Effects of awareness and nociception on heart rate variability during general anaesthesia.

During anaesthesia awareness and nociception are serious complications that may further lead to haemodynamic instability. Specific monitoring of depth of hypnosis and depth of analgesia based on heart rate variability (HRV) analysis is eligible to improve patient safety and reduce efforts in post-operative care. Consequently, in this analysis we assess the applicability of HRV parameters during surgical interventions with standardized intravenous propofol-remifentanil-anaesthesia. Peri-operative electrocardiograms were recorded from cardiovascular stable patients (ASA Score I/II, N = 32, age: 36.4 ± 11.23 a, BMI: 25.2 ± 3.16) scheduled for trauma and dentofacial surgery. HRV time- and frequency-domain parameters, measures of complexity and nonlinear dynamics were compared by analysing longitudinally distributed 300 s intervals preceding/following induction of anaesthesia (BL-I1), intubation (I1-I2) and extubation (E1-E2). Mean value (meanNN) and standard deviation (sdNN) of the heart rate are influenced in BL-I1 (p < 0.001), I1-I2 (p < 0.05) and E1-E2 (p < 0.001). The number of forbidden words of symbolic dynamics changes significantly for BL-I1 (p < 0.001) and not for I1-I2 and E1-E2 (p > 0.05). Probability of low-variability POLVAR10 is significantly altered in all comparisons (BL-I1: Δ = 0.032, p < 0.01, I1-I2: Δ = 0.12, p < 0.05, E1-E2: Δ = 0.169, p < 0.01) but especially during nociception. While standard time-domain parameters lacked selectivity, parameters of symbolic dynamics appear to be specifically influenced by changes in depth of hypnosis and nociception, respectively. However, the lack of steady-state ventilation/breathing in this study needs to be considered in future research. To be used for clinical anaesthesia monitoring our results have to be prospectively validated in clinical studies.

The effects of electromyographic activity on the accuracy of the Narcotrend monitor compared with the Bispectral Index during combined anaesthesia.

The Narcotrend is a monitor system for the assessment of depth of anaesthesia. The objective of this trial was to investigate the susceptibility of the Narcotrend to electromyographic (EMG) activity when compared with the Bispectral Index (BIS). We enrolled 33 patients undergoing major urological procedures under combined anaesthesia (thoracic epidural analgesia and general anaesthesia). Anaesthetic depth was assessed simultaneously by the BIS XP and Narcotrend. The intended anaesthetic depth ranged between 40 and 55 in the BIS and between D2 and D0 in the Narcotrend. BIS, but not Narcotrend, values correlated significantly (p < 0.0001) with EMG. BIS values between 70 and 80 occurred intermittently above an EMG activity of 35 dB, whereas the Narcotrend and the clinical signs remained unchanged during the period of elevated BIS values. None of the patients reported intra-operative awareness. Increased electromyographic activity does not affect Narcotrend values. Under combined anaesthesia, the Narcotrend monitor is more reliable when compared with the BIS regarding susceptibility to increased EMG activity.

[Pacemaker therapy of hypertrophic obstructive cardiomyopathy. PIC (Pacing in Cardiomyopathy) Study Group]. / Schrittmacher-Therapie der hypertroph-obstruktiven Kardiomyopathie. PIC-Studiengruppe.

Clinical management of patients with symptoms caused by pharmacological refractory hypertrophic obstructive cardiomyopathy must consider surgical myectomy, percutaneous transluminal septal myocardial ablation and implantation of a DDD pacemaker. Until now, no prospective, double blind, randomized studies have yet been carried out to determine the merits of each of these treatment alternatives. However, uncontrolled studies have shown that short atrioventricular delay dual-chamber pacing reduces outflow tract obstruction. Aim of the study was to investigate the results of the pacemaker therapy in a prospective, double blind randomized crossover procedure. All patients with hypertrophic obstructive cardiomyopathy included in this multicenter study were either refractory or intolerant to drugs and typically had pressure gradients higher than 30 mm Hg. In 83 patients, mean age 53 (18 to 82) years who responded favorably to a temporary pacing test, a DDD pacemaker was implanted. After echo- and echo-Doppler-based measurements of hemodynamic parameters the patients were randomized into 2 groups, those with an implanted pacemaker in the inactivated mode (AAI) and those with a pacemaker in the activated mode (DDD with optimized short AV delay). A crossover of these groups was performed after 12 and 24 weeks, respectively. Both objective parameters of echo including Doppler, and spiroergometry, and subjective parameters of angina, dyspnea, and quality of life were recorded. Additionally, subgroups based on age decades were analyzed. After 12 weeks in the DDD mode, regardless of the randomization sequence, a decrease of the pressure gradient from 59 +/- 36 mm Hg (median) to 30 +/- 25 mm Hg was proven significant (p < 0.001). The endurance of the patients who, during screening, achieved less than 10 minutes of exercise by the Bruce protocol improved by 21% under DDD mode. The main symptoms, as measured by the NYHA classification, improved statistically significant from a mean of 2.4 to 1.7 for functional class, from a mean of 2.4 to 1.4 for dyspnea and from a mean of 1.0 to 0.4 for angina. Subgroup analysis showed improvements depended significantly upon age, with a marked improvement between the ages of 60 and 70, which was statistically significant as compared to other decades. Subjective improvements in the quality-of-life of patients was measured using a specially developed questionnaire. These findings justify, by all means, the intention to implant a DDD pacemaker in older patients. In younger and/or such patients with elevated pressure gradients, the results of ongoing randomized studies comparing myectomy, PTSMA and pacing have to be considered.

Exercise at menopause: a critical difference.

Even at menopause, fitness can reduce the risk of heart disease, osteoporosis, and diabetes, yet only 38% of women over age 19 exercise regularly. A sports medicine expert recommends that exercise be encouraged and prescribed, even for women with a variety of comorbidities.

Brachial and digital artery pulse pressures in hypertensive and normotensive subjects.

OBJECTIVES AND PATIENTS: To determine whether or not the pulsatile component of blood pressure (BP) measured centrally and peripherally allows a separation between hypertensive and normal subjects, as well as within hypertensive and normal subjects, as well as within hypertensive patients. We tested the hypothesis that the difference in central and peripheral pulse pressures is increased in hypertensive, compared to normotensive persons, and that this component is influenced by genetic variance. We studied 46 hypertensive patients and 56 age-matched normal subjects, as well as 10 hypertensive families with 74 members of the same age range. DESIGN: Pulse pressure was measured at the brachial artery and the digital artery in the standing and supine position. The difference in the pulse pressures between these sites was calculated. Further, digital volume-pulse amplitude and stroke volume measurements were determined with impedance plethysmography. RESULTS: The differences between central and peripheral pulse pressures were similar in hypertensive patients compared to normal subjects, regardless of posture. However, in the standing position the frequency distribution of this variable in hypertensive patients was bimodal and split into two significantly different distributions (P < 0.05) with peaks at -24 mm Hg and -1 mm Hg, compared to a single peak at -11 mm Hg in normal subjects. Furthermore, these two subgroups of hypertensive patients differed in their brachial systolic BP (127 +/- 10 vs 134 +/- 12 mm Hg; P < 0.05), their brachial pulse pressures (32 +/- 8 vs 42 +/- 8 mm Hg; P < 0.05), and in their peripheral compliance (1.59 +/- 0.92 vs 2.21 +/- 1.00 microliter/mm Hg per 100 ml tissue; P < 0.05). The frequency distribution of pulse pressure differences was also bimodal in members of hypertensive families, even though most (46 out of 74) were normotensive. CONCLUSION: The difference between the digital and brachial pulsatile component may be a useful intermediary phenotype in essential hypertension. Furthermore, the nonuniform decreases in arterial compliance exhibited by our patients may be of pathogenic significance.