Investigation of a potential electrogenic transport-system for myo-inositol in the small intestine of laying hens.

1. Myo-inositol (MI) is an essential metabolite for cell function in animals and humans. The aim of this study was to characterise the transport mechanism of MI in the small intestine of laying hens as there is a lack of knowledge about the MI uptake mechanisms. The hypothesised secondary active, cation coupled transport of MI was assessed by electrophysiological measurements with Ussing chambers, and was compared to the electrophysiology of glucose transport.2. Twenty-six laying hens were used. The potential ion-dependent transport was tested in tissue of the small intestine. Barrier function of the tissue was shown by determining the transepithelial resistance. During the experiments, mucosal and serosal buffers were sampled to measure time-dependent changes in MI concentrations. Samples from eight hens were further used for Western blot analyses of the jejunal apical membranes.3. Active MI transport, indicated by changes in the short circuit current after MI addition, could not be demonstrated in the Ussing chambers experiments. MI was further not detectable in the serosal buffer, nor in the lysates of mucosal tissue cytoplasm nor lipids. Thus, there was no evidence for a MI transport or absorption. However, Western blot analyses of the jejunal apical membrane revealed signals indicated the expression of the MI transport proteins SMIT-1 and SMIT-2.4. In conclusion, the MI transport process in the chicken intestine is more complex than it was presumed and is probably influenced by still unknown regulations or metabolic processes.

Assessment of recovery, dreaming, hemodynamics, and satisfaction in postcardiac surgery patients receiving supplementary propofol sedation with S(+)-ketamine.

BACKGROUND: S(+)-ketamine is an analgesic and sedative drug with dissociative attributes. When it is used without sedatives, nightmares have been described. The aim of this study was to assess the effects of postoperative analgosedation with propofol and S(+)-ketamine when compared to standard propofol analgosedation in terms of recovery, dreaming, hemodynamics, and patient satisfaction. METHODS: Forty-eight patients were sedated with propofol (1-3 mg/kg/h) after coronary artery bypass grafting and allocated randomly on admission to the intensive care unit to receive either S(+)ketamine (2 mg mg/kg/h; group A) or 0.9% saline as a placebo (group B) in a double-blind fashion. If necessary, boli of 3.75 mg piritramide (an opioid) were given in both groups. RESULTS: Patients receiving S(+)-ketamine had significantly higher satisfaction for pain management (Visual Analog Scale [VAS] = group A: median 10 [range 9-10]; group B: median 9 [range 6-10]) despite their lower piritramide consumption. Patients receiving S(+)ketamine showed significantly faster eye opening (82+/-51 vs 156+/-110 min) but dreamed significantly more often (at 2 h, 67% in group A vs 29% in group B; at 24 h, 43% in group A vs 10% in group B), whereas no significant differences were detected in the incidence of nightmares at 2 h, 14% in group A vs 10% in group B; at 24 h, 5% in group A vs 5% in group B. CONCLUSIONS: Patients receiving S(+)-ketamine showed higher satisfaction for pain management and dreamed more often, but they did not have more nightmares.

[Propofol administration systems. Handling, hemodynamics and propofol consumption]. / Propofolapplikationssysteme: Handhabung, Kreislaufverhalten und Propofolverbrauch.

BACKGROUND: During anaesthesia propofol is administered either by manual controlled infusion (MCI) or by target controlled infusion (TCI) techniques. In this study two different TCI systems for propofol administration were evaluated with regard to handling, patient safety, and costs and compared to administration of propofol by the MCI technique. METHODS: In a prospective study, 90 patients scheduled for elective surgery of the nose or nasal sinuses were randomly enrolled in three groups. The two TCI systems were examined in two groups of 30 patients: one group received propofol following the pharmacokinetic TCI model of Schnider (TCI-Schnider) and the other group received propofol following the TCI model of Marsh (TCI-Marsh). A manual perfusion technique (MCI, n=30) was used in the control group. Depth of anesthesia was controlled using the bispectral index (BSI) which was adjusted to fall within the range of 40-55. Hemodynamics, extubation times and time of awaking, rate and quality of propofol dose adjustment, total drug requirements, costs, and quality of recovery were documented. The incidence of postoperative nausea and vomiting (PONV) as well as shivering and patient satisfaction were also documented. RESULTS: Demographics, hemodynamics and perioperative data did not differ between the groups. Propofol consumption within the first 60 min also showed no significant differences. In the course of extended anaesthesia, propofol consumption was significantly less in both TCI groups compared to the control group (MCI) and the TCI-Schnider group also showed less episodes of bradycardia. The necessity of propofol dose adjustment did not differ significantly between the TCI groups. Administration and consumption of anaesthesia co-medication (fentanyl, remifentanil, cisatracurium) did not differ between the groups. CONCLUSION: The investigated propofol administration procedures using the MCI or TCI techniques were safe and easy to handle under BIS monitoring. No differences were found concerning extubation times and time of awaking. During extended anaesthesia procedures (>60 min), propofol consumption was lower with both TCI techniques and thus costs could be saved.

Whole-blood aggregometry: are there any limits with regard to platelet counts?

BACKGROUND: Whole-blood aggregometry (WBA) is a promising tool to assess platelet function in its physiological environment. Dilution of whole blood in WBA disregards platelet concentrations that may impact the results, especially in the case of low platelet counts. In a blinded, prospective in vitro study, the influence of platelet concentrations on WBA was assessed. METHODS: Aggregation studies were carried out using whole blood from 10 healthy volunteers adjusted to platelet concentrations of 150, 100, 75, 50 and 25/nl using a plasma-balanced crystalloid solution. Platelet aggregation was measured by a new near-side whole blood aggregometer, activated by adenosin-diphosphate, collagen and thrombin-receptor activating protein. Three different approaches were applied: P1: whole blood diluted by an isotonic saline solution before activation, P2: undiluted whole blood with the single and P3: with the twofold concentration of the stimulating agent. RESULTS: Aggregometry in diluted whole blood (P1) decreased significantly from a platelet concentration of 100/nl (P<0.01). In undiluted whole blood, aggregation declined significantly from concentrations of 75 and 50/nl for P2 and P3 (P<0.01). No correlation to platelet count occurred in the undiluted approaches until a platelet concentration of 75/nl, whereas correlation in the diluted test run was detected starting from 100/nl. CONCLUSIONS: This study demonstrates that WBA depends on the platelet count and sensitivity towards low platelet concentrations may be improved by abdication of further dilution and the use of undiluted whole blood.

Is albumin administration in hypoalbuminemic elderly cardiac surgery patients of benefit with regard to inflammation, endothelial activation, and long-term kidney function?

BACKGROUND: Because patients with low albumin levels may benefit from human albumin (HA) administration, we studied correction of hypovolemia with HA in hypoalbuminic elderly cardiac surgery patients. METHODS: In a prospective, randomized study, 50 patients aged >80 yr undergoing cardiac surgery using cardiopulmonary bypass with a preoperative serum albumin concentration of <3.5 mg/dL, received either 5% HA (n = 25) or hydroxyethyl starch (6% HES 130/0.4) (n = 25). Volume was added to the priming (500 mL) and given until the morning of the second postoperative day to keep pulmonary capillary wedge pressure or central venous pressure between 12 and 14 mm Hg. RESULTS: Inflammatory response (interleukins-6, -10), endothelial activation (intercellular adhesion molecule-1), and kidney function (including glutathione transferase-alpha and neutrophil gelatinase-associated lipocalin) were measured after induction of anesthesia, 5 h after surgery, and the first and second postoperative day. A follow-up, approximately 60 days after discharge from the hospital, was done. Two thousand nine hundred eighty +/- 430 mL of HA and 3060 +/- 680 mL of HES 130/0.4 were given. Serum albumin concentration was significantly increased by HA (to 4.5 +/- 0.3 mg/dL). Serum creatinine, glomerular filtration rate, and urinary levels of alpha-glutathione transferase and neutrophil gelatinase-associated lipocalin were not different in the HA-compared to the HES-treated patients. The inflammatory response was similar in both groups, whereas endothelial activation was less in the HES group. None of the patients developed renal failure requiring renal replacement therapy. CONCLUSION: Use of HA in hypoalbuminemic cardiac surgery patients aged >80 yr was without benefit with regard to inflammatory response, endothelial activation, and renal function compared to 6% HES 130/0.4.

Association of N-terminal pro-brain natriuretic peptide and cardiac troponin T with in-hospital cardiac events in elderly patients undergoing coronary artery surgery.

BACKGROUND AND OBJECTIVES: Despite evidence of their prognostic power for non-surgical patients, the value of perioperative natriuretic peptides and cardiac troponins as markers of cardiac events is incompletely defined. This study sought to examine whether perioperative N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT) levels could be used for the prediction of in-hospital cardiac events in elderly patients undergoing elective coronary artery bypass grafting. METHODS: Ninety-eight elderly patients (>75 yr) undergoing elective coronary artery bypass grafting with cardiopulmonary bypass were enrolled and followed up for 121 and 0.66 1 for NT-proBNP and cTnT (sensitivity, specificity, positive predictive value and negative predictive value of 84.3%, 89.4%, 78.9% and 92.4%, and 93.7%, 74.2%, 63.8% and 96.1%, respectively) at 24 h after surgery to be associated with in-hospital cardiac events. An elevation of both biomarkers above these threshold values was independently associated with individual postoperative complications (odds ratio, 18.9; 95%, CI, 2.3-106.1). CONCLUSIONS: In elderly patients undergoing elective coronary artery bypass grafting surgery, high values of NT-proBNP and cTnT measured 24 h after the end of surgery were independently associated with in-hospital cardiac events.

Hepatocellular integrity in patients requiring parenteral nutrition: comparison of structured MCT/LCT vs. a standard MCT/LCT emulsion and a LCT emulsion.

BACKGROUND AND OBJECTIVE: The aetiology of parenteral nutrition-associated hepatic injury remains unresolved. The aim of the study was to evaluate the effects of structured triglycerides in parenteral nutrition compared either to a physical medium-chain triglycerides (MCT)/long-chain triglcerides (LCT) mixture or to a LCT emulsion on hepatic integrity. METHODS: In a randomized, double-blinded trial, we studied 45 patients undergoing abdominal surgery, who were expected to receive parenteral nutrition for 5 days. Patients were allocated to one of three nutrition regimens: Group A (n = 15) received structured triglycerides, Group B (n = 15) a MCT/LCT and Group C (n = 15) a LCT lipid emulsion. Before the start of parenteral nutrition (T0), 24 h (T1), 48 h (T2), 72 h (T3) and 120 h (T4) after start of infusion the following parameters were measured: Alpha-glutathione S-transferase (alpha-GST), alanine aminotransferase (ALT), aspartate aminotransferase (AST), glucose and serum triglycerides. RESULTS: At T3 and T4, alpha-GST levels were significantly higher in Group B (T3: 9.4 +/- 9.9; T4: 14.6 +/- 19.5 microg L-1) and Group C (T3: 14.2 +/- 20.8; T4: 22.4 +/- 39.3 microg L-1) compared with the patients receiving structured triglycerides (T3: 1.9 +/- 1.8; T4: 3.2 +/- 2.7 microg L-1). Whereas the mean alpha-GST-levels in structured triglycerides group always remained in the normal range, this was not the case in both other groups at T3 and T4. There were no significant differences concerning ALT, AST and glucose levels. At T3 and T4, triglyceride levels were significantly lower in Group A than in Groups B and C. CONCLUSIONS: Hepatic integrity was well retained with the administration of structured triglycerides, whereas both MCT/LCT emulsion and LCT emulsion caused subclinical hepatic injury.

[Continuous beta-block with esmolol in combination with enoximone: influence on cardiac function in high risk patients undergoing vascular surgery]. / Kontinuierliche beta-Blockade mit Esmolol in Kombination mit Enoximon-Gabe : Einfluss auf die kardiale Funktion bei gefässchirurgischen Risikopatienten.

BACKGROUND: The aim of this study was to assess cardiac function in vascular surgery patients with known coronary artery disease (CAD) who received continuous perioperative beta blocker therapy with esmolol alone versus esmolol in combination with the phosphodiesterase (PDE) III inhibitor enoximone. PATIENTS AND METHODS: Over a period of 24 h, 28 patients were assigned to receive heart rate (HR) control by continuous infusion of esmolol in combination with the PDE III inhibitor enoximone (Esmolol+Enoximone group) or esmolol alone (Esmolol group; n=14). Cardiac function was assessed by the use of a pulmonary artery catheter and serial measurements of plasma troponin T (TnT) und B-type natriuretic peptide (BNP). RESULTS: The heart rate significantly decreased to the target rate of 50-60 min(-1) in both groups over the observation period. Cardiac index increased significantly only in Esmolol+Enoximone-treated patients (from 2.4+/-0.2 lxmin(-1)xm(-2) to 3.1+/-0.1 lxmin(-1)xm(-2)) and was significantly higher than in the esmolol alone group (from 2.5+/-0.2 lxmin(-1)xm(-2) to 2.4+/-0.1 lxmin(-1)xm(-2)). No patient had detectable levels of cTnT perioperatively. Peak plasma BNP concentrations were significantly increased in both groups but the highest values were measured in the esmolol alone group. CONCLUSION: Inotropic therapy with the PDE III inhibitor enoximone improves cardiac function in high risk patients with known CAD undergoing vascular surgery and also when receiving systematic heart rate control by continuous infusion of esmolol.

Comparison of the effects of gelatin and a modern hydroxyethyl starch solution on renal function and inflammatory response in elderly cardiac surgery patients.

BACKGROUND: The effects of hydroxyethylstarch (HES) 130/0.4 6% and gelatin 4% on inflammation, endothelial integrity, and renal function after cardiac surgery were compared. METHODS: Sixty patients aged >80 yr undergoing cardiac surgery were randomized to receive gelatin (n=30) or HES 130/0.4 (n=30). The colloid was used in the priming of the cardiopulmonary bypass circuit (500 ml) and for volume replacement until the second postoperative day (POD). Serum creatinine, creatinine clearance, IL-6, IL-10, intercellular adhesion molecule-1 (sICAM-1), urinary glutathione transferase-alpha, and neutrophil gelatinase-associated lipocalin (NGAL) were measured perioperatively. Serum creatinine was also reported approximately 60 days after discharge. RESULTS: The mean(sd) volume of gelatin infused was 4180(440) ml, which was greater than the volume of HES infused 2910(330) ml (P=0.002). The mean(sd) volume of serum creatinine on the first POD was 151(24) micromol litre(-1) in the gelatin group and 126(13) micromol litre(-1) in the HES group (P=0.004). Values for the second POD were 161(0.26) and 133(16) micromol litre(-1), respectively (P=0.004). Creatinine clearance was lower in the gelatin group on the first POD [37(7) vs 46(8) ml min(-1) 1.73 m2 (P=0.004)] and the second POD [32(8) vs 45(10) ml min(-1) 1.73 m2 (P=0.002)]. Kidney function approximately 60 days after discharge did not differ between the groups. IL-6, IL-10, and sICAM-1 were significantly lower in the HES group than in the gelatin group on the first and second PODs. Urinary alpha-GST increased in both groups to a comparable extent. Urinary NGAL concentrations were higher in the gelatin than in the HES patients 5 h after surgery and on the first and second PODs. CONCLUSIONS: In cardiac surgery patients aged >80 years, volume therapy with HES 130/0.4 6% was associated with less marked changes in kidney function and a less marked endothelial inflammatory response than gelatin 4%.

[An unusual complication of chronic pancreatitis]. / Ungewöhnliche Komplikation eines akuten Schubs bei chronischer Pankreatitis.

Atraumatic rupture of the spleen is a rare, but life-threatening complication of pancreatitis. We report a case of an atraumatic spleenic rupture in chronic pancreatitis. A 41 year old man presented in the emergency room with abdominal pain and typical signs of acute pancreatitis. His medical history showed a chronic pancreatitis due to alcoholism with recurrent acute pancreatitic episodes. He denied any trauma in the recent past. In the next few hours he showed clinical signs of a severe hemorrhagic shock. The haemoglobin level fell from 9.4 to 3.0 g/dl. Abdominal ultrasound and abdominal CT scan showed free fluid. In the following laparotomy a splenectomy was performed due to splenic rupture. A histological examination of the spleen revealed no reason, that could explain the splenic rupture. Hence we assumed a spontaneous rupture. The reported case demonstrates that in acute pancreatitis and signs of shock it is necessary to rule out rupture of the spleen e.g. via ultrasound and abdominal CT scan. If there are signs of spleenic rupture, the only therapy of this life-threatening complication is instant operation to save patient's life.

Nutrition support and treatment of motility disorders in critically ill patients - results of a survey on German intensive care units.

BACKGROUND AND OBJECTIVE: To evaluate the current clinical attitude in enteral nutrition support and motility disorders in adult critically ill patients on German intensive care units. METHODS: A total of 1493 questionnaires, including 25 items on the medical environment, treatment of motility disorders and enteral nutrition, were sent to German intensive care units in September 2005. Responses were collected during a 2-month period. RESULTS: A total of 593 questionnaires were returned (response rate 41%). The intensive care units were mainly led by anaesthesiologists (63%) or internists (17%). Standard nutrition protocols were used in 44%. Feeding was mainly started as a combined enteral-parenteral regimen (70%). Early enteral nutrition was performed in 58% using a volume of 250-500 mL (66%) and increased by 200-400 mL day-1 (55%). It was mainly delivered by gastric tube (76%) via continuous pump systems (72%) with short interruption intervals of <4 h (86%). Enteral nutrition solutions were mainly standard polymeric formulae (86%). Modified solutions for diabetics and those with renal or liver failure were uncommonly used; immunonutrition did not play a role. Prokinetic agents, especially metoclopramide, laxatives and neostigmine, were routinely used (39%). Further therapeutic options in motility dysfunction included purgative enemas (96%), gastrografin (72%) and colon massage (39%). CONCLUSIONS: The concept of early enteral nutrition has been well established and approved in German intensive care units, though the recommendations only meet level C criteria in the current ESPEN guidelines. The current survey may serve for further updates on practical nutrition support in intensive care medicine.

Prevention of atrial fibrillation after coronary artery bypass graft surgery using a potassium-magnesium-aspartate solution (Inzolen).

BACKGROUND: Atrial fibrillation (AFIB) following cardiac surgery is a frequent complication. The purpose of this study was to evaluate the efficacy of a potassium-magnesium-aspartate solution (Inzolen) for the prevention of AFIB. METHODS: In a randomised, prospective, double-blinded study, we studied 88 patients undergoing elective coronary artery bypass graft surgery (CABG). After surgery, patients were allocated randomly to one of two groups. Group A (n = 43) received a potassium-magnesium-aspartate solution (Inzolen), group B (n = 45) received potassium chloride; both solutions were administered continuously for 48 hours to keep the potassium serum levels between 4.5 and 5.5 mmol/l. Patients were observed for 5 days postoperatively and the incidence of atrial fibrillation was noted. At the end of surgery (T0), 4 h (T1), 24 h (T2), 48 h (T3), and 120 h (T4) postoperatively, magnesium and potassium serum levels were measured. RESULTS: The two groups did not differ significantly with regard to demographics and perioperative data. No significant difference in the incidence of postoperative atrial fibrillation was seen (group A: 41.9 % vs. group B 31.1 %; P = 0.53). In group A, the magnesium serum levels were significantly higher at T1 (1.15 +/- 0.18 vs. 0.87 +/- 0.11 mmol/l), T2 (1.24 +/- 0.22 vs. 0.82 +/- 0.10 mmol/l) and T3 (1.15 +/- 0.18 vs. 0.81 +/- 0.20 mmol/l) compared to group B, whereas potassium levels were similar in the two groups throughout the study period. CONCLUSIONS: The use of a potassium-magnesium-aspartate solution (Inzolen) showed no significant difference in potassium chloride for the prophylaxis of postoperative atrial fibrillation secondary to CABG.

Influence of controlled hypotension using esmolol and sodium nitroprusside on natriuretic peptides in patients undergoing endonasal sinus surgery.

BACKGROUND AND OBJECTIVE: Atrial and brain natriuretic peptide, synthesized by cardiac myocytes, are mediators secreted secondary to cardiac volume expansion and increased filling pressure. The study was designed to assess serum concentration of atrial and brain natriuretic peptide in patients undergoing endonasal sinus surgery receiving controlled hypotension. METHODS: We studied 45 patients without cardiovascular history, scheduled for elective endonasal sinus surgery. Patients were allocated to one of three groups: controlled hypotension was induced either by using esmolol (n = 15) or sodium nitroprusside (n = 15) with a mean arterial pressure of 50-55 mmHg. In the control group (n = 15), mean arterial pressure was adjusted to 70-80 mmHg. Atrial and brain natriuretic peptides were measured preoperatively (T1), at the end of surgery (T2), 2 h (T3), 24 h (T4) and 48 h (T5) postoperatively. RESULTS: Preoperative atrial and brain natriuretic peptide plasma levels were within normal ranges and similar between all groups. Patients treated with esmolol (atrial natriuretic peptide: 2.46 +/- 0.75 microg mL(-1) brain natriuretic peptide: 4.34 +/- 3.06 microg mL(-1)) and sodium nitropusside (atrial natriuretic peptide: 2.48 +/- 0.92 microg mL(-1); brain natriuretic peptide: 4.49 +/- 3.21 microg mL(-1)) showed significantly lower concentrations of atrial and brain natriuretic peptide at T2 and T3 compared with controls (atrial natriuretic peptide: 5.31 +/- 2.32 microg mL(-1); brain natriuretic peptide: 13.26 +/- 8.98 microg mL(-1)) , P < 0.01) as well as a reduction in blood loss and duration of surgery. CONCLUSIONS: Controlled hypotension decreases the release of natriuretic peptides in cardiovascular healthy patients. This effect may be contributed to by changes in cardiac filling pressure due to lower systemic resistance and diminished perfusion pressure.

Semi-invasive monitoring of cardiac output by a new device using arterial pressure waveform analysis: a comparison with intermittent pulmonary artery thermodilution in patients undergoing cardiac surgery.

BACKGROUND: Thermodilution technique using a pulmonary artery catheter (PAC) is a widely used method to determine cardiac output (CO). It is increasingly criticized because of its invasiveness and its unclear risk-benefit ratio. Thus, less invasive techniques for measuring CO are highly desirable. We compared a new, semi-invasive device (FloTrac/Vigileo) using arterial pressure waveform analysis for CO measurement in patients undergoing cardiac surgery with bolus thermodilution measurements. METHODS: Forty patients undergoing coronary artery bypass grafting or valve repair were enrolled. A PAC was inserted and routine radial arterial access was used for semi-invasive determination of CO with the Vigileo. CO was measured simultaneously by bolus thermodilution and the Vigileo technique after induction of anaesthesia (T1), before cardiopulmonary bypass (CPB) (T2), after CPB (T3), after sternal closure (T4), on arrival in the intensive care unit (ICU) (T5), and 4 h (T6), 8 h (T7), and 24 h after surgery (T8). CO was indexed to the body surface area (cardiac index, CI). RESULTS: A total of 244 pairs of CI measurements were analysed. Bias and precision (1.96 sd of the bias) were 0.46 litre min(-1) m(-2) and +/- 1.15 litre min(-1) m(-2) (r = 0.53) resulting in an overall percentage error of 46%. Subgroup analysis revealed a percentage error of 51% for data pairs obtained intraoperatively (T1-T4), 42% in ICU (T5-T8), and 56% for values obtained during low CI (T1-T8). CONCLUSIONS: In cardiac surgery patients, CO measured by a new semi-invasive arterial pressure waveform analysis device showed only moderate agreement with intermittent pulmonary artery thermodilution measurement.

Retracted: Do patients profit from physostigmine in recovery from desflurane anaesthesia?

BACKGROUND: Physostigmine is the drug of choice in the central anticholinergic syndrome, but has also been used in post-operative mental derangement secondary to sedatives and volatile anaesthetics. The aim of this double-blind, randomized, prospective study was to determine whether physostigmine alters recovery after desflurane anaesthesia. METHODS: One hundred patients undergoing urologic or surgical procedures were enrolled to receive either NaCl 0.9% (n = 50) or 2 mg of physostigmine (n = 50) at the end of general anaesthesia with propofol, fentanyl, cisatracurium and desflurane. Times to extubation, stating name, birthday and place of residence, and obeying commands such as eye opening and hand squeezing were noted. Haemodynamics, Aldrete and pain scores, the analgesic requirements, and any adverse side-effects were documented until the 1st post-operative day. RESULTS: Demographic, peri-operative data including duration of anaesthesia, surgery and postanaesthetic care unit (PACU) stay, and consumption of anaesthetics were comparable in both groups. No significant difference between the groups was found for extubation time or other emergence parameters. Patients undergoing anaesthesia >150 min showed after receiving physostigmine significantly (P < 0.05) faster spontaneous breathing (2.6 +/- 3.1 vs. placebo 5.0 +/- 4.2 min) and extubation time (6.2 +/- 3.7 vs. placebo 8.8 +/- 5.0 min). Women showed significantly shorter extubation times (5.5 +/- 3.4 min) and eye opening (5.5 +/- 2.6 min) with physostigmine than placebo (7.7 +/- 4.5 and 7.8 +/- 4.0 min). The incidence of post-operative nausea and vomiting (PONV) was significantly higher after physostigmine than placebo, whereas shivering occurred more often after placebo. CONCLUSION: Physostigmine does not alter desflurane-based anaesthesia compared with placebo. An option is to use physostigmine in patients with a duration of anaesthesia >150 min who profit in earlier return to spontaneous breathing and shorter extubation time.

Inspired oxygen fraction of 0.8 compared with 0.4 does not further reduce postoperative nausea and vomiting in dolasetron-treated patients undergoing laparoscopic cholecystectomy.

BACKGROUND: Postoperative nausea and vomiting (PONV) is one of the most frequent complications after general anaesthesia. Single-dose antiemetic prophylaxis has limited efficacy in high-risk patients. Adding a simple potential antiemetic approach, such as increasing the inspired oxygen fraction, to the antiemetic portfolio would preserve pharmacological interventions for treatment of symptoms in the postoperative period. However, the antiemetic effect of a high inspired oxygen fraction is still discussed controversially. The aim of the study was to evaluate whether an inspired oxygen fraction of 0.8 decreases PONV in patients receiving the 5-HT3-antagonist dolasetron. METHODS: In a randomized, placebo-controlled, double-blinded trial we studied 377 patients (ASA I-III) undergoing elective laparoscopic cholecystectomy. Induction of anaesthesia was standardized, including thiopental fentanyl and cis-atracurium. For all patients the individual risk for PONV was calculated using the Koivuranta score and all patients received 12.5 mg dolasetron i.v. before surgery. Patients were allocated randomly to one of three groups: Group A (n=125) received 80% oxygen in air, Group B (n=125) 40% oxygen in air and Group C (n=127) 40% oxygen in nitrous oxide. Postoperative nausea, postoperative vomiting (PV), or nausea, vomiting, or both (PONV) was assessed in the early (0-4 h) and overall postoperative period (0-24 h) by an anaesthesiologist unaware of patient allocation. RESULTS: There was a significantly lower incidence of PONV and PV in Groups A (PONV: 11.2%; PV: 3.2%) and B (PONV: 10.4%; PV: 3.2%) compared with Group C (PONV: 26.7%; PV: 13.3%), but there were no significant differences between Groups A and B. CONCLUSIONS: An inspired oxygen fraction of 0.8 does not further decrease PONV or vomiting in dolasetron-treated patients undergoing laparoscopic cholecystectomy. The lower incidence of PONV in Groups A and B compared with Group C is most likely caused by the omission of nitrous oxide.

[Comparison of a propofol-based anesthesia regimen using optimated-target-controlled-infusion (OTCI) and manually-controlled infusion (MCI) technique]. / Propofol-Anästhesie mittels Target-Controlled-Infusion (TCI). Ein Vergleich der Verfahren: Optimated-Target-Controlled Infusion (OTCI) und Manually-Controlled-Infusion (MCI).

BACKGROUND: Propofol anesthesia based on target-controlled-infusion (TCI) has been shown to be superior to a manually-controlled-infusion (MCI) technique. A new optimal-target-controlled-infusion (OTCI) technique enables an individual plasma-targeted adjustment by including the concentration in the effect-compartment. This study compared practicability and costs of the new system with a conventional MCI-based propofol anesthesia regimen. METHODS: In a prospective study, 50 patients scheduled for elective surgery of nose or nasal sinuses were randomly enrolled to receive BIS-controlled anaesthesia (level: 40-55) using either OTCI (n = 25) or MCI (n = 25). Hemodynamics, extubation times and time of awaking, rate and quality of propofol adjustment, total drug requirements, costs, postanaesthetic care unit (PACU) stay, Aldrete and pain scores, and adverse effects (postoperative nausea and vomiting (PONV), shivering) were recorded. RESULTS: Demographics, hemodynamics, and perioperative data including extubation times were comparable for both study groups. Propofol consumption was similar within the first 60 min for both groups, thereafter, significantly less propofol in the OTCI group (5.03 mg/kg/h) than the MCI group (5.79 mg/kg/h) was used. Costs for propofol was significantly reduced with OTCI (0.2 vs. 0.23 Cent/anaesthesia minute/kg), the administration of other anaesthetics (fentanyl, remifentanil, cis-atracurium) did not differ between the groups. The number of infusion adjustments to BIS values were not significantly different. CONCLUSION: The new OTCI-system is a safe and easily controllable technique. The obvious advantage of this infusion system appears to be a reduction in propofol consumption and direct drug costs for anaesthesia lasting longer than 60 min.

Early recovery, cognitive function and costs of a desflurane inhalational vs. a total intravenous anaesthesia regimen in long-term surgery.

BACKGROUND: The purpose of the study was to compare time of recovery, return of cognitive function, post-anaesthetic care unit (PACU) stay and costs of a propofol/remifentanil (TIVA) with a desflurane/fentanyl-based anaesthesia (desflurane group) in surgical procedures lasting more than 150 min. METHODS: Forty-nine patients undergoing elective abdominal prostatectomy were allocated randomly to receive bispectal index (BIS)-controlled desflurane/fentanyl (n=24) or propofol/remifentanil (n=25). Awakening, clinical recovery, direct drug acquisition and post-operative pain treatment were documented. Cognitive skills were tested using the Mini-Mental Status (MMST) test. RESULTS: Extubation was significantly faster with desflurane (6.9+/-3.5 min) than with TIVA (11.2+/-4.0 min) as well as times for stating name and date of birth (desflurane: 6.1+/-3.9 and 6.6+/-4.0 min; TIVA: 12.4+/-11.5 min and 13.4+/-11.3 min). There were no significant differences in PACU discharge times or MMS scores between the groups. Significantly more patients suffered post-operative nausea and vomiting (PONV) in the desflurane (33% vs. 0%) than the TIVA group. Overall costs were significantly higher in the TIVA (58.8+/-11.6 euro) than in the desflurane group (35.0+/-5.7 euro). CONCLUSION: Patients undergoing prolonged surgical procedures showed a faster early recovery after desflurane/fentanyl than using TIVA, whereas stay in the PACU and recovery of cognitive function were similar in both groups. Costs of a TIVA regimen were significantly higher than using a desflurane-based anaesthesia technique.

Insignificant effect of desflurane-fentanyl-thiopental on hepatocellular integrity--a comparison with total intravenous anaesthesia using propofol-remifentanil.

BACKGROUND AND OBJECTIVE: Inhalational anaesthetics have been associated with hepatotoxicity. Even desflurane, with its low solubility in blood and tissues, and its minimal hepatic biotransformation, is known to affect hepatic integrity. The effects of propofol on hepatic function are, however, a matter of controversy. Alpha-glutathione S-transferase (alpha-GST), a sensitive and specific biomarker for hepatic integrity, was measured to assess the influence of total intravenous anaesthesia (TIVA) with propofol vs. anaesthesia with desflurane. METHODS: Forty-two patients scheduled for elective prostatectomy were randomly allocated to receive either desflurane, fentanyl and thiopental (desflurane group) or propofol and remifentanil (TIVA group). Depth of anaesthesia was guided by bispectral index. Plasma concentrations of alpha-GST and aminotransferases were measured before induction of anaesthesia (TO), at the end of surgery (T1), as well as 2 h (T2) and 24 h (T3) postoperatively. Haemodynamic parameters and bispectral index values were documented. RESULTS: alpha-GST increased significantly in the desflurane group from TO (3.0 +/- 2.2 microg L(-1)) to T1 and T2 (5.5 +/- 4.3 and 5.6 +/- 3.7 microg L(-1), respectively), whereas no changes were seen in the TIVA group. alpha-GST values above the normal upper limit (> 7.5 microg L(-1)) were seen in 24% of the patients receiving desflurane. Aminotransferases remained unchanged in both groups throughout the study period. CONCLUSIONS: The use of propofol as part of a TIVA regimen seems to have no influence on hepatocellular function during and after surgery. In contrast, patients receiving desflurane showed a transient slight, but significant, increase of alpha-GST to above the normal upper limit after anaesthesia, although this was without further clinical relevance.