Desflurane pharmacokinetics during cardiopulmonary bypass.

OBJECTIVE: To describe the washin and washout of desflurane when first administered during cardiopulmonary bypass (CPB) for cardiac surgery. DESIGN: A single-arm prospective study. SETTING: University-affiliated hospital operating room. PARTICIPANTS: Ten adult patients presenting for cardiac surgery. INTERVENTIONS: Consenting patients presenting for cardiac surgery received anesthesia with midazolam and fentanyl. Patients were cooled to 32 degrees C on CPB, then desflurane 6% was administered and blood samples drawn repeatedly from the arterial and venous bypass cannulae as well as from the membrane oxygenator inlet and exhaust from 2 to 32 minutes of desflurane administration. Just before rewarming, final (maximum) washin samples were taken. On rewarming, desflurane was discontinued, and blood and gas samples were taken 2 to 24 minutes thereafter. MEASUREMENTS AND MAIN RESULTS: CPB time was 116 +/- 10 minutes, and ischemic time was 81 +/- 6 minutes. Mean pump flow was 4.49 +/- 0.03 L/min, and mean arterial pressure was 70.1 +/- 1 mmHg during the study period. Arterial washin of desflurane was initially rapid; arterial concentrations reached 50% of administered concentrations within 4 minutes, but then slowed, reaching 68% of inspired concentrations at 32 minutes (desflurane concentration 4.0% +/- 0.3%). Arterial washout of desflurane was more rapid; arterial concentrations fell to 18% of the maximum concentration reached within 4 minutes, and only 8% of the maximum arterial concentration was present in blood 20 minutes later. CONCLUSION: Desflurane showed rapid initial washin and washout on CPB when administration was started at 32 degrees C and stopped at time of rewarming.

Blood product use in cardiac revascularization: comparison of on- and off-pump techniques.

BACKGROUND: Cardiac revascularization on a beating heart avoids the side effects of cardiopulmonary bypass (eg, neurologic injury, hemodilution, and coagulopathy). We examined perioperative bleeding and use of blood products during coronary artery bypass grafting using either on-pump or off-pump techniques. METHOD: The charts of 126 patients who had coronary artery bypass grafting were reviewed. Data from 66 patients revascularized off pump and 60 patients with cardiopulmonary bypass (on pump) were analyzed using unpaired Student's t test. RESULTS: Average age was 62.5 years in either group. More patients received heparin preoperatively in the off-pump group that resulted in mild elevation of preoperative partial thromboplastin time and activated clotting time (40.4 +/- 2.9 seconds and 150.1 +/- 5.3 seconds, respectively). However, the off-pump group had less perioperative (intraoperative or postoperative) bleeding (2312 +/- 212 mL versus 3251 +/- 155 mL, p < 0.05) and required fewer blood products compared with the on-pump group. Hemoglobin and platelets decreased more in the conventional on-pump group. CONCLUSIONS: Avoiding cardiopulmonary bypass decreases perioperative bleeding and, consequently, reduces the use of blood products after coronary artery bypass grafting, which might result in fewer transfusion-related complications.

The impact of a major televised sporting event on emergency department census.

This study examines the effect of a major televised sporting event, the Super Bowl, on emergency department (ED) census. Daily patient census figures for the month of January 1988-1992 were obtained. Individual shift census was divided by monthly mean census to compare relative volume. Census figures for 4 of the 5 Super Bowl days were significantly lower than the remaining 143 days studied. The day of the Super Bowl was the month's slowest shift for 3 of the 5 days. When the local team was a playoff participant, a stronger association was noted. The results demonstrate a significant decrease in ED utilization coinciding with the Super Bowl broadcast. Major televised events can significantly decrease ED volume, especially when local interest is present. Staffing changes may then be made accordingly.

Axial motor organization in postmetamorphic tiger salamanders (Ambystoma tigrinum): a segregation of epaxial and hypaxial motor pools is not necessarily associated with terrestrial locomotion.

The axial motor column has undergone a major reorganization during the evolution of vertebrates. In aquatic anamniotes including lampreys, goldfish, and mudpuppies, epaxial and hypaxial motoneurons are intermingled in the column. In contrast, epaxial and hypaxial motoneurons are spatially segregated in water snakes, rats, and monkeys, apparently as a consequence of an isomorphic mapping of motoneuron location onto the position of innervated muscle in the embryonic myotome. The presence of these two very different arrangements of motoneurons requires a major restructuring of the motor column during vertebrate evolution. The time of this reorganization is unknown. All amniotes studied to date have an epaxial/hypaxial segregation, and all anamniotes do not, suggesting that the map arose with the origin of amniotes. All the anamniotes examined previously were permanently aquatic, however, and the map might therefore be associated with terrestrial locomotion. If so, we would expect terrestrial anamniotes to have an arrangement of motoneurons like that in amniotes. We studied the organization of motoneurons innervating the trunk muscles of postmetamorphic, terrestrial tiger salamanders and asked whether their motor columns are more like those of amniotes or those of aquatic anamniotes. The motor column in tiger salamanders is similar to that seen in aquatic anamniotes and very like that in mudpuppies--permanently aquatic salamanders. There are several classes of motoneurons with morphological similarities to the primary and secondary motoneurons characteristic of aquatic anamniotes. Epaxial and hypaxial motoneurons show no obvious morphological differences and occupy extensively overlapping positions in the motor column. The only epaxial/hypaxial distinction is the presence of a few, small, relatively undifferentiated motoneurons located subadjacent to the ependymal layer. These motoneurons are filled only by horseradish peroxidase (HRP) applied to hypaxial nerves. They are probably newly born motoneurons, and their presence suggests continued addition of motoneurons, even in adult salamanders. We conclude that the epaxial/hypaxial segregation seen in amniotes is not necessarily associated with terrestrial locomotion. The segregation and the topographic map it reflects may have arisen in conjunction with the origin of amniotes. If they instead arose prior to the origin of extant amphibians, they must have been secondarily lost in those salamanders studied to date. An examination of the motor column of other amphibians should help to resolve this issue.