate-induced myoclonus and pain. A prospective double-blind study was performed on 100 ASA physical status I-III patients who were randomized into 4 groups according to the pretreatment drug: ketamine 0.2 mg/kg, ketamine 0.5 mg/kg, magnesium sulfate (Mg) 2.48 mmol, or normal saline. Ninety seconds after the pretreatment, anesthesia was induced with etomidate 0.2 mg/kg. Vecuronium 0.1 mg/kg was used as the muscle relaxant. An anesthesiologist, blinded to group allocation, recorded the myoclonic movements, pain, and sedation on a scale between 0-3. Nineteen of the 25 patients receiving Mg (76%) did not have myoclonic movements after the administration of etomidate, whereas 18 patients (72%) in the ketamine 0.5 mg/kg, 16 patients (64%) in the ketamine 0.2 mg/kg, and 18 patients (72%) in the control group experienced myoclonic movements (P < 0.05). We conclude that Mg 2.48 mmol administered 90 s before the induction of anesthesia with etomidate is effective in reducing the severity of etomidate-induced myoclonic muscle movements and that ketamine does not reduce the incidence of myoclonic movements.

The effect of acute normovolemic hemodilution and acute hypervolemic hemodilution on coagulation and allogeneic transfusion.

OBJECTIVE: In this study, acute normovolemic hemodilution (ANH) and hypervolemic hemodilution (HHD) were compared with no hemodilution with regards to the effectiveness in blood usage and coagulation parameters. METHODS: The study was performed from February to August 2001 at Hacettepe University Hospital, Ankara, Turkey. Thirty patients undergoing hip arthroplasty surgery were prospectively randomized into: ANH group [autologous blood 15 mL kg(-1) was withdrawn and replaced by 6% hydroxyethylstarch (HES)] or HHD group (HES was administered without removal of any autologous blood) or the control group (no hemodilution). In all groups, blood was given when hemoglobin concentration was <9 g dl(-1). RESULTS: Three groups were clinically similar regarding blood loss, mean arterial pressures and coagulation parameters. But allogeneic transfusion requirements were significantly less in hemodilution groups (20% in ANH, 40% in HHD) compared to the control group (100% of patients). CONCLUSION: We conclude that hemodilution (both ANH and HHD) decreases the demand for homologous blood without adversely affecting hemodynamics or coagulation parameters and HHD seems to be a simple and valuable alternative to ANH in orthopedic patient undergoing hip replacement.

Lack of effect of N-acetylcysteine treatment to ameliorate the progression of multiple organ failure.

OBJECTIVE: To investigate whether prolonged infusion of the oxygen free radical scavenger N-acetylcysteine (NAC) that is commenced immediately after admission to intensive care unit (ICU) could ameliorate the development or progression of multiple organ failure (MOF). METHODS: After receiving ethical committee approval, a prospective randomized, double-blind, placebo controlled study was performed in the Anesthesiology and Reanimation Intensive Care Unit, Hacettepe University Hospital, Ankara, Turkey between December 2002 and May 2003. Twenty-six patients were randomized to receive either NAC in 5% dextrose 40 mg/kg/day or the same volume of 5% dextrose both in 4 divided doses. Two patients were withdrawn due to ICU stay <24 hours. Treatment effect on organ function was assessed by the sequential organ failure assessment (SOFA) scores according to physiological parameters of respiratory, hematological, hepatic, cardiovascular, central nervous system (CNS) and renal system scores that were obtained on admission, then daily. Chi-square, Mann Whitney U tests were used for statistical analysis. RESULTS: There was no significant difference between the 2 groups in any of the 5 organ dysfunction parameters, total maximum SOFA, delta SOFA length of intensive care stay, days of mechanical ventilation and mortality. In the NAC treatment group, the maximum SOFA coagulation score was higher than the control group (p<0.05). CONCLUSION: N-acetylcysteine (40 mg/kg/day) that was commenced immediately after admission to ICU did not ameliorate the progression of MOF in this small cohort of patients. We believe routine prophylactic use of low-dose NAC in all critically ill patients does not provide positive protection.

Effects of postmenopausal hormone replacement therapy on insulin resistance.

Postmenopausal hormone replacement therapy (HRT) protects women from the risk of cardiovascular system disease, osteoporosis, and dementia. There are conflicting reports about the effects of HRT on insulin resistance. The purpose of this study was to investigate the effects of HRT on insulin resistance with the hyperinsulinemic euglycemic clamp technique, the most sensitive technique measuring insulin resistance. Conjugated estrogen (0.625 mg/d) and medroxyprogesterone acetate (5 mg/d) were given to 15 postmenopausal women with insulin resistance. After 3 mo of HRT, the M value (total glucose consumption) increased 28% (p < 0.001), low-density lipoprotein (LDL) cholesterol decreased 12.9% (p < 0.044), high-density lipoprotein (HDL) cholesterol increased 17% (p < 0.009), total cholesterol decreased 9.1% (p < 0.016), and serum insulin decreased 33% (p < 0.022) compared to baseline values before HRT was started. No significant changes in glucose, C-peptide, and triglyceride levels were observed. Whereas there were no differences regarding glucose, total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride levels between the insulin-resistant (n = 15) and non-insulin-resistantwomen (n = 24) (p > 0.05), there were significant differences in M value, insulin, and C-peptide levels between these groups (p < 0.05). We believe that HRT with this combination may protect postmenopausal women from coronary artery disease (CAD) through its beneficial effects on insulin resistance, hyperinsulinemia, and lipid levels, which are considered to be important factors in CAD pathogenesis.

Pulmonary alveolar microlithiasis after Varicella zoster infection in a patient presenting with antiphospholipid syndrome and discoid lupus.

We present a case with diagnosis of pulmonary alveolar microlithiasis that illustrates the appearance of this rare chronic lung disease on conventional chest X-ray, high-resolution CT, and transbronchial lung biopsy. This is the first case reported which developed pulmonary alveolar microlithiasis after Varicella zoster infection in a patient with antiphospholipid antibodies and discoid lupus.

Cardiac tamponade in an orthotopic liver recipient with pulmonary hypertension.

OBJECTIVE: To describe the clinical, hemodynamic, and echocardiographic findings of cardiac tamponade in a patient with portopulmonary hypertension shortly after orthotropic liver transplantation. DESIGN: Case report. SETTING: Surgical intensive care unit of a university teaching hospital. PATIENT: One patient with portopulmonary hypertension deteriorated progressively after orthotropic liver transplantation and developed cardiogenic shock. INTERVENTION: Serial transthoracic echocardiography showed increased right ventricular pressures and pericardial effusion without evidence of cardiac tamponade. Since right ventricular diastolic collapse may not be present in the setting of pulmonary hypertension and her clinical scenario was consistent with tamponade, pericardiocentesis was performed. MEASUREMENTS AND MAIN RESULTS: There was dramatic improvement of the clinical, hemodynamic, and echocardiographic variables after pericardiocentesis CONCLUSION: Pulmonary hypertension may decrease the predictive accuracy of echocardiographic clues for cardiac tamponade. Pericardiocentesis should be considered with clinical suspicion of cardiac tamponade without classic echocardiographic evidence in portopulmonary hypertension.