Epidural anesthesia and analgesia decrease the postoperative incidence of insulin resistance in preoperative insulin-resistant subjects only.

BACKGROUND: Insulin resistance (IR) is a feature of the endocrine stress response to surgery. It is not known whether a preoperative state of IR would affect the postoperative endocrine response. We sought to characterize the preoperative state of IR in a group of patients undergoing elective hip and knee arthroplasty, and to determine to what extent perioperative epidural analgesia modifies the postoperative state of IR in those who are and are not insulin-resistant before surgery. METHODS: Sixty patients undergoing either hip or knee arthroplasty were screened by using the homeostatic model assessment (HOMA) in two populations: insulin-resistant patients and noninsulin-resistant patients, whereas HOMA is fasting insulin (microU/mL) x fasting glucose (mmol/L)/22.5. The patients belonging to each population were then randomly assigned to receive either intraoperative epidural blockade followed by postoperative epidural analgesia (epidural group) or general anesthesia followed by patient-controlled analgesia (control group). Analgesia was assessed with visual analog scale up to 48 h after surgery and HOMA was repeated at the end of surgery and 48 h after surgery to determine the postoperative state of IR. RESULTS: Epidural anesthesia and analgesia significantly influenced the postoperative HOMA score (smaller proportion of IR) in the postoperative period only in those patients who were insulin-resistant before surgery (P < 0.01). In contrast, noninsulin-resistant patients had a similar postoperative proportion of IR between the epidural and control groups (P > 0.05). At rest and during movement, visual analog scale scores were not different between groups at the end of surgery and in the first and second days after surgery. CONCLUSIONS: Epidural anesthesia and analgesia compared to general anesthesia followed by patient-controlled analgesia decreased the incidence of IR soon after surgery and 48 h after surgery only in patients who were insulin-resistant before surgery.

Complete rightward cardiac luxation caused due to left tension pneumothorax.

We present a 4-year-old patient with severe rightward cardiac dislocation due to left tension pneumothorax after surgical closure of a perimembranous ventricular septal defect. The chest roentgenograms showed the "dextrocardia-like" appearance of the cardiac silhouette. Given the persistent severe cardiac dislocation despite resolution of the pneumothorax, and considering the patient's ongoing hemodynamic instability, we decided to reopen the chest to return the heart to its natural position. The procedure was uneventful, and the patient was discharged at home on postoperative day 5.

Fenoldopam prophylaxis of postoperative acute renal failure in high-risk cardiac surgery patients.

BACKGROUND: Acute renal failure requiring replacement therapy occurs in 1% to 2% of patients who have undergone cardiac surgery with cardiopulmonary bypass and is associated with a very high mortality rate. The aim of this study was to determine if prophylactic treatment with fenoldopam mesylate of patients at high risk of postoperative acute renal failure reduced the incidence of this event. METHODS: This was a multicenter, prospective, cohort study in which 108 patients at high risk of postoperative acute renal failure and undergoing cardiac surgery with cardiopulmonary bypass were treated with fenoldopam mesylate (0.08 microg x kg(-1) x min(-1)) starting at the induction of anesthesia and throughout at least the next 24 hours. A homogeneous control group of 108 patients was created using a propensity-score analysis. RESULTS: Fenoldopam prophylaxis was significantly associated with a reduction in acute renal failure incidence (from 22% to 11%, p = 0.028), a less pronounced creatinine clearance decrease (p = 0.05), and a lower mortality rate (6.5% versus 15.7%, p = 0.03) by the univariate analysis, but these results were not confirmed by a multivariable analysis. Within the subgroup of patients who suffered a postoperative low output syndrome, fenoldopam prophylaxis was an independent protective factor for postoperative renal failure (odds ratio, 0.14; 95% confidence interval, 0.03 to 0.7; p = 0.017). CONCLUSIONS: Given the limitations of a nonrandomized prospective trial, our results support the hypothesis that fenoldopam may reduce the risk of acute renal failure in patients in whom endogenous and exogenous cathecolamines action may induce a renal vascular constrictive condition.