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Karimi M. A Surgeon's Perspective on Blood Conservation Practice in Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2022; 13:782-787. [DOI: 10.1177/21501351221114846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blood conservation practice in pediatric cardiac surgery has not been consistently adopted as quality improvement in many centers despite known risks associated with allogeneic blood products, shortage of donors, and costs. There are many blood conservation strategies available which collectively minimize exposure to allogeneic transfusion by maximizing the use of autologous red cells. These strategies are safe, reproducible, and have been implemented in clinical practice collectively with great efficacy for all patient ages and complexity levels. Institutional commitment to a set guideline will improve their blood conservation practice and quality outcome. The purpose of this article is to provide early career and practicing congenital cardiac surgeons with practical information concerning blood conservation strategies which can be considered for implementation in any pediatric cardiac surgery program, and which may be of particular value in resource-limited programs.
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Affiliation(s)
- Mohsen Karimi
- Department of Cardiothoracic Surgery, Stead Family Children’s Hospital, University of Iowa Healthcare, Iowa City, IA, USA
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Hemodilution on microvascular oxygen delivery potential of the blood during coronary bypass surgery. J Anesth 2022; 36:723-730. [PMID: 36161534 DOI: 10.1007/s00540-022-03109-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/14/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE The hematocrit-to-whole blood viscosity ratio (Hct/WBV) reflects the blood O2 delivery potential (O2-DP). WBV is variable to the dynamic vascular shear rate (SR), 1-5/s at microcirculation and 300/s at larger vessels. To estimate the impact of hemodilution on the blood O2-DP to the myocardium, we analyzed the hemodilution-induced change of Hct/WBV at SR 5/s (Hct/WBV5) during off-pump coronary bypass (OPCAB) surgery. METHODS During OPCAB surgery (n = 21), 10% acute normovolemic hemodilution (HD 10%) was applied. Arterial blood samples were taken: one before and two after HD 10%. One of which after HD 10% underwent an additional 33% in vitro hemodilution (reaching 40% hemodilution in total, HD 40%). WBV of all blood samples was determined using a scan-capillary tube viscometer (Hemovister™). The changes of Hct/WBV5 were analyzed as a primary measure of the study and compared with those of Hct/WBV at SR 300/s (Hct/WBV300). RESULTS Median[IQR] of Hct/WBV5 [3.5 (2.8-4.2)%/cPoise] was significantly increased by HD 10 and HD 40% [3.6 (3.2-4.6)%/cPoise and 4.2 (3.3-5.2)%/cPoise, respectively, all P < 0.001], but the degrees of changes after HD 10 and HD 40% were not different. Median[IQR] of Hct/WBV300 [10.3(8.6‒10.8)%/cPoise] was not changed by HD 10% [10.3(9.1-11.1)%/cPoise], but it was significantly decreased by HD 40% [8.4(7.4‒9.2)%/cPoise, P < 0.001]. CONCLUSION The increased Hct/WBV5 suggests that 10-40% hemodilution improves the blood O2-DP to the myocardium during OPCAB surgery. The SR-specific discrepancy in Hct/WBV changes advocates using microvascular WBV and Hct/WBV to evaluate the blood O2-DP changes to the myocardium. Further study is warranted to assess the actual changes in myocardial O2 delivery.
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Vega RA, Lyon C, Kierce JF, Tye GW, Ritter AM, Rhodes JL. Minimizing transfusion requirements for children undergoing craniosynostosis repair: the CHoR protocol. J Neurosurg Pediatr 2014; 14:190-5. [PMID: 24877603 DOI: 10.3171/2014.4.peds13449] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECT Children with craniosynostosis may require cranial vault remodeling to prevent or relieve elevated intracranial pressure and to correct the underlying craniofacial abnormalities. The procedure is typically associated with significant blood loss and high transfusion rates. The risks associated with transfusions are well documented and include transmission of infectious agents, bacterial contamination, acute hemolytic reactions, transfusion-related lung injury, and transfusion-related immune modulation. This study presents the Children's Hospital of Richmond (CHoR) protocol, which was developed to reduce the rate of blood transfusion in infants undergoing primary craniosynostosis repair. METHODS A retrospective chart review of pediatric patients treated between January 2003 and Febuary 2012 was performed. The CHoR protocol was instituted in November 2008, with the following 3 components; 1) the use of preoperative erythropoietin and iron therapy, 2) the use of an intraoperative blood recycling device, and 3) acceptance of a lower level of hemoglobin as a trigger for transfusion (< 7 g/dl). Patients who underwent surgery prior to the protocol implementation served as controls. RESULTS A total of 60 children were included in the study, 32 of whom were treated with the CHoR protocol. The control (C) and protocol (P) groups were comparable with respect to patient age (7 vs 8.4 months, p = 0.145). Recombinant erythropoietin effectively raised the mean preoperative hemoglobin level in the P group (12 vs 9.7 g/dl, p < 0.001). Although adoption of more aggressive surgical vault remodeling in 2008 resulted in a higher estimated blood loss (212 vs 114.5 ml, p = 0.004) and length of surgery (4 vs 2.8 hours, p < 0.001), transfusion was performed in significantly fewer cases in the P group (56% vs 96%, p < 0.001). The mean length of stay in the hospital was shorter for the P group (2.6 vs 3.4 days, p < 0.001). CONCLUSIONS A protocol that includes preoperative administration of recombinant erythropoietin, intraoperative autologous blood recycling, and accepting a lower transfusion trigger significantly decreased transfusion utilization (p < 0.001). A decreased length of stay (p < 0.001) was seen, although the authors did not investigate whether composite transfusion complication reductions led to better outcomes.
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Bailey AG, McNaull PP, Jooste E, Tuchman JB. Perioperative crystalloid and colloid fluid management in children: where are we and how did we get here? Anesth Analg 2009; 110:375-90. [PMID: 19955503 DOI: 10.1213/ane.0b013e3181b6b3b5] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It has been more than 50 yr since the landmark article in which Holliday and Segar (Pediatrics 1957;19:823-32) proposed the rate and composition of parenteral maintenance fluids for hospitalized children. Much of our practice of fluid administration in the perioperative period is based on this article. The glucose, electrolyte, and intravascular volume requirements of the pediatric surgical patient may be quite different than the original population described, and consequently, use of traditional hypotonic fluids proposed by Holliday and Segar may cause complications, such as hyperglycemia and hyponatremia, in the postoperative surgical patient. There is significant controversy regarding the choice of isotonic versus hypotonic fluids in the postoperative period. We discuss the origins of perioperative fluid management in children, review the current options for crystalloid fluid management, and present information on colloid use in pediatric patients.
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Affiliation(s)
- Ann G Bailey
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina, USA.
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Development of spontaneous subdural hematoma and bone marrow depression after hydroxyethyl starch administration. J Pediatr 2008; 153:579-81. [PMID: 18847623 DOI: 10.1016/j.jpeds.2008.04.073] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Revised: 03/27/2008] [Accepted: 04/30/2008] [Indexed: 11/24/2022]
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Ranucci M, Isgrò G, De La Torre T, Romitti F, De Benedetti D, Carlucci C, Kandil H, Ballotta A. Continuous monitoring of central venous oxygen saturation (Pediasat) in pediatric patients undergoing cardiac surgery: a validation study of a new technology. J Cardiothorac Vasc Anesth 2008; 22:847-52. [PMID: 18834840 DOI: 10.1053/j.jvca.2008.04.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2008] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Mixed venous oxygen saturation and central venous oxygen saturation are considered possible indicators of the adequacy of oxygen delivery with respect to the oxygen needs of critically ill adult and pediatric patients. The present study was aimed at validating the accuracy of a new technology (Pediasat central venous catheter) in providing a continuous measurement of the central venous oxygen saturation in pediatric patients. DESIGN A prospective observational study. PARTICIPANTS Thirty pediatric patients (age, 6 days-9 years) undergoing cardiac operations. Data obtained with the Pediasat during and after the operation were compared with simultaneously collected venous blood samples analyzed with standard laboratory techniques. SETTING A clinical research hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A Bland and Altman analysis was performed on 30 matched sets of data collected before cardiopulmonary bypass, during cardiopulmonary bypass, and during the intensive care unit stay. Before cardiopulmonary bypass, there was a bias of 0.003, with lower and upper limits of agreement, -5.84 and 5.84 (percentage error, 17.3%). During cardiopulmonary bypass, the bias was 0.57 and lower and upper limits of agreement were -7.7 and 8.7 (percentage error, 23.2%). At 2 hours after the arrival in the intensive care unit, the bias was -0.6 and the lower and upper limits of agreement were -8 and 6.8 (percentage error, 20.3%). CONCLUSIONS Because of the minimal bias and the acceptable value of percentage error, the Pediasat may be considered as an accurate tool for the continuous measurement of the central venous oxygen saturation in neonates and pediatric patients during and after cardiac operations.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic-Vascular Anesthesia and Intensive Care, IRCCS Policlinico S. Donato, Milan, Italy.
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HES 130/0.4 (Voluven) or human albumin in children younger than 2 yr undergoing non-cardiac surgery. A prospective, randomized, open label, multicentre trial. Ugeskr Laeger 2008; 25:437-45. [PMID: 18339212 DOI: 10.1017/s0265021508003888] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE For perioperative volume therapy in infants and young children, human albumin has frequently been the colloid of choice. Recently, HES 130/0.4 (6% hydroxyethyl starch, Voluven; Fresenius Kabi, Bad Homburg, Germany) was developed, which demonstrated improved pharmacokinetics and a favourable safety profile in adults compared with hydroxyethyl starch products with a less rapid metabolization. METHODS Our prospective, controlled, randomized, open, multicentre pilot study was designed to obtain data on the effects of HES 130/0.4 compared with human albumin 5% with regard to haemodynamics in children <2 yr scheduled for elective non-cardiac surgery. RESULTS A total of 81 patients were treated. Comparable amounts of both study solutions (16.0 mL kg(-1) hydroxyethyl starch 130/0.4 vs. 16.9 mL kg(-1) human albumin 5%) as well as add-on crystalloids were used until 4-6 h postoperatively. No differences were detected between the two treatment groups regarding perioperative stabilization of haemodynamics, coagulation parameters, blood gas analyses or other laboratory values. Blood loss was 96 +/-143 mL for hydroxyethyl starch and 145+/- 290 mL for human albumin (P > 0.05). There were no relevant differences in the amount of red blood cells, fresh frozen plasma or platelet concentrates in both treatment groups. Median length of ICU stay was 3.5 days (range 1-57 days, mean +/- SD 7.6 +/- 11.5 days) in the hydroxyethyl starch group and 6.0 days (range 1-71 days; mean +/- SD 9.1 +/- 14.2 days) in the human albumin group. There was no difference for hospital stay (median: 12 days for both groups). CONCLUSIONS Both HES 130/0.4 and human albumin 5% were effective for haemodynamic stabilization in non-cardiac surgery of young infants with no adverse impact on coagulation or other safety parameters in our study population.
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Habler O, Meier J, Pape A, Kertscho H, Zwissler B. [Tolerance to perioperative anemia. Mechanisms, influencing factors and limits]. Urologe A 2007; 46:W543-56; quiz W557-8. [PMID: 17429601 PMCID: PMC7095997 DOI: 10.1007/s00120-007-1344-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The expected cost explosion in transfusion medicine increases the socio-economic significance of specific institutional transfusion programs. In this context the estimated use of the patient's physiologic tolerance represents an integral part of any blood conservation concept. The present article summarizes the mechanisms, influencing factors and limits of this natural tolerance to anemia and deduces the indication for perioperative red blood cell transfusion. The current recommendations coincide to the effect that perioperative transfusion is unnecessary up to a Hb concentration of 10 g/dl (6.21 mmol/l) even in older patients with cardiopulmonary comorbidity and is only recommended in cases of Hb <6 g/dl (<3.72 mmol/l) in otherwise healthy subjects including pregnant women and children. Critically ill patients with multiple trauma and sepsis do not seem to benefit from transfusions up to Hb concentrations >9 g/dl (>5.59 mmol/l). In cases of massive hemorrhaging and diffuse bleeding disorders the maintenance of a Hb concentration of 10 g/dl (6.21 mmol/l) seems to contribute to stabilization of coagulation.
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Affiliation(s)
- O Habler
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Krankenhaus Nordwest GmbH, Steinbacher Hohl 2-26, 60488 Frankfurt a.M.
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Habler O, Meier J, Pape A, Kertscho H, Zwissler B. [Tolerance to perioperative anemia. Mechanisms, influencing factors and limits]. Anaesthesist 2006; 55:1142-56. [PMID: 16826416 PMCID: PMC7095856 DOI: 10.1007/s00101-006-1055-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The expected cost explosion in transfusion medicine (increasing imbalance between donors and potential recipients, treatment of transfusion-associated complications) increases the socio-economic significance of specific institutional transfusion programs. In this context the estimated use of the patient's physiologic tolerance to anemia enables 1) the tolerance of larger blood losses (loss of "diluted blood"), 2) the onset of transfusion to the time after surgical control of bleeding to be delayed and 3) the perioperative collection of autologous red blood cells. The present review article summarizes the mechanisms, influencing factors and limits of this natural tolerance to anemia and deduces the indication for perioperative red blood cell transfusion. Under strictly controlled conditions (anesthesia, normovolemia, complete muscular relaxation, hyperoxemia, mild hypothermia) extremely low hemoglobin concentrations [Hb <3 g/dl (<1.86 mmol/l)] are tolerated without transfusion by individuals with no cardiopulmonary disease. In the clinical routine these situations are limited to borderline situations e.g. unexpected massive blood losses in Jehovah's Witnesses or unexpected shortcomings in blood supply. The current recommendations coincide to the effect that perioperative red blood cell transfusion 1) is unnecessary up to a Hb concentration of 10 g/dl (6.21 mmol/l) even in older patients with cardiopulmonary comorbidity and 2) is only recommended in cases of Hb <6 g/dl (<3.72 mmol/l) in otherwise healthy subjects including pregnant women and children. Critically ill patients with multiple trauma and sepsis do not seem to benefit from transfusions up to Hb concentrations >9 g/dl (>5.59 mmol/l). In cases of massive hemorrhaging and diffuse bleeding disorders the maintenance of a Hb concentration of 10 g/dl (6.21 mmol/l) seems to contribute to stabilization of coagulation.
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Affiliation(s)
- O Habler
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Krankenhaus Nordwest GmbH, Steinbacher Hohl 2-26, 60488 Frankfurt am Main.
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Affiliation(s)
- Bogumila Woloszczuk-Gebicka
- Department of Anaesthesiology and Intensive Therapy, The Children's Memorial Health Institute, Warsaw, Poland.
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Abstract
This review focuses on perioperative blood conservation techniques and the role of transfusion triggers and algorithms, preoperative autologous donation, acute normovolemic hemodilution, intraoperative blood salvage, deliberate hypotension, and preoperative recombinant human erythropoietin in avoiding allogeneic blood transfusion in pediatric patients.
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Affiliation(s)
- B Craig Weldon
- Department of Anesthesiology, Duke University School of Medicine, 3200 Erwin Road, P.O. Box 3094, Suite 3425 DN, Durham, NC 27710, USA.
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Abstract
One of the main risks of craniosynostosis surgery is the possible need for an allogenic blood transfusion (ABT). Most patients are operated on in the first months of life, when physiological conditions are particularly sensitive to even limited blood losses. Furthermore, most surgical techniques proposed in the past were based on extensive craniectomies and cranial remodeling. Because of the known infective and immunologic risks of ABT, in recent years more attention has been dedicated to factors that might help reduce the risk of ABT. We review recent preoperative (ie, erythropoietin administration), intraoperative (ie, acute normovolemic hemodilution, intraoperative blood salvage), and postoperative (ie, clinical monitoring, postoperative blood salvage) anesthesiologic procedures developed with this aim in mind. We also consider operative techniques and technical apparatus that reduce surgical invasiveness, particularly preoperative planning, age selection, and the role of endoscopic assistance and gradual distraction devices.
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Affiliation(s)
- C Di Rocco
- Pediatric Neurosurgical Unit, Institute of Anesthesiology, Catholic University Medical School, Largo "A. Gemelli," 8, 00,168 Rome, Italy
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Paul M, Dueck M, Joachim Herrmann H, Holzki J. A randomized, controlled study of fluid management in infants and toddlers during surgery: hydroxyethyl starch 6% (HES 70/0.5) vs lactated Ringer's solution. Paediatr Anaesth 2003; 13:603-8. [PMID: 12950861 DOI: 10.1046/j.1460-9592.2003.01113.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Volume replacement with hydroxyethyl starch (HES), a synthetic colloid, is widely accepted in adults, but only few data exist regarding its use in children. The aim of this study was to assess the effect of a low molecular weight HES solution (HES 70/0.5) compared with lactated Ringer's solution (LR) on haemoglobin levels as an indirect measure of plasma expansion in infants and toddlers, and its perioperative safety. METHODS Sixty-four patients, aged 1-38 months, were allocated randomly to receive 20 ml x kg-1 body weight of either HES 70/0.5 or LR during the first hour of urological surgery lasting >2 h. Thereafter, only LR was infused to maintain haemodynamic stability. Intraoperative blood loss and administered fluid volumes were analysed. Haemoglobin levels were determined perioperatively and intraoperatively at completion of volume loading. Changes in body weight and the incidence of postoperative oedema were assessed 24 and 48 h after surgery. For the safety analysis, patients were monitored for 72 h. RESULTS Intraoperative haemoglobin levels decreased significantly more with HES 70/0.5 (30 +/- 10 g.l-1) compared with LR (21 +/- 12 g.l-1) (P < 0.01). The overall administered fluid volumes during surgery did not differ between groups. The postoperative changes in body weight and incidence of postoperative oedema did not differ between groups. No anaphylactoid reactions, pruritus or adverse effects were observed during the study period. CONCLUSIONS A larger decrease in haemoglobin levels in infants and toddlers after HES 70/0.5 (20 ml.kg-1) compared with LR indicates a more effective plasma expansion. HES might be considered as a volume expander in the paediatric population.
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Affiliation(s)
- Matthias Paul
- Department of Anaesthesia and Intensive Care, University of Cologne, Cologne, Germany
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Ashwal S, Holshouser BA, del Rio MJ, Tong KA, Applegate RL, Bailey LL. Serial proton magnetic resonance spectroscopy of the brain in children undergoing cardiac surgery. Pediatr Neurol 2003; 29:99-110. [PMID: 14580652 DOI: 10.1016/s0887-8994(03)00045-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We used proton magnetic resonance spectroscopy to study 11 children (age < 8 years) with congenital heart disease undergoing cardiopulmonary bypass to determine whether low (10 +/- 4; n = 6) vs high (20 +/- 4; n = 5) perfusate hematocrits during bypass resulted in changes in brain metabolites which correlate with neurologic injury. Long and short echo time single voxel magnetic resonance spectroscopy in occipital gray matter and neurologic assessment were performed preoperatively and 2 and 5 days postoperatively. We also determined whether prolonged periods at low flow rates during bypass affected spectroscopy variables. We found no significant differences in metabolite ratios between the low vs high hematocrit groups or the lower vs higher flow rate groups (repeated measures analysis of variance of observation ranks converted to normal scores). However, our study was limited by statistical power due to the small sample size, therefore no conclusions could be made. Additional studies involving a greater number of patients are necessary. In all 11 children, magnetic resonance spectroscopy detected a significant decrease in brain N-acetyl-aspartate, and increases in myoinositol and glutamate/glutamine after surgery (Quade test) demonstrating that magnetic resonance spectroscopy is sensitive in detecting subtle postoperative changes in brain metabolites.
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Affiliation(s)
- Stephen Ashwal
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA 92350, USA
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Liet JM, Bellouin AS, Boscher C, Lejus C, Rozé JC. Plasma volume expansion by medium molecular weight hydroxyethyl starch in neonates: a pilot study. Pediatr Crit Care Med 2003; 4:305-7. [PMID: 12831411 DOI: 10.1097/01.pcc.0000074262.84240.1e] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To study the renal effects (measured by creatininemia) of plasma volume expansion with a medium molecular weight hydroxyethyl starch in the newborn. DESIGN A prospective, randomized, double-blinded, pilot study. PATIENTS The study included 26 neonates weighing 690-4030 g (gestational age, 26-40 wks), without cardiac or renal failure or major hemostasis abnormalities and requiring a peripherally inserted central catheter for parenteral nutrition. SETTING Pediatric and neonatal intensive care unit of a university-affiliated hospital. INTERVENTIONS Plasma volume expansion was performed to facilitate insertion of the central catheter. After parental consent, neonates were randomly allocated to receive intravenous infusions at 10 mL.kg(-1) of 5% albumin or 6% hydroxyethyl starch 200/0.5. Sample size was calculated to detect an increase in mean creatininemia of >20 micromol.L(-1) (with alpha = 0.05, beta = 0.80). MEASUREMENTS AND MAIN RESULTS No clinically or statistically significant differences were found between the two groups 6 hrs, 24 hrs, 48 hrs, and 7 days after plasma volume expansion. The study could detect an increase in creatininemia > or =20 micromol.L(-1) with a power of 80%. CONCLUSIONS In 13 healthy neonates, plasma volume expansion with 10 mL.kg(-1) of 6% hydroxyethyl starch 200/0.5 does not increase creatininemia.
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Affiliation(s)
- Jean-Michel Liet
- Pediatric and Neonatal Critical Care Unit, University Hospital of Nantes, Nantes, France
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Meneghini L, Zadra N, Aneloni V, Metrangolo S, Faggin R, Giusti F. Erythropoietin therapy and acute preoperative normovolaemic haemodilution in infants undergoing craniosynostosis surgery. Paediatr Anaesth 2003; 13:392-6. [PMID: 12791111 DOI: 10.1046/j.1460-9592.2003.01091.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND A retrospective study was performed to evaluate whether pretreatment with erythropoietin and iron combined with acute preoperative normovolaemic haemodilution (APNH) could decrease homologous blood transfusion in craniosynostosis (CS) surgery. A treated group was compared with a historical group of infants who underwent surgery with no pretreatment. METHODS The charts of 25 healthy infants who underwent CS surgery were reviewed. Nine of them underwent surgery with no treatment beforehand. Sixteen infants were given erythropoietin at a dosage of 300 U.kg -1 two times per week and iron (elemental iron 10 mg.kg-1.day-1) for 3 weeks before surgery. On the day of surgery APNH was performed after induction of general anaesthesia; a precalculated amount of autologous blood was withdrawn and replaced by hydroxyethyl starch 6%. RESULTS Eleven of the 16 infants of the study group received only autologous blood. Five of 16 received homologous blood transfusion vs seven of nine infants in the control group. CONCLUSIONS APNH combined with erythropoietin was effective in reducing homologous blood requirements during CS surgery. Further studies are necessary on a larger scale to assess the role of this technique in avoiding homologous blood transfusion and to evaluate how infants can benefit from this combined approach.
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Affiliation(s)
- Luisa Meneghini
- Anesthesiology and Intensive Care Institute, Transfusion Medicine and Immune-Hematology and Pediatric Neurosurgery, University of Padua, Italy
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Naughton C, Reilly N, Powroznyk A, Aps C, Hunt T, Hunter D, Parsons RS, Sherry E, Spackman D, Wielogorski A, Feneck RO. Factors determining the duration of tracheal intubation in cardiac surgery: a single-centre sequential patient audit. Eur J Anaesthesiol 2003; 20:225-33. [PMID: 12650494 DOI: 10.1017/s0265021503000383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVE The study was designed to identify those factors associated with early tracheal extubation following cardiac surgery. Previous studies have tended to concentrate on surgery for coronary artery bypass or on other selected cohorts. METHODS Sequential cohort analysis of 296 unselected adult cardiac surgery patients was performed over 3 months. RESULTS In total, 39% of all patients were extubated within 6 h, 89% within 24 h and 95% within 48 h. Delayed extubation (>6 h after surgery) appeared unrelated to age, gender, body mass index, a previous pattern of angina or myocardial infarction, diabetes, preoperative atrial fibrillation, and preoperative cardiovascular assessment, as well as other factors. Delayed tracheal extubation was associated with poor left ventricular, renal and pulmonary function, a high Euroscore, as well as the type, duration and urgency of surgery. Early extubation (<6 h) was not associated with a reduced length of stay in either the intensive care unit or in hospital compared with patients who were extubated between 6 and 24 h. In these groups, it is presumed that organizational and not clinical factors appear to be responsible for a delay in discharge from intensive care. Patients who were extubated after 24 h had a longer duration of hospital stay and a greater incidence of postoperative complications. Postoperative complications were not adversely affected by early tracheal extubation. CONCLUSIONS In an unselected sequential cohort, both patient- and surgery-specific factors may be influential in determining the duration of postoperative ventilation of the lungs following cardiac surgery. In view of the changing nature of the surgical population, regular re-evaluation is useful in reassessing performance.
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Affiliation(s)
- C Naughton
- St Thomas' Hospital NHS Trust, London, UK
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Blunk JA, Seifert F, Schmelz M, Reeh PW, Koppert W. Injection pain of rocuronium and vecuronium is evoked by direct activation of nociceptive nerve endings. Eur J Anaesthesiol 2003; 20:245-53. [PMID: 12650497 DOI: 10.1017/s0265021503000413] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVE Rocuronium and, to a lesser extent, vecuronium can induce burning sensations associated with withdrawal reactions during administration. Dermal microdialysis in human and electrophysiological recordings of nociceptors in mouse skin were used to elucidate the underlying mechanisms of pain induction. METHODS Microdialysis catheters were inserted intradermally into the forearm of 10 volunteers and were perfused with two different concentrations of rocuronium and vecuronium (1 and 10 mg mL(-1)) or a control. Dialysis samples were taken every 15 min and analysed for protein, histamine, tryptase and bradykinin content. Pain intensity was rated on a numerical scale of 0-10. In a parallel design, activation of cutaneous nociceptors was assessed directly in a skin-nerve in vitro preparation of the mouse hind paw. The receptive fields of identified single C-nociceptors (n = 12) were superfused with rocuronium or vecuronium solutions (10 mg mL(-1)) at physiological pH. RESULTS In accordance with clinical observations, microdialysis of rocuronium (10 mg mL(-1)) induced sharp burning pain (NRS 4.1 +/- 1.8), whereas vecuronium given in the usual clinical concentration (1 mg mL(-1)) induced only minor pain sensations (NRS 0.6 +/- 1.3). At equimolar concentrations, pain sensation and concomitant mediator release evoked by both drugs were similar. No correlations were found between pain rating and mediator release. In the in vitro preparation, C-fibres showed a consistent excitatory response with rapid onset after stimulation with vecuronium as well as rocuronium (differences not significant). CONCLUSIONS The algogenic effect of aminosteroidal neuromuscular blocking drugs can be attributed to a direct activation of C-nociceptors.
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Affiliation(s)
- J A Blunk
- Friedrich-Alexander University, Department of Anaesthesiology, Erlangen, Germany
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Weber TP, Grosse Hartlage MA, Van Aken H, Booke M. Anaesthetic strategies to reduce perioperative blood loss in paediatric surgery. Eur J Anaesthesiol 2003; 20:175-81. [PMID: 12650487 DOI: 10.1017/s0265021503000310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In adults, a number of measures to reduce perioperative blood loss have been established. These techniques serve to reduce patients' exposure to homologous blood. Most adults are concerned with this issue especially since many patients became infected with human immunodeficiency virus (HIV) during the 1980s through exposure to blood components. While blood-saving strategies are widely used in adults, they are mostly neglected in infants. However, it is these young patients with their whole life in front of them who, it could be argued, would benefit especially from any potentially avoidable infection (HIV, hepatitis, etc.) or immunological complications. In infants and small children, these blood-sparing techniques may not be as effective as in adults and technical limitations may prevent their application. However, some of these measures can be used and may serve to prevent or reduce exposure to homologous blood. In the following review, blood-saving techniques established in adults are described and their applicability for paediatric patients discussed.
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Affiliation(s)
- T P Weber
- University Hospital, Department of Anaesthesiology and Intensive Care, Münster, Germany
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Leykin Y, Rubulotta F. Prophylactic continuous intravenous ephedrine infusion for elective Caesarean section under spinal anaesthesia. Eur J Anaesthesiol 2003; 20:257-8. [PMID: 12650500 DOI: 10.1017/s0265021503240424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Leather HA, De Wolff MH, Wouters PF. Effects of propofol on the systolic and diastolic performance of the postischaemic, reperfused myocardium in rabbits. Eur J Anaesthesiol 2003; 20:191-8. [PMID: 12650489 DOI: 10.1017/s0265021503000334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE The effect of propofol on myocardial dysfunction during ischaemia and reperfusion is controversial yet important because of its frequent use in cardiac anaesthesia. Although animal studies suggest a free radical-scavenging potential, the cardioprotective properties of propofol have not been demonstrated consistently in vivo. Previous studies focused on systolic function while diastolic function may be a more sensitive marker of ischaemic injury. The main aim was to document the effect of propofol on diastolic function in isolated, blood perfused rabbit hearts subjected to moderate global ischaemia and reperfusion. METHODS Propofol 168 micromol L(-1), or the equivalent of its vehicle, Intralipid, was administered to 34 paced parabiotic Langendorff blood-perfused isolated rabbit hearts before and after 30 min of global normothermic ischaemia. Recovery of systolic function was quantified with the maximum rate of rise of left ventricular pressure. Diastolic performance was assessed using the time constant of the decline in left ventricular pressure (tau) and chamber stiffness (VdP/dV at 12 mmHg). RESULTS Recovery of systolic function during reperfusion was comparable in the two groups. There was no difference in left ventricular pressure between the two groups at any time during the experiments. Chamber stiffness increased significantly during ischaemia and reperfusion in the control group (from 34 +/- 9 to 54 +/- 8 mmHg during ischaemia, and 43 +/- 5 mmHg after 30 min reperfusion; mean +/-95% confidence interval) but not in the propofol-treated group (29 +/- 5, 36 +/- 8 and 30 +/- 8 at baseline, ischaemia and 30 min reperfusion, respectively). CONCLUSIONS Propofol has no protective effect on active relaxation or on systolic function in the present model, but it reduces ischaemic and postischaemic chamber stiffness.
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Affiliation(s)
- H A Leather
- Katholieke Universiteit Leuven, Department of Anaesthesiology, Leuven, Belgium
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Bozkurt P, Süzer O, Ekici E, Demirci O, Kaya G, Hacibekiroğlu M. Effects of bupivacaine used with sevoflurane on the rhythm and contractility in the isolated rat heart. Eur J Anaesthesiol 2003; 20:199-204. [PMID: 12650490 DOI: 10.1017/s0265021503000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE The effects of sevoflurane on bupivacaine cardiotoxicity are mainly attributed to systemic effects. The purpose of this study was to investigate the direct myocardial effects of sevoflurane on bupivacaine toxicity. METHODS Hearts of 30 Wistar albino rats were isolated and mounted on a Langendorff apparatus perfused by modified Tyrode solution. Experimental groups were: a sevoflurane group (Group S, n = 10)--following baseline and 20 min (Stage 1) recordings, sevoflurane was added in doses of 1.4% (1 MAC) and 2.8% (2 MAC). In the two bupivacaine groups, bupivacaine 5 micromol (Group B5, n = 10) and bupivacaine 10 micromol (Group B10, n = 10) was added to the solution at Stage 1, and sevoflurane was added to the system as in Group S. Haemodynamic variables, i.e. heart rate, PR interval, QRS duration, left ventricular systolic pressure, contractility (+dp/dtmax), relaxation, time to reach peak systolic pressure, change in left ventricular diastolic pressure from baseline, and rate-pressure product were recorded. RESULTS In Group S, there was no change in cardiac rhythm. In bupivacaine groups, severe rhythm disturbances occurred and both the PR intervals and QRS complexes were prolonged significantly. All contractility variables deteriorated and the rate-pressure product decreased by 67-90% with the addition of bupivacaine. In all groups, 2 MAC sevoflurane lowered +dp/dtmax further. CONCLUSIONS Sevoflurane does not have any untoward effect on bupivacaine-induced cardiotoxicity in clinically relevant doses in the isolated rat heart.
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Affiliation(s)
- P Bozkurt
- Istanbul University Cerrahpaşa Medical Faculty, Department of Anaesthesiology, Istanbul, Turkey.
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Kobayashi S, Katoh T, Iwamoto T, Bito H, Sato S. Effect of the neuronal nitric oxide synthase inhibitor 7-nitroindazole on the righting reflex ED50 and minimum alveolar concentration during sevoflurane anaesthesia in rats. Eur J Anaesthesiol 2003; 20:212-9. [PMID: 12650492 DOI: 10.1017/s026502150300036x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVE The aim was to determine the effect of acute and chronic administration of 7-nitroindazole, a selective neuronal nitric oxide synthase inhibitor, on the righting reflex ED50 and the minimum alveolar concentration during sevoflurane anaesthesia in rats. METHODS 7-Nitroindazole was acutely (0, 50 and 100 mg kg(-1)) and chronically (0 and 150 mg kg(-1) day(-1), 4 days) administered to rats. After the preparation, the minimum alveolar concentration and the righting reflex ED50 were measured. The concentration of cGMP in the brain, cerebellum and spinal cord was also measured. RESULTS Acute administration reduced the minimum alveolar concentration (50 mg kg(-1), 58.8% (95% CI: 50.3-67.3%) of the baseline value, P < 0.01; 100 mg kg(-1), 55.8 (46.9-64.7), P < 0.01) and the righting reflex ED50 (50 mg kg(-1), 27.2 (17.2-37.2), P < 0.01; 100 mg kg(-1), 14.3 (6.6-22.0), P < 0.01). Chronic administration did not reduce the minimum alveolar concentration; however, it reduced the righting reflex ED50 (65.3 (52.9-77.7), P < 0.01). Overall, the reduction in minimum alveolar concentration in the acute and chronic protocol did not correlate with that of the righting reflex ED50. 7-Nitroindazole (100 mg kg(-1), acute) reduced the cGMP concentration within the cerebellum by 55.4%; however, it did not decrease concentrations in the brain or spinal cord. CONCLUSIONS Different mechanisms are responsible for the observed alterations to the minimum alveolar concentration and the righting reflex ED50 following treatment with 7-nitroindazole. The nitric oxide-cGMP pathway might play a less important role in the determination of minimum alveolar concentration than the righting reflex ED50.
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Affiliation(s)
- S Kobayashi
- Hamamatsu University School of Medicine, Department of Anesthesiology and Intensive Care, Hamamatsu, Japan.
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Hong JY, Lee IH. Suprascapular nerve block or a piroxicam patch for shoulder tip pain after day case laparoscopic surgery. Eur J Anaesthesiol 2003; 20:234-8. [PMID: 12650495 DOI: 10.1017/s0265021503000395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE The reported incidence of shoulder tip pain following laparoscopic surgery varies from 35 to 63%. This study evaluated the analgesic efficacy of either performing a prophylactic suprascapular nerve block with bupivacaine or applying a piroxicam patch to the skin over both shoulders for the relief of shoulder tip pain after laparoscopy. METHODS Sixty healthy informed female patients were randomly assigned to one of three groups: (a) a control group (n = 20), no treatment; (b) a suprascapular nerve block group (n = 20) in which a bilateral suprascapular nerve block was performed before induction of anaesthesia with 5 mL 0.5% bupivacaine with epinephrine; and (c) a piroxicam patch group (n = 20) in which a 48 mg piroxicam patch on the skin of each shoulder was applied before induction of anaesthesia. All patients received a total intravenous anaesthesia technique with propofol, fentanyl and vecuronium. Shoulder tip and wound pain were recorded on a visual analogue pain scale at five time intervals for 24 h after surgery. RESULTS A total of 80% of patients in the control group, 75% in the suprascapular nerve block group and 45% in the piroxicam patch group complained of shoulder tip pain during the recording period (P < 0.05). The scores for shoulder tip pain in the piroxicam patch group were significantly lower compared with the control group at 3, 6 and 12 h, and compared with the suprascapular nerve block group at 6 and 12 h. The need for analgesics was also significantly lower in the piroxicam patch group compared with the other two groups. CONCLUSIONS Prophylactic piroxicam patches are effective and safe for the relief of shoulder tip pain after laparoscopy. Bilateral suprascapular nerve block is not effective in this setting.
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Affiliation(s)
- J Y Hong
- Sungkyunku'an University School of Medicine, Department of Anesthesiology, Samsung Cheil Hospital, Seoul, South Korea.
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Kranke P, Eberhart LH, Morin AM, Cracknell J, Greim CA, Roewer N. Treatment of hiccup during general anaesthesia or sedation: a qualitative systematic review. Eur J Anaesthesiol 2003; 20:239-44. [PMID: 12650496 DOI: 10.1017/s0265021503000401] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Acute hiccup is a minor complication that can occur during sedation or general anaesthesia. The disorder can disturb the surgical field, might interfere with lung ventilation or could hamper diagnostic procedures. The objective was to perform a systematic search for interventions aimed at treating hiccup occurring during anaesthesia or sedation. METHODS A systematic search for reports describing interventions to treat hiccup in conjunction with anaesthesia was carried out (MEDLINE, EMBASE, Cochrane-Library, manual screening of reference lists and review articles, up to December 2001). Search terms were 'hiccup', 'singultus' or 'hiccough'. RESULTS Twenty-six reports involving approximately 581 patients focused on hiccup remedies in the anaesthesia setting. Only one report was substantiated by a randomized controlled trial. This investigated methylphenidate 10 mg intravenously in 51 patients, which did not show a beneficial effect compared with placebo. Hiccup was a self-limiting phenomenon. Case series and case reports focused on various systemically applied drugs in 12 reports, stimulating techniques (e.g. pharyngeal stimulation) in seven, topical applied remedies (e.g. intranasal ice-cold water) in four, and ventilation techniques (e.g. continuous positive pressure ventilation) in two. CONCLUSIONS A large variety of interventions have been proposed for the treatment of hiccup during anaesthesia and sedation. However, perioperative treatment is still based on empirical findings and no treatment is 'evidence-based'. Thus, no valid recommendations for the treatment of hiccup can be derived. Uncontrolled observations are inadequate to establish treatment efficacy.
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Affiliation(s)
- P Kranke
- University of Würzburg, Department of Anaesthesiology, Germany.
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Schywalsky M, Ihmsen H, Tzabazis A, Fechner J, Burak E, Vornov J, Schwilden H. Pharmacokinetics and pharmacodynamics of the new propofol prodrug GPI 15715 in rats. Eur J Anaesthesiol 2003; 20:182-90. [PMID: 12650488 DOI: 10.1017/s0265021503000322] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVE We studied the pharmacokinetics and pharmacodynamics of GPI 15715 (Aquavan injection), a new water-soluble prodrug metabolized to propofol by hydrolysis. METHODS Nine adult male Sprague-Dawley rats (398 +/- 31 g) received a bolus dose of 40 mg GPI 15715. The plasma concentrations of GPI 15715 and propofol were determined from arterial blood samples, and the pharmacokinetics of both compounds were investigated using compartment models whereby the elimination from the central compartment of GPI 15715 was used as drug input for the central compartment of propofol. Pharmacodynamics were assessed using the median frequency of the EEG power spectrum. RESULTS A maximum propofol concentration of 7.1 +/- 1.7 microg mL(-1) was reached 3.7 +/- 0.2 min after bolus administration. Pharmacokinetics were best described by two-compartment models. GPI 15715 showed a short half-life (2.9 +/- 0.2 and 23.9 +/- 9.9 min), an elimination rate constant of 0.18 +/- 0.01 min(-1) and a central volume of distribution of 0.25 +/- 0.02 L kg(-1). For propofol, the half-life was 1.9 +/- 0.1 and 45 +/- 7 min, the elimination rate constant was 0.15 +/- 0.02 min(-1) and the central volume of distribution was 2.3 +/- 0.6 L kg(-1). The maximum effect on the electroencephalogram (EEG)--EEG suppression for >4 s--occurred 6.5 +/- 1.2 min after bolus administration and baseline values of the EEG median frequency were regained 30 min later. The EEG effect could be described by a sigmoid Emax model including an effect compartment (E0 = 16.9 +/- 7.9 Hz, EC50 = 2.6 +/- 0.8 microg mL(-1), ke0 = 0.35 +/- 0.04 min(-1)). CONCLUSIONS Compared with known propofol formulations, propofol from GPI 15715 showed a longer half-life, an increased volume of distribution, a delayed onset, a sustained duration of action and a greater potency with respect to concentration.
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Affiliation(s)
- M Schywalsky
- University of Erlangen-Nuremberg, Department of Anaesthesiology, Erlangen, Germany
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29
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Haeseler G, Leuwer M. High-affinity block of voltage-operated rat IIA neuronal sodium channels by 2,6 di-tert-butylphenol, a propofol analogue. Eur J Anaesthesiol 2003; 20:220-4. [PMID: 12650493 DOI: 10.1017/s0265021503000371] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Propofol is a phenol derivative (2,6 di-isopropylphenol) with a unique effect profile including activating effects on GABA(A) and blocking effects on voltage-operated sodium channels. If the substituents in the 2- and the 6-positions are replaced by tert-butyl groups, the resulting phenol derivative, 2,6 di-tert-butylphenol, despite being a close structural propofol analogue, completely lacks GABA(A) receptor effects. The aim of this in vitro study was to investigate the effects of 2,6 di-tert-butylphenol on voltage-operated neuronal sodium channels in order to determine whether and, if so, how these structural changes alter the sodium channel-blocking effect seen with propofol. METHODS Whole-cell sodium inward currents through heterologously expressed rat type IIA sodium channels were recorded in the absence and presence of definite concentrations of 2,6 di-tert-butylphenol and propofol. RESULTS When applied at concentrations > or = 30 micromol, 2,6 di-tert-butylphenol completely and irreversibly blocked sodium inward currents. The blockade equilibrium time was about 2 min. A partial washout was possible only if the application was stopped before the equilibrium of the blockade was achieved. CONCLUSIONS 2,6 Di-tert-butylphenol exerts a high-affinity block of neuronal sodium channels. Apparently, the slight structural differences of 2,6 di-tert-butylphenol in comparison with propofol--which account for the lack of GABA(A) receptor effects--enhance its voltage-operated sodium channel-blocking effects. As 2,6 di-tert-butylphenol is much more potent than most sodium channel blockers in clinical use, it might be of interest in the development of local anaesthetics.
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Affiliation(s)
- G Haeseler
- Hannover Medical School, Department of Anesthesiology, Hannover, Germany.
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Sakka SG, Meier-Hellmann A. Intrathoracic blood volume in a patient with pulmonary embolism. Eur J Anaesthesiol 2003; 20:256-7. [PMID: 12650499 DOI: 10.1017/s0265021503230428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Carceles MD, Aleixandre F, Fuente T, López-Vidal J, Laorden ML. Effects of rolipram, pimobendan and zaprinast on ischaemia-induced dysrhythmias and on ventricular cyclic nucleotide content in the anaesthetized rat. Eur J Anaesthesiol 2003; 20:205-11. [PMID: 12650491 DOI: 10.1017/s0265021503000358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE This study was designed to compare the haemodynamic, electrophysiological and pharmacodynamic effects of three selective inhibitors of the different isoenzyme forms of phosphodiesterase (PDE) on ischaemia-induced dysrhythmias in the anaesthetized rat. The drugs used were pimobendan, a selective PDE III inhibitor, rolipram, a selective PDE IV inhibitor, and zaprinast, a selective PDE V inhibitor. METHODS The coronary artery was occluded 15 min after commencing drug administration, and myocardial ischaemia was maintained for 30 min during which the heart rate and mean arterial pressure were recorded. cAMP and cGMP were determined by radioimmunoassay. RESULTS Pretreatment with rolipram decreased the duration of ventricular tachycardia without any change in the incidences of dysrhythmias or the mortality rate. This drug did not modify ventricular content of adenosine 3',5'-cyclic monophosphate (cAMP) or guanosine 3',5'-cyclic monophosphate (cGMP). Pimobendan (1 mg kg(-1) + 0.1 mg kg(-1) min) decreased the duration of ventricular tachycardia. This dose of pimobendan and zaprinast (1 mg kg(-1) + 0.1 mg kg(-1) min(-1)) increased the incidence rate of ventricular fibrillation following coronary artery ligation and the mortality rate. Moreover, both drugs increased cGMP in the ventricle. CONCLUSIONS The results demonstrated that pimobendan and zaprinast increased the incidence of dysrhythmias and the mortality rate, which was accompanied by an increase in the ventricular content of cGMP. Rolipram decreased the duration of ventricular tachycardia without a change in the cyclic nucleotide content or in the mortality rate.
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Affiliation(s)
- M D Carceles
- University School of Medicine, Department of Anaesthesiology, CSV Arrixaca Hospital, Murcia, Spain
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Abstract
In general, transfusion guidelines for non-neonatal pediatric patients are similar to those for adults. However, some differences do exist and certain precautions may be necessary particularly in the setting of massive transfusions. We review these differences as they apply to general pediatric surgery outside of the neonatal period, with respect to the transfusion of red blood cells (RBCs), platelets, fresh-frozen plasma (FFP), and cryoprecipitate. We include a discussion of the indications for transfusion and practical considerations such as dosing and administration. Finally, we briefly review the use of directed donations and specialized (irradiated, CMV seronegative) blood components.
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Abstract
Acute normovolemic hemodilution (ANH) entails the removal of blood from a patient either immediately before or shortly after induction of anesthesia and the simultaneous replacement with cell-free fluid, preferably synthetic colloids with a predictable volume effect (6% dextran 60/70, 6% hydroxyethyl starch 200,000 and 130.000, respectively). Hemodilution is part of the concept for avoiding or limiting the use of allogeneic blood and should be considered for patients undergoing elective surgery free of contraindications and presenting with an initial hemoglobin concentration > or = 12 g/dl and an anticipated blood loss of > or = 1500 ml. The efficacy of ANH, judged by the necessity to transfuse homologous blood, depends on the preoperative (initial) hematocrit, the target hematocrit (to which hemodilution is performed), and the preset intra- and postoperative transfusion trigger. In the past data from clinical trials have shown that in healthy subjects a target hematocrit of 20-25% (7.0-8.0 g/dl hemoglobin concentration) is feasible and safe for the patient. The lower the target hemoglobin concentration, the more extensive monitoring is required: intraoperative target hemoglobin concentrations of 5.0 g/dl and less have been tolerated by young surgical patients without adverse effects. The safety as well as efficacy of acute normovolemic hemodilution in terms of reducing homologous blood transfusion requirements have been demonstrated in various clinical studies. ANH therefore is regarded an integral part of programs aimed at reducing the need for homologous blood, and can thus be successfully combined with preoperative autologous blood deposition, intraoperative blood salvage and carefully adjusted surgical techniques.
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Booke M, Reich A. Autotransfusion and blood-sparing techniques in infants and children. Curr Opin Anaesthesiol 2000; 13:303-6. [PMID: 17016319 DOI: 10.1097/00001503-200006000-00012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
While several techniques to reduce perioperative blood loss have been established for surgery in adults, not all of them are applicable in paediatric surgery. Further, far less is known about the efficacy of these techniques in this specific population. Consequently, techniques for the prevention of blood loss are often neglected. However, it is these young patients, with their remaining life expectancy, who will benefit the most from any prevented infection (HIV, hepatitis, etc.) or from any immunological complications. Hemodilution is limited because of the high percentage of fetal hemoglobin in small infants, as well as the additional anaesthetic needed to obtain blood. Until recently, intraoperative autotransfusion was ineffective in small children due to technical limitations; however, advanced technology now renders intraoperative autotransfusion possible, even in infants weighing less than 20 kg.
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Affiliation(s)
- M Booke
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Westfälische Wilhelms-Universität, Münster, Germany.
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Abstract
Autologous blood donation in children has become a standard of care. Children have to live with the life-time complications associated with allogeneic blood including the transmission of known and unknown pathogens, and the impact of alloimmunization on future blood transfusions, organ transplants and pregnancies. Donor reaction, allogeneic exposure and utilization rates in pediatric preoperative autologous donation (PAD) programs are as good if not better than reported in adult literature. Children are very resilient when undergoing extreme isovolemic hemodilution (IHD). PAD, IHD and intraoperative blood recovery appear to be useful components of a pediatric blood conservation program. Prospective, randomized studies addressing the specific needs of children are required to properly define their perioperative role.
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Affiliation(s)
- K T Murto
- Anesthesia Department, Children's Hospital Of Eastern Ontario, Ottawa, Canada.
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Abstract
The heightened awareness of the problems of transfusion reactions, disease transmission, and potential immunosuppression has led surgeons to reevaluate their reasons for transfusion. Current practice policies recommend that elective transfusion of allogeneic blood be avoided whenever possible in patients having surgery. If patients are to have appropriate transfusion, the basic pathophysiology and clinical response of the patient to anemia must be understood. This article reviews the physiologic response to anemia in the patient having surgery and explores the components of the decision to use transfusion.
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Affiliation(s)
- R K Spence
- Department of Surgery, Health Science Center, State University of New York at Brooklyn, USA
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