[Anesthesia for electroconvulsive therapy]. / Narkose zur Elektrokrampftherapie.

Electroconvulsive therapy is a well-established form of treatment for a broad spectrum of severe psychiatric disorders. The treatment, in which a generalized epileptic seizure is provoked by electrical stimulation of the brain, is performed with the patient under anesthesia and muscle relaxation. Therefore, sufficient knowledge of the physiological and pharmacological characteristics is an essential requirement for safe anesthesia. The following review is intended to provide some new aspects of the procedure and management of anesthesia.

Impact of shed blood products on stimulated cytokine release in an in vitro model of transfusion.

BACKGROUND: Blood transfusion is reported to suppress the recipient's immune system. To avoid allogenic transfusion, post-operative shed blood retransfusion is a commonly used method. The aim of this study was to investigate the dose-related impact of post-operatively collected shed blood products on the stimulated cytokine release in an in vitro model of transfusion. METHODS: Venous blood samples obtained from 20 patients undergoing hip arthroplasty were mixed with post-operatively collected unprocessed, processed, and irradiated shed blood as well as normal saline as a control. Shed blood was processed by centrifugation and separating the cellular fraction from the soluble fraction and washing the cellular fraction with phosphate buffered saline to eliminate any cell fragments and other substances. Mixing ratios were 1:3, 1:1, and 3:1. Endotoxin-stimulated release of Tumor Necrosis Factor-alpha (TNF-α) was measured after 24 h of culture by enzyme-linked immunosorbent assay. RESULTS: Unprocessed, irradiated shed blood and the soluble fraction caused a significant suppression of stimulated TNF-α release compared to control. The addition of the cellular shed blood fraction had no significant influence on the TNF-α release compared to control. CONCLUSION: Shed blood and its components caused a dose-independent immunomodulation as indicated by a suppressed stimulated TNF-α release. Leukocytes seem to play a minor role, as we observed a sustained suppression after transfusion of γ-irradiated shed blood. Only the elimination of soluble factors by centrifugation and followed by an additional washing step prevented the observed suppression of TNF-α. Thus, we assume that washing of shed blood can prevent potential detrimental effects.

Impact of platelets and fresh frozen plasma in contrast to red cell concentrate on unstimulated and stimulated cytokine release in an in vitro model of transfusion.

Transfusion of blood may contribute to immunomodulation. Leuco-depleted standard blood products are supposed to result in less immunomodulation compared with whole blood. To determine the influence of leuco-depleted blood products on the cytokine response, red blood cell concentrates (RBC), fresh frozen plasma (FFP) and platelet concentrates (PC) were investigated in an in vitro model of blood transfusion. Leuco-depleted standard blood bank RBC, FFP and PC were mixed in vitro with AB0 compatible venous blood from healthy volunteers in ratios of 3:1, 1:1 and 1:3. Specimens were incubated in presence or absence of lipopolysaccharide, 1 mug/ml. After 24 h of incubation cytokine release of tumour necrosis factor (TNF)-alpha and interleukin-10 (IL-10) was measured in cell culture supernatants by means of enzyme-linked immunsorbent assay. Addition of RBC, FFP and PC to venous blood from healthy volunteers led to a significant and dose-dependent increase in spontaneous TNF-alpha and IL-10 release. After endotoxin stimulation, RBC, FFP and PC significantly suppressed the TNF-alpha response, while the stimulated release of IL-10 tended to increase, reaching significance only after high doses of FFP. Addition of leuco-depleted blood products changed the spontaneous and stimulated cytokine response in an in vitro model of transfusion. These data may suggest a possible contribution of transfused FFP and PC to immunomodulation after transfusion similar to RBC.

Effects of haemofiltration and mannitol treatment on cardiopulmonary-bypass induced immunosuppression.

Cardiac surgery using cardiopulmonary bypass (CPB) causes a systemic inflammatory response. Additionally, an impairment of the responsiveness of peripheral blood mononuclear cells (PBMC) to further immunological stimuli has been observed. The aim of our present study was to evaluate the ability of antioxidant therapy with mannitol or haemofiltration during CPB to modulate this immunosuppression after CPB. Forty-five patients undergoing elective heart-surgery were prospectively enrolled and randomized into three groups (control, mannitol, haemofiltration). Blood samples were taken after induction of anaesthesia (T1), 20 min after CPB (T2) and 24 h post-operatively (T3). Expression density of the monocytic surface receptor CD14, HLA-DR expression and cytokine release (TNF-alpha and IL10) after lipopolysaccharide-stimulation were evaluated. At T2, the CD14(dim) cell population was maintained in both intervention groups while in the control group there was a decrease of this proinflammatory monocytic phenotype. No significant differences regarding HLA-DR expression or cytokine release could be demonstrated. This study shows that the suppression of the stimulated immune response after CPB can potentially be alleviated by mannitol or haemofiltration in an experimental in-vitro setting. In the light of data showing that this depression of the immune response might affect the post-operative course of patients, these results could have a potential clinical relevance.