MedWorm: Anesthesiology

Factors in delaying or declining total knee replacement surgery

Pain / Anesthetics News From Medical News Today — Sat, 17 May 2008 10:00:00 +0100

A study led by Dr. Ann F. Jacobson, associate professor in Kent State's College of Nursing, unveils the reasons why people may initially choose to postpone but ultimately undergo total knee replacement surgery and emphasizes the need for better patient education before and after the procedure. (Source: Pain / Anesthetics News From Medical News Today)

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[chronic back pain resulting from a retroperitoneal lymphangioma.]

Schmerz — Sat, 17 May 2008 04:00:00 +0100

[Chronic back pain resulting from a retroperitoneal lymphangioma.]

Schmerz. 2008 May 17;

Authors: Justinger C, Weinrich M, Katoh M, Schilling MK

A 39-year-old female patient presented with a 3-year history of lower back pain which had not been alleviated by pain treatment combined with physiotherapy. Radiological findings were normal with the exception of a cystic paravertebral tumor in the left retroperitoneum. The cyst was primarily regarded as a coincidental finding because no criteria for malignancy were present. Magnetic resonance tomography, however, the cyst showed a progressive increase in size and the pain remained unchanged so that surgical resection was performed. The histopathological examination showed a lymphangioma and the pain was nearly completely resolved after surgery.

PMID: 18483749 [PubMed - as supplied by publisher]

(Source: Schmerz)

[cortical spreading depression (csd) : a neurophysiological correlate of migraine aura.]

Schmerz — Sat, 17 May 2008 04:00:00 +0100

[Cortical spreading depression (CSD) : A neurophysiological correlate of migraine aura.]

Schmerz. 2008 May 17;

Authors: Richter F, Lehmenkühler A

Cortical spreading depression (CSD) is a transient (60-120 s) and at 3-5 mm/min propagating depolarization wave of cortical neurons and glial cells and is characterized by a DC shift of 20-35 mV. It is accompanied by massive redistribution of ions between extracellular and intracellular compartments and by a water influx into the cells. Extracellular potassium ion concentration increases up to 60 mM/l. Potassium ions and the excitatory neurotransmitter glutamate essentially contribute to the initiation and propagation of CSD. Both depolarization and disturbance of brain ion homeostasis regenerate within a few minutes while enhancing energy metabolism, but do not cause damage to normally perfused brain tissue. The similar propagation velocity of CSD and visual scotoma during migraine aura led to the assumption that CSD could be the underlying mechanism of migraine aura. The observation of CSD waves in migraine aura patients with the magnet encephalogram (MEG) technique confirmed this theory. Although many data support the relationship between CSD and aura phase in migraine, the role of CSD in migraine headache is still disputed.

PMID: 18483750 [PubMed - as supplied by publisher]

(Source: Schmerz)

[therapy of primary chronic headache : chronic migraine, chronic tension type headache and other forms of daily chronic headache.]

Schmerz — Sat, 17 May 2008 04:00:00 +0100

[Therapy of primary chronic headache : Chronic migraine, chronic tension type headache and other forms of daily chronic headache.]

Schmerz. 2008 May 17;

Authors: Straube A, May A, Kropp P, Katsarava Z, Haag G, Lampl C, Sándor PS, Diener HC, Evers S

The criteria of the International Headache Society (IHS) define four different primary headache syndromes with daily chronic headaches: chronic migraine, episodic and chronic tension type headache, hemicrania continua, new daily persisting headache. A further important differential diagnosis is medication overuse headache (previously known as analgesia headache). The German, Austrian, and Swiss headache societies now present the first joint guidelines for therapy of these headache syndromes. The current literature was reviewed and a summary is presented. The therapy recommendations do not only include the scientific evidence but also the practical relevance.

PMID: 18483751 [PubMed - as supplied by publisher]

(Source: Schmerz)

[differential therapeutic aspects of analgesia with oral sustained-release strong opioids : application intervals, metabolism and immunosuppression.]

Schmerz — Sat, 17 May 2008 04:00:00 +0100

[Differential therapeutic aspects of analgesia with oral sustained-release strong opioids : Application intervals, metabolism and immunosuppression.]

Schmerz. 2008 May 17;

Authors: Güttler K, Sabatowski R

The oral "around-the clock" administration of sustained-release strong opioids has been recommended for the long-term treatment of patients suffering from chronic severe pain. At present a plethora of products are available in Germany. Modern galenics even allow for only once-daily oral application without clinically relevant negative chronobiological interference. This application scheme has been shown to improve compliance and sleep quality, factors that influence treatment outcome. Randomized controlled studies revealed no relevant differences between the different strong opioids with respect to efficacy and tolerability. However, hydromorphone and oxycodone appear to be advantageous over morphine due to a lack of immunosuppression. Hydromorphone has the additional benefit of a lower risk of intoxication by accumulation of active metabolites in patients with decreased renal function. As a result, although morphine has been regarded as the standard for the treatment of chronic severe pain, hydromorphone and oxycodone may be better and safer alternatives for certain patient groups (e.g. older age, multimorbidity, cancer).

PMID: 18483817 [PubMed - as supplied by publisher]

(Source: Schmerz)

[multimodal integrated assessment and treatment of patients with back pain : pain related results and ability to work.]

Schmerz — Sat, 17 May 2008 04:00:00 +0100

[Multimodal integrated assessment and treatment of patients with back pain : Pain related results and ability to work.]

Schmerz. 2008 May 17;

Authors: Marnitz U, Weh L, Müller G, Seidel W, Bienek K, Lindena G, Gussek A

INTRODUCTION: The results of conventional chronic back pain therapy are unsatisfactory. Deconditioning, psychosocial disorders and prolonged disability are common sequelae. MATERIAL AND METHODS: The health insurance fund Deutsche Angestellten Krankenkasse (DAK) offers an interdisciplinary assessment by the Berlin-Brandenburg back pain network (BBR) to its members with ongoing work disability on account of back pain. After medical, physiotherapeutic and psychological exploration one of the following four options is suggested: further diagnostics, outpatient monomodal treatment, day-care pain management program of two intensities or inpatient pain treatment. The data of 394 patients with the leading diagnostic group of back pain (M54, ICD 10, 65.7%) and disability for 92.7 days (mean) are presented. RESULTS: The patients were severely impaired in physical and psychosocial aspects. The chronification was moderate (stage II-III of Mainz Staging System, MPSS). The success of treatment was evaluated 6 months after the initial assessment. All groups showed a significant reduction of pain, anxiety and depression whereas the wellbeing and daily activities improved, but best in the day-care pain management groups. CONCLUSION: Patient selection by a health fund, interdisciplinary assessment and severity adapted treatment resulted in significant reduction in pain and functional improvement in disabled back pain patients.

PMID: 18483818 [PubMed - as supplied by publisher]

(Source: Schmerz)

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Mortality and utilisation of critical care resources amongst high-risk surgical patients in a large nhs trust*

Anaesthesia — Fri, 16 May 2008 18:04:34 +0100

Anaesthesia, Volume 0, Issue 0, Page ???, OnlineEarly Articles. SummaryPrevious reports describe a population of non-cardiac surgical patients at high risk of complications and death. Outcomes are sub-optimal for such patients, perhaps in part related to inadequate provision or ineffective utilisation of critical care ... (Source: Anaesthesia)

Age 60 or older? get shingles vaccine

MedicineNet Chronic Pain General — Fri, 16 May 2008 07:00:00 +0100

Title: Age 60 or Older? Get Shingles VaccineCategory: Health NewsCreated: 5/16/2008Last Editorial Review: 5/16/2008 (Source: MedicineNet Chronic Pain General)

Stroke patients at high risk for falls

MedicineNet Chronic Pain General — Fri, 16 May 2008 07:00:00 +0100

Title: Stroke Patients at High Risk for FallsCategory: Health NewsCreated: 5/16/2008 2:00:00 AMLast Editorial Review: 5/16/2008 (Source: MedicineNet Chronic Pain General)

Pain free without numbness - substance combination with chili peppers

Pain / Anesthetics News From Medical News Today — Fri, 16 May 2008 07:00:00 +0100

A dentist's injection typically causes numbness for several hours. This experience could soon be history. Now, Clifford Woolf, professor at Harvard Medical School and the Massachusetts General Hospital, Boston, USA, and his colleagues have developed a combination of two agents which is able to specifically block pain without producing numbness or motor paralysis. (Source: Pain / Anesthetics News From Medical News Today)

Office initiative reduces headaches and neck and shoulder pain by more than 40 per cent

Pain / Anesthetics News From Medical News Today — Fri, 16 May 2008 07:00:00 +0100

Office staff who took part in an eight-month workplace initiative reported that headaches and neck and shoulder pain fell by more than 40 per cent and their use of painkillers halved, according to research published in the May issue of Cephalalgia. They also reported that pain levels were less severe at the end of the study than at the start. (Source: Pain / Anesthetics News From Medical News Today)

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[first-line treatment for acute low back pain : assessment of diclofenac or spinal manipulative therapy.]

Schmerz — Fri, 16 May 2008 04:00:00 +0100

[First-line treatment for acute low back pain : Assessment of diclofenac or spinal manipulative therapy.]

Schmerz. 2008 May 16;

Authors: Schiltenwolf M, Althaus E

PMID: 18481114 [PubMed - as supplied by publisher]

(Source: Schmerz)

[impact of a motivational intervention on coping with chronic pain : results of a controlled efficacy study.]

Schmerz — Fri, 16 May 2008 04:00:00 +0100

[Impact of a motivational intervention on coping with chronic pain : Results of a controlled efficacy study.]

Schmerz. 2008 May 16;

Authors: Rau J, Ehlebracht-König I, Petermann F

BACKGROUND: For effective self-management of chronic pain changes of cognitive and behavioral attitudes are required. The readiness to change can be described within the framework of the transtheoretical model (TTM) and is facilitated through motivational interviewing. This prospective study evaluated the effectiveness of brief motivational interviewing by telephone for the variables self-efficacy, cognitive and behavioral coping and psychological strain through chronic pain over a period of 9 months. METHODS: Different questionnaires, the self-efficacy expectations (ASES-D), cognitive, behavioral coping and psychological strain through chronic pain (FESV) and the German version of the pain stages of change questionnaires (PSOCQ), the FF-STABS were distributed to 147 patients at a rehabilitation clinic (indications: fibromyalgia syndrome, rheumatoid arthritis, ankylosing spondylitis). The intervention group participants received 3 telephone calls at intervals of 2 months with a follow-up time of 9 months after first study admission. At the end of the study 91 patients were enrolled for analysis (drop out rate 38%). To evaluate the effects of treatment nonparametric-analysis for longitudinal data was used. RESULTS AND CONCLUSION: The analysis showed significant positive effects in the intervention group for cognitive coping (U-value -2.423; p=0.015 group x time-effect) and for coping with emotional strains of chronic pain (subscale anxiety: U-value -2.3618; p=0.018; subscale anger: U-value 2.8638; p=0.004; group x time-effect). No significant effects were shown for self-efficacy expectations and behavioral coping with pain. Further explorative analysis of subgroups revealed slightly better treatment effects for patients with rheumatoid arthritis and ankylosing spondylitis than for those with fibromyalgia syndrome.

PMID: 18481115 [PubMed - as supplied by publisher]

(Source: Schmerz)

Common drug eases leg pain from walking

MedicineNet Chronic Pain General — Thu, 15 May 2008 07:00:00 +0100

Title: Common Drug Eases Leg Pain From WalkingCategory: Health NewsCreated: 5/15/2008 2:00:00 AMLast Editorial Review: 5/15/2008 (Source: MedicineNet Chronic Pain General)

Acupuncture and myofascial trigger therapy treat same pain areas

Pain / Anesthetics News From Medical News Today — Thu, 15 May 2008 07:00:00 +0100

Ancient acupuncture and modern myofascial pain therapy each focus on hundreds of similar points on the body to treat pain, although they do it differently, says a physician at Mayo Clinic in Jacksonville who analyzed the two techniques.Results of the study, published in the Journal of Complementary and Alternative Medicine, suggest that people who want relief from chronic musculoskeletal pain may benefit from either therapy, says chronic pain specialist Dr. (Source: Pain / Anesthetics News From Medical News Today)

[principles of treatment, coordination of medical care and patient education in fibromyalgia syndrome and chronic widespread pain.]

Schmerz — Thu, 15 May 2008 04:00:00 +0100

[Principles of treatment, coordination of medical care and patient education in fibromyalgia syndrome and chronic widespread pain.]

Schmerz. 2008 May 15;

Authors: Klement A, Häuser W, Brückle W, Eidmann U, Felde E, Herrmann M, Kühn-Becker H, Offenbächer M, Settan M, Schiltenwolf M, von Wachter M, Eich W

BACKGROUND: A guideline for the treatment and diagnostic procedures for fibromyalgia syndrome (FMS) was developed in cooperation with 10 German medical and psychological associations and 2 patient self-help groups. METHODS: A systematic literature search including all controlled studies evaluating physiotherapy, exercise and strength training as well as physical therapies was performed in the Cochrane Collaboration Reviews (1993-12/2006), Medline (1980-12/2006), PsychInfo (1966-12/2006) and Scopus (1980-12/2006). Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. Grading of the strengths of recommendations was done according to the German program for disease management guidelines. Standardized procedures to reach a consensus on recommendations were used. RESULTS: Patient's information at first diagnosis of FMS is strongly recommended (grade A). Patient-centered communication is recommended (grade B). A stepwise treatment approach depending on the adapatation to restrictions in daily life and response to treatment options can be considered (grade C). CONCLUSIONS: The long-term treatment should be based on principles of basic psychosomatic care and shared decision making on treatment options.

PMID: 18478270 [PubMed - as supplied by publisher]

(Source: Schmerz)

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[definition, classification and diagnosis of fibromyalgia syndrome.]

Schmerz — Thu, 15 May 2008 04:00:00 +0100

[Definition, classification and diagnosis of fibromyalgia syndrome.]

Schmerz. 2008 May 15;

Authors: Eich W, Häuser W, Friedel E, Klement A, Herrmann M, Petzke F, Offenbächer M, Schiltenwolf M, Sommer C, Tölle T, Henningsen P

BACKGROUND: Interdisciplinary guidelines for the definition, classification and diagnosis of chronic widespread pain (CWP) and fibromyalgia syndrome (FMS) were developed by collaboration of 10 German medical and psychological associations and 2 patient self-help organizations. METHODS: A systematic literature search was performed in the Cochrane Library (1993-12/2006), Medline (1980-2006), PsychInfo (1966-12/2006), and Scopus (1980-12/2006). Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. Grading of the strength of recommendation was done according to the German program for disease management guidelines. Standardized procedures to reach a consensus on recommendations were used. RESULTS: CWP is defined by the criteria of the American College of Rheumatology (ACR - strong consensus). FMS can be diagnosed for clinical purposes by symptom-based criteria (without tender point examination) as well as by the ACR criteria (strong consensus).

PMID: 18478271 [PubMed - as supplied by publisher]

(Source: Schmerz)

[significance of health-related quality of life and religiosity for the acceptance of chronic pain.]

Schmerz — Thu, 15 May 2008 04:00:00 +0100

[Significance of health-related quality of life and religiosity for the acceptance of chronic pain.]

Schmerz. 2008 May 15;

Authors: Gerbershagen K, Trojan M, Kuhn J, Limmroth V, Bewermeyer H

BACKGROUND: Modern medical analgesia is based on a bio-psycho-social model of disease. From this bio-psycho-social perspective it seems essential to include religiosity in the multidimensional and interdisciplinary assessment of pain patients. MATERIAL AND METHODS: A total of 450 consecutively referred in- and outpatients to a neurological department completed an epidemiologic pain questionnaire. This patient self-administered questionnaire included diagnostic screening tests for anxiety and depression, a generic health-related quality of life measure and sociodemographic questions. Pain severity grades and pain chronicity stages were measured. The acceptance of chronic pain was assessed with the chronic pain acceptance questionnaire. The significance of religiosity was measured employing the structure of religiosity test. RESULTS: Of the neurological patients 82% complained of having had pain within the past 3 months and 79% within the last 12 months. Patients who accepted the pain and pursued their daily activities despite the pain were less depressive and anxious and showed an enhanced health-related quality of life. The importance of religion to the pain patients was associated with a higher level of pain tolerance. CONCLUSIONS: This study proved that the significance of religiosity to the patient is related to psychic distress and health-related quality of life and at the same time may play an important role in the bio-psycho-social pain concept.

PMID: 18478272 [PubMed - as supplied by publisher]

(Source: Schmerz)

Proceedings of the 7th international symposium memory and awareness in anaesthesia

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

Resuscitation greats

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

Crisis management in acute care settings

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

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Obstetric anesthesia

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

Manual of emergency and critical care ultrasound

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

Understanding anesthesia equipment

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

A wireless remote controlled infusion pump for anaesthesia during magnetic resonance imaging

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

Statins and sepsis

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

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Does celecoxib have pre-emptive analgesic effect after caesarean section surgery?

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

Ultrasound technique for neuraxial procedures

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

Coanda effect as an explanation for unequal ventilation of the lungs in an intubated patient?

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

Unexpected awakening from anaesthesia after hyperstimulation of the medial thalamus in the rat

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

Nephrotoxicity of hydroxyethyl starch solution

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

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Complications of awake fibreoptic intubation without sedation in 200 healthy anaesthetists attending a training course

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background Two hundred anaesthetists underwent airway endoscopy and attempted awake fibreoptic intubation (FOI) on a training course. Complications were recorded and each subject's response to the procedure was assessed. Methods Topical airway local anaesthesia was produced with up to 9 mg kg–1 of lidocaine, sedation was not used. Complications during and after the procedure were noted. Later, the subjects completed an anonymous questionnaire about anxiety, pain, coughing, and side-effects of lidocaine. Results More than 1300 endoscopies were performed, 180 delegates were intubated, 175 by the nasal route and five orally. Intubation was abandoned in 20 (10%) subjects. Nasal bleeding occurred in 20 (10%) subjects. Symptoms that could be attributed to lidocaine were reported by 71 (36%) subjects. Afterwards, two (1%) subjects experienced rigors and one developed a lower respiratory tract infection. Conclusions Nasendoscopy and FOI under local anaesthesia are associated with complications, notably those of infection and airway trauma. Side-effects potentially attributable to lidocaine administration were commonly reported. (Source: British Journal of Anaesthesia)

Withdrawal forces of lumbar spinal catheters: no dependence on body position

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background Spinal catheters, because of their smaller diameter, have lower tensile strength than epidural catheters. This study was designed to measure the withdrawal forces needed to remove lumbar spinal catheters and to determine whether patient position affects withdrawal forces. Methods Eighty-two patients with a 24-gauge spinal catheter placed midline at the lumbar L3/4 or L4/5 level were randomly assigned to catheter removal either in flexed lateral or sitting position. Withdrawal forces were measured using a tension spring balance. Results Mean withdrawal force was 0.91 N (95% CI: 0.73, 1.09) with extremes up to 5 N. Withdrawal force in the flexed lateral position was 1.04 N (95% CI: 0.73, 1.34) or in the sitting position was 0.78 N (95% CI: 0.59, 0.97). The 95% CI for the difference of the means was –0.62 N, 0.10 N. Thus, the absolute mean difference between the positions can be assumed to be smaller than 0.62 N. Neither the length of the spinal catheter under the skin or in the subarachnoid space, nor BMI influenced withdrawal force. Conclusion Withdrawal force of spinal catheters is not influenced by body position during catheter removal, length of catheter under skin, or BMI. (Source: British Journal of Anaesthesia)

Lipophilic {beta}-adrenoceptor antagonist propranolol increases the hypnotic and anti-nociceptive effects of isoflurane in a swine model

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background We have previously reported that landiolol, an ultra-short-acting β1-adrenoceptor antagonist, does not alter the anaesthetic effects of isoflurane. Here, we investigated the influence of propranolol on the electroencephalographic (EEG) effects and minimum alveolar concentration (MAC) of isoflurane. Methods Fourteen swine [25.0 (sd 4.0) kg] were anaesthetized by isoflurane inhalation. The inhalation concentration was decreased to 0.5% and maintained for 25 min, before being returned to 2%, and maintained for a further 25 min. End-tidal isoflurane concentrations and spectral edge frequencies were recorded. Pharmacodynamic analysis was performed using a sigmoidal inhibitory maximal effect model for spectral edge frequency vs effect-site concentration. After measurement of the EEG effect, MAC was determined using the dew-claw clamp technique, in which movement in response to clamping is recorded. After completion of control measurements, a propranolol 4 mg bolus followed by an infusion (2 mg h–1) was started. After a 30 min stabilization period, the inhalation concentration of isoflurane was varied as in the control period and MAC was re-assessed. Results Propranolol shifted the concentration–effect relationship to the left and decreased the effect–site concentration that produced 50% of the maximal effect from 1.30 (0.18) to 1.13 (0.17)%. Propranolol also decreased isoflurane MAC from 1.91 (0.35) to 1.54 (0.32)%. Conclusions Propranolol alters both the hypnotic and anti-nociceptive effects of isoflurane. In contrast to landiolol, lipophilic β-adrenoceptor antagonists may increase the potency of inhalational anaesthetics. (Source: British Journal of Anaesthesia)

Premedication with pregabalin 75 or 150 mg with ibuprofen to control pain after day-case gynaecological laparoscopic surgery

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background Multimodal pain management has been suggested to improve postoperative analgesia. In this study, we evaluated the quality of analgesia in women undergoing day-case gynaecological laparoscopic surgery, after premedication with pregabalin 75 mg (P75) or 150 mg (P150), compared with diazepam 5 mg (D5). All patients were given ibuprofen 800 mg orally. Methods Altogether 90 consenting women were anaesthetized in a standardized fashion. Postoperative analgesia was provided by ibuprofen 800 mg twice a day with fentanyl i.v. on request in the recovery room (RR), and combination tablets with acetaminophen and codeine after the RR. The visual analogue scale (VAS) scores for pain and side-effects and the amounts of postoperative analgesics were recorded for 24 h after surgery. The areas under the curves (AUC) were calculated for the VAS scores for pain at rest, pain in motion, and pain at cough 1–8 and 1–24 h after surgery. Results The median AUC values for VAS scores for pain at rest (P=0.048) and in motion (P=0.046) 1–8 h after surgery were lower in the P150 group than that in the D5 group. The amounts of rescue analgesics or the degree of drowsiness did not differ in the three study groups. Conclusions Analgesia was better after premedication with pregabalin 150 mg than after diazepam 5 mg, both with ibuprofen 800 mg, during the early recovery after day-case gynaecological laparoscopic surgery. Pregabalin 150 mg did not reduce the amount of postoperative analgesics required. (Source: British Journal of Anaesthesia)

Lornoxicam characteristically modulates cerebral pain-processing in human volunteers: a functional magnetic resonance imaging study

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background Lornoxicam like other non-steroidal anti-inflammatory drugs (NSAIDs) is widely used for postoperative pain therapy. Evaluation of the effect of lornoxicam on cerebral processing of surgical pain was thus the aim of the present functional magnetic resonance imaging (fMRI) study. Methods An fMRI-compatible pain model that mimics surgical pain was used to induce pain rated 4–5 on a visual analogue scale (VAS) at the anterior margin of the right tibia in volunteers (n=22) after i.v. administration of saline (n=11) or lornoxicam (0.1 mg kg–1) (n=11). Results Lornoxicam, which significantly reduced pain sensation [VAS: mean (sd) 4.6 (0.7) vs 1.2 (1.5)], completely suppressed pain-induced activation in the SII/operculum, anterior cingulate cortex, insula, parietal (inferior), prefrontal (inferior, medial), temporal (inferior, medial/superior) lobe, cerebellum, and contralateral (e.g. left-sided) postcentral gyrus (SI). Only the hippocampus and the contralateral superior parietal lobe (BA 7) were activated. Conclusions As compared with saline, lornoxicam typically suppressed pain-induced brain activation in all regions except the hippocampus. Furthermore, de novo activation was found in the contralateral, superior parietal lobe (BA 7). (Source: British Journal of Anaesthesia)

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Experiences in the development of non-heart beating organ donation scheme in a regional neurosciences intensive care unit

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background In the UK demand for organ transplantation continues to outstrip supply and one strategy aimed at reversing this trend is the introduction of non-heart beating donor (NHBD) schemes. In this paper we describe our experience after the introduction of the NHBD scheme at a regional neuroscience intensive care unit (ICU) that also provides general intensive care. Methods We describe the steps taken to establish the scheme and present our results from the time of its implementation in July 2002 until March 2007. Results Of the 100 patients whom we referred to the transplant co-ordinators, 71 were identified as potential NHBDs and of these 29 went on to become actual donors (conversion rate of 40.8%). Fifty-six kidneys were retrieved and 53 successfully transplanted. In addition, two livers were retrieved but subsequently found to be unsuitable for transplantation, while eight pancreas were retrieved and used for islet cell research. The serum creatinine at 1 yr demonstrates that there is no significant difference between transplanted kidney function from NHBDs and heart-beating donors (HBDs). Conclusions We believe that by establishing the NHBD organ donation scheme we are able to fulfil the wishes of more patients who have indicated that they would like to donate their organs while increasing the availability of solid organs for transplantation. With careful preparation, audit, and communication our experience demonstrates that the NHBD scheme can be successfully introduced in an ICU and expanded to other ICUs in a region. (Source: British Journal of Anaesthesia)

Activated protein c inhibits chemotaxis and interleukin-6 release by human neutrophils without affecting other neutrophil functions

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background Activated protein C (APC) therapy reduces mortality in high-risk patients with severe sepsis. The effects of APC on inflammatory responses have also been reported. Neutrophils are key cells involved in early host defence mechanisms in sepsis. We hypothesized that APC may have effects on neutrophil function. Methods Neutrophils were isolated from 10 healthy volunteers and incubated in the presence of lipopolysaccharide (LPS) with and without a range of therapeutically relevant concentrations of recombinant human APC. Respiratory burst activity was determined using flow-activated cell sorting (FACS) analysis. Apoptosis was determined using Annexin-V staining and FACS analysis. Cytokine bead array was used to simultaneously measure three key cytokines in culture supernatants: interleukin (IL)-1β, -6, and -8. For chemotaxis, neutrophil migration through a 5 µm membrane was measured in response to formyl–methyl–leucine–phenylalanine (FMLP) or IL-8 in the presence and absence of APC. Results Exposure to LPS resulted in significant increases in respiratory burst activity, IL-1β, -6, and -8 expression (all P<0.0001) and decreased the number of apoptotic cells (P<0.0001). The APC exposure resulted in a significant release of IL-6 (P=0.04) without affecting other cytokines. Respiratory burst and apoptosis were also unaffected by APC. Neutrophil chemotaxis in response to either FMLP or IL-8 was reduced by APC (P=0.005 and 0.007, respectively). Conclusions This pilot study showed that APC treatment of human neutrophils results in a decreased IL-6 expression and chemotaxis, without affecting other cytokines, apoptosis, or respiratory burst activity. (Source: British Journal of Anaesthesia)

Nociceptin and urotensin-ii concentrations in critically ill patients with sepsis

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background The systemic inflammatory response to infection (sepsis) involves widespread organ dysfunction, including changes in immune modulation, cardiovascular derangements, and neural activation. Two neuropeptide/receptor systems, nociceptin/orphanin FQ (N/OFQ) which acts at the non-classical opioid receptor NOP and urotensin-II (U-II) which acts at the urotensin receptor (UT), have been implicated in neural, immune, and cardiovascular system function. In this study, we make measurements of these peptides in critically ill patients. Methods Plasma samples from 21 critically ill patients with sepsis were collected over four consecutive days. Plasma N/OFQ and U-II concentrations were determined by radioimmunoassay and compared with biochemical and clinical markers of illness severity, including serum creatinine, bilirubin, platelet and white cell counts, admission APACHE II and serial SOFA scores. Results Median (inter-quartile range) admission plasma N/OFQ concentrations in sepsis were higher in patients who died within 30 days (n=4) compared with survivors (n=17); 3.0 (2.5–5.0) vs 1.0 (1.0–2.5) pg ml–1 (P=0.028). Plasma N/OFQ concentrations were increased in a subgroup of five patients who had undergone major gastrointestinal surgery. There were no significant changes in plasma U-II concentrations. There were no correlations between plasma U-II and N/OFQ concentrations and markers of illness severity and organ system dysfunction. Conclusions Plasma N/OFQ concentrations were increased in critically ill patients with sepsis who had undergone major gastrointestinal surgery and in patients who subsequently died. Further work is required to clarify the significance of plasma N/OFQ concentrations in sepsis. (Source: British Journal of Anaesthesia)

Endogenous antimicrobial peptide ll-37 induces human vasodilatation

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background Septic shock includes blood vessel dilatation and activation of innate immunity, which in turn causes release of antimicrobial peptides such as LL-37. It has been shown that LL-37 can attract leucocytes via the lipoxin A4 receptor (ALX, FPRL1). ALX is also present in vascular endothelial cells. To explore possible ways of pharmacological intervention in septic shock, we investigated if LL-37 can affect vascular tone. Methods Human omental arteries and veins were obtained during abdominal surgery, and circular smooth muscle activity was studied in organ baths. Gene expression was studied using reverse transcriptase–polymerase chain reaction. Results LL-37, at micromolar concentrations, induced a concentration- and endothelium-dependent relaxation in vein but not in artery segments precontracted by endothelin-1. The relaxation was profoundly reduced by potassium chloride (30 mM) to inhibit endothelium-derived hyperpolarizing factor (EDHF), whereas it was less affected by the NOS inhibitor, l-NG-nitroarginine methyl ester, and not at all by indomethacin. The ALX agonist, WKYMVm, also induced a relaxation and both the relaxations induced by LL-37 and WKYMVm were inhibited by the ALX antagonist, WRWWWW. ALX was expressed in the vein endothelium. Conclusions We demonstrate, for the first time, that the human antimicrobial peptide, LL-37, induces endothelium-dependent relaxation in human omental veins mediated via an effect on endothelial ALX. The relaxation involves the release of nitric oxide and EDHF but not prostanoids. LL-37 released from white blood cells could contribute to blood vessel dilatation during sepsis and treatment with ALX antagonists might be successful. (Source: British Journal of Anaesthesia)

Influence of a continuous prednisolone medication on the time course of neuromuscular block of atracurium in patients with chronic inflammatory bowel disease

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background Corticosteroids interact with neuromuscular blocking agents. However, experimental data are contradictory: enhancement and attenuation of the neuromuscular block has been observed. This study tested the influence of long-term medication with prednisolone on atracurium-induced neuromuscular block. Methods Sixty patients with chronic inflammatory bowel disease undergoing elective abdominal surgery were investigated. Thirty patients received a long-term medication with prednisolone (Group A) and 30 were without corticoid medication (Group B). Additionally, another 30 patients without inflammatory bowel disease and without corticoid medication served as control (Group C). The following parameters of an atracurium-induced neuromuscular block (0.25 mg kg–1) were measured: onset time, maximum block, recovery to 25% first twitch height, recovery index (time from 25% until 75% recovery of first twitch), duration to recovery to a train-of-four (TOF) rate of 0.7 and 0.9. Results The groups did not differ with regard to onset time, maximum block, and recovery index. The duration to 25% twitch height was significantly lower in Group A [18.1 (0–30.7) min] compared with Group B [23.5 (0–36.7) min; P<0.05]. Duration to a TOF rate of 0.7 and 0.9, respectively, were significantly reduced in Group A [36.1 (7.9) and 40.9 (9.0 min)] compared with Group B [47.9 (7.6) and 53.4 (9.2) min; P<0.001]. Conclusions Long-term medication with prednisolone resulted in a shorter duration of an atracurium-induced neuromuscular block in patients with Crohn's disease or ulcerative colitis. The presence of the inflammatory bowel disease did not influence the time course of the neuromuscular block. (Source: British Journal of Anaesthesia)

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Evaluation of rotation thrombelastography for the diagnosis of hyperfibrinolysis in trauma patients

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background Blood loss and uncontrollable bleeding are major factors affecting survival in trauma patients. Because treatment with antifibrinolytic drugs may be effective, early detection of hyperfibrinolysis with rotation thrombelastography (ROTEM®) may be beneficial. Methods Eighty-seven trauma patients were included in this prospective observational study. Blood samples were collected at admission. After in vitro activation with tissue factor (EXTEM) and inhibition with aprotinin (APTEM), ROTEM® parameters including maximal clot firmness (MCF) and clot lysis index at 30 min (CLI30) were determined. Hyperfibrinolysis was defined as a euglobulin lysis time (ELT) <90 min. Threshold for ROTEM® parameters were determined with receiver-operating characteristic curves (ROC) analysis according to the ELT results. Results ELT was determined in a subgroup of 23 patients. In this group of patients, ROC analysis showed that for a threshold of 18 mm (MCF-EXTEM), 71% (CLI30) and 7% (increase of MCF-APTEM), sensitivity was, respectively, 100%, 75%, and 80% with a specificity of 100%. With the application of these thresholds to the whole trauma cohort, ROTEM® analysis detected hyperfibrinolysis in five patients [6%, 95% confidence interval (CI): 2–13%]. As expected, patients with hyperfibrinolysis were more severely injured (median Injury Severity Score: 75 vs 20, P<0.05), had greater coagulation abnormalities [international normalized ratio (INR): 8.2 vs 1.3, P<0.05; fibrinogen: 0.0 vs 2.2 g litre–1, P<0.05], and a higher mortality rate (100%, CI: 48–100% vs 11% CI: 5–20%, P<0.05). Conclusions ROTEM® provided rapid and accurate detection of hyperfibrinolysis in severely injured trauma patients. (Source: British Journal of Anaesthesia)

Incidence of postoperative nausea and emetic episodes after xenon anaesthesia compared with propofol-based anaesthesia

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background Xenon has been proved to be safe and efficacious for general anaesthesia in numerous trials. In addition, experimental studies demonstrate that xenon inhibits the 5-hydroxytryptamine type 3 (5-HT3) receptor. As 5-HT3 receptor antagonists are known to decrease postoperative nausea and vomiting (PONV) to an extent comparable with a propofol-based total i.v. technique, we tested the hypothesis that general anaesthesia with xenon would result in a reduced incidence of PONV similar to that observed with propofol-based anaesthesia. Methods After obtaining approval from the local ethics committee and written informed consent, 142 patients were randomized to receive xenon anaesthesia or propofol-based total i.v. anaesthesia (TIVA), both supplemented with remifentanil. The incidence of postoperative nausea and emetic episodes was recorded in the post-anaesthesia care unit and on the ward more than 24 h after anaesthesia. Results A total of 142 patients were equally distributed between the xenon and TIVA groups. Anaesthesia was maintained with mean (sd) concentrations of either xenon 61 (2)% or propofol 100 (20) µg kg–1 min–1. Incidences of nausea and emetic episodes over the whole 24-h period were 66.2% and 35.2% in the xenon group and 26.8% and 16.9% in the TIVA group (P<0.001 and P<0.021). Conclusion Despite knowing the 5-HT3 antagonistic properties of xenon, its use is associated with a higher incidence of nausea and emetic episodes compared with TIVA with propofol. (Source: British Journal of Anaesthesia)

Effect of nitrous oxide on plasma homocysteine and folate in patients undergoing major surgery

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background Nitrous oxide (N2O) inhibits methionine synthetase resulting in elevated plasma homocysteine (Hcy) concentration after surgery. In epidemiological studies, hyperhomocysteinaemia is associated with increased risk of cardiovascular disease and dementia. Methods Blood samples were obtained to measure plasma folate and Hcy concentrations from two centres participating in a multicentre randomized trial investigating the effects of N2O on the outcome after major surgery. The effect of N2O and duration of anaesthesia on plasma Hcy, and the relationship between hyperhomocysteinaemia and outcomes were assessed. Results We enrolled 394 patients. The N2O Group had an increase in plasma Hcy concentration after surgery when compared with the N2O-free Group: 11.1 (3.8) vs 8.5 (4.0) µmol litre–1, P<0.0005. Postoperative hyperhomocysteinaemia was associated with an increased risk of major complications: risk ratio (RR) 2.8 (95% CI: 1.4–5.4), P=0.002 and cardiovascular events, RR 5.1 (95% CI: 3.1–8.5), P<0.0005. There was a significant association between duration of anaesthesia and the relative change in plasma Hcy concentration, particularly in the N2O Group: r=0.42, P<0.001. Conclusions N2O increases plasma Hcy concentration; this effect is greater with a longer duration of anaesthesia. Hyperhomocysteinaemia is a risk factor for major postoperative complications. N2O-induced increases in plasma Hcy concentration may be a cause of postoperative cardiovascular morbidity. (Source: British Journal of Anaesthesia)

Increased non-stationarity of heart rate during general anaesthesia with sevoflurane or desflurane in children

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background During general anaesthesia, the most prominent change in heart rate variability (HRV) is a decrease in the magnitude of heart rate (HR) oscillation in the high- and low-frequency ranges. In children receiving sevoflurane or desflurane, we observed a significant increase in HR non-stationarity, that is, a significant change of mean HR over time. The aim of our study was to describe this increased non-stationarity and compare it with the decrease in the magnitude of HR oscillation. Methods Sixty children received sevoflurane (n=30) or desflurane anaesthesia (n=30). The magnitude of HR oscillation and non-stationarity during pre-anaesthesia and anaesthesia were measured by spectral and Hurst analyses using structure function, respectively. Results Low- and high-frequency powers decreased significantly and the very-short-term (2≤≤8 s, H) and short-term Hurst exponent (8≤≤45 s, Hβ) increased significantly during the anaesthetic period compared with the pre-anaesthetic period, regardless of the anaesthetic agent [sevoflurane: mean (sd) H 0.414 (0.169) vs 0.252 (0.0655), Hβ 0.481 (0.169) vs 0.078 (0.0409); desflurane H 0.336 (0.171) vs 0.261 (0.0614), Hβ 0.471 (0.221) vs 0.0813 (0.049)]. Stepwise discriminant analysis showed that the short-term Hurst exponent was better than the spectral indices at differentiating between the pre-anaesthetic period and anaesthetic period. Conclusions During sevoflurane and desflurane anaesthesia in children, there is a significant increase in very-short-term and short-term HR non-stationarity. Furthermore, the greater short-term non-stationarity differentiates better between the pre-anaesthesia and anaesthesia than the decreased magnitude of HR oscillation in the high- and low-frequency ranges. (Source: British Journal of Anaesthesia)

Comparison of s-(+)-ketamine- with sufentanil-based anaesthesia for elective coronary artery bypass graft surgery: effect on troponin t levels

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background S-(+)-ketamine anaesthesia carries potential benefits for the cardiovascularly compromised patient. However, the use of S-(+)-ketamine in ischaemic coronary artery disease is controversial. In a prospective, randomized, clinical trial, we have investigated whether an S-(+)-ketamine-based anaesthetic protocol leads to increased cardiac troponin T levels (cTnT) after coronary artery bypass grafting (CABG). Methods Two hundred and nine patients undergoing elective CABG were randomized to receive either i.v. anaesthesia with sufentanil–midazolam–propofol (SMP; n=108) or S-(+)-ketamine–midazolam–propofol (KMP; n=101). Haemodynamic variables were maintained within the normal range. Invasive haemodynamic monitoring was performed using a pulmonary artery catheter. Plasma cTnT levels were sampled before induction and 1, 6, and 24 h after aortic unclamping. Cardiovascular adverse events, such as electrocardiographic signs of ischaemia, perioperative myocardial infarction, and death, were recorded. Results Patient characteristics, cardiac profile, intraoperative management, and the incidence of cardiovascular adverse events were comparable between the groups. Plasma cTnT levels increased after operation in both groups. cTnT levels were significantly lower in the KMP group 6 h after aortic unclamping compared with the SMP group (P=0.004), but did not differ 24 h after aortic unclamping [median (range): SMP 0.4 (0.01–3.9) vs KMP 0.4 (0.07–6.6) µg litre–1, P=0.338]. Conclusions S-(+)-ketamine does not accentuate postoperative cTNT rises in haemodynamically stable elective CABG patients. (Source: British Journal of Anaesthesia)

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Changes in glomerular filtration rate after cardiac surgery with cardiopulmonary bypass in patients with mild preoperative renal dysfunction

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Background Cardiac surgery with cardiopulmonary bypass (CPB) is commonly perceived as a risk factor for decline in renal function, especially in patients with preoperative renal dysfunction. There are few data on the effects of CPB on renal function in patients with mild preoperative renal dysfunction. The purpose of this study was to evaluate renal function in patients with pre-existing mild renal dysfunction undergoing cardiac surgery with CPB. Methods In a multicentre study cohort we measured prospectively the glomerular filtration rate (GFR) by radioactive markers both before operation and on the 7th postoperative day in cardiac surgical patients with preoperative serum creatinine >120 µmol l–1 (n=56). In a subgroup of patients (n=14) in addition to the GFR, the effective renal plasma flow (ERPF) and the filtration fraction (FF) were measured. Results While preoperative GFR [77.9 (25.5) ml min–1] increased to 84.4 (23.7) ml min–1 (P=0.005) 1 week after surgery, ERPF did not change [295.8 (75.2) ml min–1 and 295.9 (75.9) ml min–1, respectively; P=0.8]. In accordance, the FF increased from 0.27 (0.05) (before operation) to 0.30 (0.04) (Day 7, P=0.01). Conclusion Our results oppose the view that cardiac surgery with CPB adversely affects renal function in patients with preoperative mild renal dysfunction and an uncomplicated clinical course. (Source: British Journal of Anaesthesia)

Opioids and the control of respiration

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

Respiratory depression limits the use of opioid analgesia. Although well described clinically, the specific mechanisms of opioid action on respiratory control centres in the brain have, until recently, been less well understood. This article reviews the mechanisms of opioid-induced respiratory depression, from the cellular to the systems level, to highlight gaps in our current understanding, and to suggest avenues for further research. The ultimate aim of combating opioid-induced respiratory depression would benefit patients in pain and potentially reduce deaths from opioid overdose. By integrating recent findings from animal studies with those from human volunteer and clinical studies, further avenues for investigation are proposed, which may eventually lead to safer opioid analgesia. (Source: British Journal of Anaesthesia)

Volume 100: case reports: should they be confined to the dustbin?

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)

Memory and awareness during anaesthesia

British Journal of Anaesthesia — Thu, 15 May 2008 04:00:00 +0100

(Source: British Journal of Anaesthesia)