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Crystal GJ, Pagel PS, Salem MR. Pleth variability index during preoxygenation did not reliably predict anesthesia-induced hypotension. J Clin Anesth 2024; 93:111370. [PMID: 38157662 DOI: 10.1016/j.jclinane.2023.111370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Affiliation(s)
- George J Crystal
- Department of Anesthesiology, the University of Illinois College of Medicine, Chicago, Illinois (GJC and MRS) and Anesthesia Service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, United States of America.
| | - Paul S Pagel
- Department of Anesthesiology, the University of Illinois College of Medicine, Chicago, Illinois (GJC and MRS) and Anesthesia Service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, United States of America
| | - M Ramez Salem
- Department of Anesthesiology, the University of Illinois College of Medicine, Chicago, Illinois (GJC and MRS) and Anesthesia Service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, United States of America
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Salem MR, Khorasani A, Zeidan A, Crystal GJ. Compelling Evidence for Effectiveness of Cricoid Pressure in Occluding the Esophageal Entrance: Where Do We Go From Here? Anesth Analg 2023; 136:e7. [PMID: 36638520 DOI: 10.1213/ane.0000000000006291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- M Ramez Salem
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois,
| | - Arjang Khorasani
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois,
| | - Ahed Zeidan
- Department of Anesthesiology, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - George J Crystal
- Department of Anesthesiology, University of Illinois, Chicago, Illinois
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Khorasani A, Salem MR, Zeidan A, Crystal GJ. Comment on 'A survey of self-reported use of cricoid pressure amongst Australian and New Zealand anaesthetists: Attitudes and practice'. Anaesth Intensive Care 2022; 50:331-332. [PMID: 35301864 DOI: 10.1177/0310057x211055743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Arjang Khorasani
- Department of Anesthesiology, 21888Advocate Illinois Masonic Medical Center, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - M Ramez Salem
- Department of Anesthesiology, University of Illinois, Chicago, IL, USA
| | - Ahed Zeidan
- Department of Anesthesiology, King Fahad Specialists Hospital, Dammam, Saudi Arabia
| | - George J Crystal
- Department of Anesthesiology, University of Illinois, Chicago, IL, USA
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Zeidan A, Al-Zaher Z, Bamadhaj M, Salem MR, Khorasani A. Better understanding of the effectiveness of cricoid pressure and the rapid sequence induction. Acta Anaesthesiol Scand 2019; 63:837-838. [PMID: 30860296 DOI: 10.1111/aas.13348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 10/04/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Ahed Zeidan
- Department of Anesthesiology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Zaki Al-Zaher
- Department of Anesthesiology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Munir Bamadhaj
- Department of Anesthesiology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - M Ramez Salem
- University of Illinois College of Medicine, Chicago, Illinois
| | - Arjang Khorasani
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center Chicago, Chicago, Illinois
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Khorasani A, Salem MR, Crystal GJ. Utility of Cricoid Pressure. JAMA Surg 2019; 154:563. [DOI: 10.1001/jamasurg.2018.5849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Arjang Khorasani
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago
| | - M. Ramez Salem
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago
| | - George J. Crystal
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago
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Zeidan A, Ramez Salem M, Khorasani A. Surface anatomical landmarks or ultrasound for cricoid pressure application. Anaesthesia 2018; 74:121. [DOI: 10.1111/anae.14522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A. Zeidan
- King Fahad Specialist Hospital; Dammam Saudi Arabia
| | - M. Ramez Salem
- University of Illinois College of Medicine; Chicago IL USA
| | - A. Khorasani
- Advocate Illinois Masonic Medical Center; Chicago IL USA
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Salem MR, Khorasani A, Al-Zaher Z, Bamadhaj M, Zeidan A. Trainability of Application of the Correct Cricoid Force. Anesth Analg 2018. [DOI: 10.1213/00000539-900000000-96515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- Usha Nimmagadda
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, Illinois,
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Zeidan A, Ramez Salem M, Bamadhaj M, Maherzi A. Is cricoid pressure effective in patients with achalasia? J Clin Anesth 2017; 38:117-118. [PMID: 28372648 DOI: 10.1016/j.jclinane.2017.01.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Ahed Zeidan
- Department of Anesthesiology, Procare Riaya Hospital, Al-Khobar, Saudi Arabia.
| | - M Ramez Salem
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States; Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL, United States
| | - Munir Bamadhaj
- Department of Anesthesiology, King Fahad Specialist Hospital, Dammam, Al-Khobar, Saudi Arabia
| | - Atef Maherzi
- Department of Plastic Surgery, Procare Riaya Hospital, Al-Khobar, Saudi Arabia
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Zeidan AM, Salem MR, Bamadhaj M, Mazoit JX, Sadek H, Houjairy H, Abdulkhaleq K, Bamadhaj N. The Cricoid Force Necessary to Occlude the Esophageal Entrance. Anesth Analg 2017; 124:1168-1173. [DOI: 10.1213/ane.0000000000001631] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- A. Zeidan
- Procare Riaya Hospital; Al-Khobar Kingdom of Saudi Arabia
| | - A. Khorasani
- Advocate Illinois Masonic Medical Center; Chicago Illinois USA
| | - M. Ramez Salem
- Advocate Illinois Masonic Medical Center; Chicago Illinois USA
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Nimmagadda U, Salem MR, Voronov D, Knezevic NN. The NuMask® is as Effective as the Face Mask in Achieving Maximal Preoxygentation. Middle East J Anaesthesiol 2016; 23:605-609. [PMID: 29939696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Background: Preoxygenation before anesthetic induction is a widely accepted maneuver to increase oxygen reserves and delay desaturation during apnea. There is limited data regarding the use of the NuMask® in the perioperative setting, and no data as to its efficacy in achieving maximal preoxygenation. We hypothesize that the NuMask® may be a useful alternative to the face mask in achieving maximal preoxygenation. Methods: After IRB approval, the NuMask® was compared with the classic face mask with respect to achieving maximal pre-oxygenation in 30 healthy volunteers using tidal volume breathing. All volunteers were tested for three periods of 5 minutes intervals and the following parameters were recorded every 30 seconds: inspired, and end-tidal oxygen concentration and endtidal carbon dioxide concentration. Results: The mean ETO2 of ≥90% was achieved with both masks at 3.5 minutes (SD = 1.62 and 1.98 for facemask and NuMask® respectively) and thereafter the ETO2 remained above 90%. There were no statistical differences noted in FiO2 and ETO2 between the face mask and the NuMask® in the same time periods. ETCO2 values were also not statistically different between the two masks. Conclusions: The study showed that the NuMask® is as effective as the classic face mask in achieving maximal pre-oxygenation during tidal volume breathing. Introduction
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Czinn EA, Salem MR, Crystal GJ. MYOCARDIAL OXYGENATION DURING ACUTE NORMOVOLEMIC HEMODILUTION: IMPACT OF HYPOCAPNIC ALKALOSIS. Middle East J Anaesthesiol 2015; 23:225-233. [PMID: 26442400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Increases in myocardial blood flow preserve myocardial oxygenation during moderate acute normovolemic hemodilution. Hypocapnic alkalosis (HA) is known to cause coronary vasoconstriction and increase hemoglobin-oxygen affinity. We evaluated whether these effects would compromise myocardial oxygenation during hemodilution. METHODS Eighteen anesthetized dogs were studied. Myocardial blood flow (MBF) was measured with radioactive microspheres. Arterial and coronary sinus samples were analyzed for oxygen content and plasma lactate. Myocardial oxygen supply, oxygen uptake, and lactate uptake were calculated. HA (PaCO2, 23 ± 2 (SD); pHa, 7.56 ± 0.03) was induced by removal of dead space tubing at baseline (n = 8) and during hemodilution (n = 10), with hematocrit at 43 ± 4% and 19 ± 2%, respectively. RESULTS Hemodilution during normocapnia caused decreases in arterial oxygen content (19.9 ± 2.4 to 9.3 ± 1.2 ml/100; P < 0.05) and the coronary arteriovenous 02 difference (13.0 ± 3.0 to 6.4 ± 0.9 ml/100ml; P < 0.05). MBF increased (52 ± 12 to 111 ± 36 ml/min/100g; P < 0.05) to maintain myocardial oxygen supply and oxygen uptake. Myocardial lactate uptake increased (31 ± 19 to 68 ± 35 µeq/min/100g; P < 0.05). At normal hematocrit, HA decreased MBF (57 ± 18 to 45 ± 10 ml/min/100; P < 0.05), implying vasoconstriction, accompanied by decreased myocardial oxygen supply. These myocardial effects of HA were not apparent during hemodilution. HA did not alter myocardial lactate uptake during hemodilution. CONCLUSION When HA was induced during hemodilution, its ability to cause coronary vasoconstriction was lost, and myocardial oxygenation remained well preserved.
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Crystal GJ, Metwally AA, Salem MR. Isoflurane preserves central nervous system blood flow during intraoperative cardiac tamponade in dogs. Can J Anaesth 2014; 51:1011-7. [PMID: 15574553 DOI: 10.1007/bf03018490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The present study tested the hypothesis that the anesthetic technique will influence the changes in regional blood flow (RBF) during intraoperative cardiac tamponade. METHODS Twenty-four dogs were divided into three equal groups: Group I, anesthesia was maintained with ketamine (25 mg.kg(-1).hr(-1)); Group II, with fentanyl and midazolam (F-M; 10 mug.kg(-1).hr(-1) and 0.5 mg.kg(-1).hr(-1), respectively); Group III with 1 minimum alveolar concentration (MAC; 1.4%) isoflurane. Radioactive microspheres were used to measure RBF in myocardium, brain, spinal cord, abdominal viscera, skeletal muscle and skin. Cardiac output (CO) was measured by thermodilution and arterial pressure with a catheter situated in the thoracic aorta. Catheters were introduced into the pericardial cavity to infuse isotonic saline and to measure intrapericardial pressure (IPP). Measurements were obtained under control conditions and during tamponade, as defined by an increase in IPP sufficient to reduce mean arterial pressure by 40%. RESULTS Tamponade caused decreases in CO and RBF that were comparable under the three anesthetics, except that RBF in subcortical regions of the brain and in the spinal cord were maintained under isoflurane but decreased under ketamine or F-M. CONCLUSIONS In dogs, intraoperative cardiac tamponade caused comparable changes in RBF under the different anesthetic techniques except that autoregulation was effective in maintaining RBF within the central nervous system only under isoflurane anesthesia. Our findings provide no compelling reason to recommend one anesthetic over the others for maintenance of anesthesia in situations with increased risk for intraoperative cardiac tamponade. However, they cannot be extrapolated to anesthesia induction in the presence of cardiac tamponade.
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Affiliation(s)
- George J Crystal
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Chicago, Illinois 60657-5193, USA.
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Salem MR, Khorasani A, Saatee S, Crystal GJ, El-Orbany M. Gastric tubes and airway management in patients at risk of aspiration: history, current concepts, and proposal of an algorithm. Anesth Analg 2014; 118:569-79. [PMID: 23757470 DOI: 10.1213/ane.0b013e3182917f11] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Rapid sequence induction and intubation (RSII) and awake tracheal intubation are commonly used anesthetic techniques in patients at risk of pulmonary aspiration of gastric or esophageal contents. Some of these patients may have a gastric tube (GT) placed preoperatively. Currently, there are no guidelines regarding which patient should have a GT placed before anesthetic induction. Furthermore, clinicians are not in agreement as to whether to keep a GT in situ, or to partially or completely withdraw it before anesthetic induction. In this review we provide a historical perspective of the use of GTs during anesthetic induction in patients at risk of pulmonary aspiration. Before the introduction of cricoid pressure (CP) in 1961, various techniques were used including RSII combined with a head-up tilt. Sellick initially recommended the withdrawal of the GT before anesthetic induction. He hypothesized that a GT increases the risk of regurgitation and interferes with the compression of the upper esophagus during CP. He later modified his view and emphasized the safety of CP in the presence of a GT. Despite subsequent studies supporting the effectiveness of CP in occluding the esophagus around a GT, Sellick's early view has been perpetuated by investigators who recommend partial or complete withdrawal of the GT. On the basis of available information, we have formulated an algorithm for airway management in patients at risk of aspiration of gastric or esophageal contents. The approach in an individual patient depends on: the procedure; type and severity of the underlying pathology; state of consciousness; likelihood of difficult airway; whether or not the GT is in place; contraindications to the use of RSII or CP. The algorithm calls for the preanesthetic use of a large-bore GT to remove undigested food particles and awake intubation in patients with achalasia, and emptying the pouch by external pressure and avoidance of a GT in patients with Zenker diverticulum. It also stipulates that in patients with gastric distension without predictable airway difficulties, a clinical and imaging assessment will determine the need for a GT and in severe cases an attempt to insert a GT should be made. In the latter cases, the success of placement will indicate whether to use RSII or awake intubation. The GT should not be withdrawn and should be connected to suction during induction. Airway management and the use of GTs in the surgical correction of certain gastrointestinal anomalies in infants and children are discussed.
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Affiliation(s)
- M Ramez Salem
- From the *Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois; and †Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Zeidan AM, Salem MR, Mazoit JX, Abdullah MA, Ghattas T, Crystal GJ. The Effectiveness of Cricoid Pressure for Occluding the Esophageal Entrance in Anesthetized and Paralyzed Patients. Anesth Analg 2014; 118:580-6. [DOI: 10.1213/ane.0000000000000068] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
The consequences of endotracheal tube (ETT) cuff leak may range from a bubbling noise to a life-threatening ventilatory failure. Although the definitive solution is ETT replacement, this is often neither needed nor safe to perform. Frequently, the leak is not caused by a structural defect in the ETT. Cuff underinflation, cephalad migration of the ETT (partial tracheal extubation), misplaced orogastric or nasogastric tubes, wide discrepancy between ETT and tracheal diameters, or increased peak airway pressure can cause leaks around intact cuffs. Correction of these problems will stop the leak without ETT replacement. Alternatively, ETT cuff, pilot balloon, and inflation system damage due to inadvertent trauma or manufacturing defects may be responsible. Conservative management ideas (management without ETT replacement) were previously published to solve the problem. However, when a large structural defect is identified or conservative measures fail, ETT replacement becomes necessary. This can be performed with direct laryngoscopy if laryngeal visualization is adequate. A difficult exchange with possible airway loss should be anticipated, and prepared for, when there are signs and/or history of difficult intubation. A risk/benefit analysis of each individual situation is warranted before decisions are made on how best to proceed. Alternative back-up ventilation plans should be preformulated and the necessary equipment ready before the exchange. In this review, various management concerns and plans are discussed, and a simple algorithm to manage leaky ETT cuff situations is presented.
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Affiliation(s)
- Mohammad El-Orbany
- Department of Anesthesiology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226, USA.
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Salem MR, Clark-Wronski J, Khorasani A, Crystal GJ. Which is the original and which is the modified rapid sequence induction and intubation? Let history be the judge! Anesth Analg 2013; 116:264-5. [PMID: 23264176 DOI: 10.1213/ane.0b013e31827696fa] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Francis A. Bainbridge demonstrated in 1915 that an infusion of saline or blood into the jugular vein of the anesthetized dog produced tachycardia. His findings after transection of the cardiac autonomic nerve supply and injection of the cholinergic blocking drug atropine demonstrated that the tachycardia was reflex in origin, with the vagus nerves constituting the afferent limb and a withdrawal of vagal tone the primary efferent limb. Subsequent investigators demonstrated that the increase in venous return was detected by stretch receptors in the right and left atria. In the 1980s, it was shown convincingly that the Bainbridge reflex was present in primates, including humans, but that the reflex was much less prominent than in the dog. This difference may be due to a more dominant arterial baroreceptor reflex in humans. A "reverse" Bainbridge reflex has been proposed to explain the decreases in heart rate observed under conditions in which venous return is reduced, such as during spinal and epidural anesthesia, controlled hypotension, and severe hemorrhage. The Bainbridge reflex is invoked throughout the anesthesia literature to describe the effect of changes in venous return on heart rate in patients in the surgical and critical care settings, but a critical analysis of the experimental and clinical evidence is lacking. Our main objectives in this review are to summarize the history of the Bainbridge reflex, to describe its anatomy and physiology, and to discuss the evidence for and against it having an influence on heart rate changes observed clinically. The interaction of the Bainbridge reflex with the arterial baroreceptor and Bezold-Jarisch reflexes is discussed.
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Affiliation(s)
- George J Crystal
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Chicago, IL 60657, USA.
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Salem MR, Crystal GJ. Pulmonary vascular tone and the anesthesiologist. Middle East J Anaesthesiol 2011; 21:147-151. [PMID: 22435266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Mahdi M, Joseph NJ, Hernandez DP, Crystal GJ, Baraka A, Salem MR. Induced hypocapnia is effective in treating pulmonary hypertension following mitral valve replacement. Middle East J Anaesthesiol 2011; 21:259-267. [PMID: 22435278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Mitral valve stenosis is often associated with increased pulmonary vascular resistance resulting in pulmonary hypertension, which may lead to or exacerbate right heart dysfunction. Hypocapnia is a known pulmonary vasodilator. The purpose of this study was to evaluate whether induced hypocapnia is an effective treatment for pulmonary hypertension following elective mitral valve replacement in adults. METHODS In a prospective, crossover controlled trial, 8 adult patients with mitral stenosis were studied in the intensive care unit following elective mitral valve replacement. Hypocapnia was induced by removal of previously added dead space. Normocapnic (baseline), hypocapnic and recovery hemodynamic parameters including cardiac output, pulmonary vascular resistance, pulmonary artery pressure and systemic oxygen delivery and consumption were recorded. RESULTS Moderate hypocapnia (an end-tidal carbon dioxide concentration reduced to 28 +/- 5 mmHg) resulted in decreases in pulmonary vascular resistance and mean pulmonary artery pressure of 33% and 25%, respectively. Hypocapnia had no other hemodynamic or respiratory effects. The changes in pulmonary vascular resistance and mean pulmonary artery pressure were reversible. CONCLUSION Moderate hypocapnia was effective in decreasing pulmonary vascular tone in adults following mitral valve replacement. The application of this maneuver in the immediate postoperative period may provide a bridge until pulmonary vascular tone begins to normalize following surgery.
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Affiliation(s)
- Mirza Mahdi
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA.
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Nimmagadda U, Salem MR, Joseph NJ, Miko I. Efficacy of preoxygenation using tidal volume and deep breathing techniques with and without prior maximal exhalation. Can J Anaesth 2007; 54:448-52. [PMID: 17541073 DOI: 10.1007/bf03022030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PURPOSE We evaluated the influence of prior maximal exhalation on preoxygenation in 15 adult volunteers using tidal volume breathing (TVB) for five minutes and deep breathing (DB) for two minutes with and without prior maximal exhalation. METHODS Inspired and end-tidal oxygen, nitrogen and carbon dioxide were monitored continuously and recorded during room air breathing and at 30-sec intervals during 100% oxygen TVB or DB (rate of 8 breaths.min(-1)). RESULTS Tidal volume breathing with prior maximal exhalation resulted in an end-tidal oxygen concentration (ETO(2)) slightly higher (P = 0.028) at 0.5 and 1.0 min as compared with TVB without prior maximal exhalation at the same time periods. Regardless of whether TVB was preceded by maximal exhalation or not, 2.5 min was required to reach a mean ETO(2) value of 90% or higher. With DB, there were no differences in ETO(2) values at any time period and 1.5 min was required to reach an ETO(2) of 90% or greater, with or without prior maximal exhalation. CONCLUSIONS Maximal exhalation prior to TVB slightly steepens the initial rise in ETO(2) during the first minute, but confers no real benefit if maximal preoxygenation is the goal. Maximal exhalation prior to DB has no added value in enhancing preoxygenation.
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Affiliation(s)
- Usharani Nimmagadda
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 W. Wellington Avenue, Chicago, IL 60657, USA
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Hu G, Schwartz DE, Shajahan AN, Visintine DJ, Salem MR, Crystal GJ, Albrecht RF, Vogel SM, Minshall RD. Isoflurane, but Not Sevoflurane, Increases Transendothelial Albumin Permeability in the Isolated Rat Lung. Anesthesiology 2006; 104:777-85. [PMID: 16571974 DOI: 10.1097/00000542-200604000-00023] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background
Caveolae mediated transendothelial transport of albumin has recently been shown to be the primary mechanism regulating microvascular endothelial albumin permeability. The authors investigated the effects of isoflurane and sevoflurane on pulmonary endothelial albumin permeability and assessed the potential role of the caveolae scaffold protein, caveolin-1, in these effects.
Methods
Isolated rat lungs and cultured rat lung microvessel endothelial cells (RLMVECs) were exposed to 1.0 or 2.0 minimum alveolar concentration (MAC) isoflurane or sevoflurane for 30 min. I-albumin permeability-surface area product and capillary filtration coefficient were determined in the isolated lungs. In RLMVECs, uptake and transendothelial transport of I-albumin were measured in the absence and presence of pretreatment with 2 mm methyl-beta-cyclodextrin, a caveolae-disrupting agent. Uptake of fluorescent-labeled albumin, as well as phosphorylation of Src kinase and caveolin-1, was also determined. In Y14F-caveolin-1 mutant (nonphosphorylatable) expressing RLMVECs, uptake of I-albumin and phosphorylation of caveolin-1 were evaluated.
Results
In the isolated lungs, 2.0 MAC isoflurane increased I-albumin permeability-surface area product by 48% without affecting capillary filtration coefficient. In RLMVECs, isoflurane more than doubled the uptake of I-albumin and caused a 54% increase in the transendothelial transport of I-albumin. These effects were blocked by pretreatment with methyl-beta-cyclodextrin. The isoflurane-induced increase in uptake of I-albumin in wild-type RLMVECs was abolished in the Y14F-caveolin-1 mutant expressing cells. Isoflurane also caused a twofold increase in Src and caveolin-1 phosphorylation. Neither 1.0 MAC isoflurane nor 1.0 or 2.0 MAC sevoflurane affected any index of albumin transport or phosphorylation of caveolin-1.
Conclusion
Isoflurane, but not sevoflurane, increased lung transendothelial albumin permeability through enhancement of caveolae-mediated albumin uptake and transport in the isolated lung. This effect may involve an enhanced phosphorylation of caveolin-1.
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Affiliation(s)
- Guochang Hu
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60612, USA
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Abstract
We evaluated whether platelets can enhance polymorphonuclear neutrophil-induced coronary endothelial dysfunction, and, after observing this, whether isoflurane can prevent the effect. Neutrophils, coronary artery segments, and platelets were obtained from 25 healthy dogs. Coronary artery rings were exposed to neutrophils activated with platelet-activating factor (1.0 microM), and after washing and preconstriction with U46619, were evaluated for concentration-related responses to acetylcholine, an endothelium-dependent vasorelaxing drug. Superoxide production by activated neutrophils was measured spectrophotometrically. Adherence of the activated neutrophils to the endothelium of coronary segments was assessed by direct counting of neutrophils labeled with fluorescent dye. Measurements were performed in absence and presence of isoflurane (1 minimum alveolar concentration) both with and without platelets. The presence of platelets enhanced the neutrophil-induced rightward shift in the concentration-vasorelaxation response curve to acetylcholine (the concentration of acetylcholine required to elicit 50% of maximal relaxation (-log M) was increased from 6.78 +/- 0.7 to 5.26 +/- 0.6), and it increased superoxide oxide production from 45.0 +/- 4.2 to 54.3 +/- 4.2 nM O2-/5 x 10(6) neutrophils and adherence of activated neutrophils from 204 +/- 10 to 268 +/- 5 neutrophils/mm2. Isoflurane abolished these effects of platelets. In conclusion, platelets enhanced the ability of neutrophils to cause coronary endothelial dysfunction. This effect was prevented by isoflurane. This may be attributable to an inhibitory action on superoxide production by the neutrophils leading to reduced expression of endothelial adhesion molecules and, in turn, reduced neutrophil adherence.
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Affiliation(s)
- Guochang Hu
- *Department of Anesthesiology, Advocate Illinois Masonic Medical Center, and Department of Anesthesiology, University of Illinois College of Medicine; †Department of Physiology and Biophysics, University of Illinois College of Medicine, Chicago, Illinois
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El-Orbany MI, Joseph NJ, Salem MR. Tracheal intubating conditions and apnoea time after small-dose succinylcholine are not modified by the choice of induction agent. Br J Anaesth 2005; 95:710-4. [PMID: 16169891 DOI: 10.1093/bja/aei241] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In a randomized, double-blind clinical trial, we studied the effect of different i.v. induction drugs on tracheal intubation conditions and apnoea time after small-dose (0.6 mg kg(-1)) succinylcholine used to facilitate orotracheal intubation at an urban, university-affiliated community medical centre. METHODS One hundred and seventy-five ASA I and II adult patients scheduled to undergo surgical procedures requiring general anaesthesia and tracheal intubation were allocated to one of five groups according to i.v. anaesthetic induction drug used. General anaesthesia was induced by i.v. administration of lidocaine 30 mg and propofol 2.5 mg kg(-1) (Group 1), thiopental 5 mg kg(-1) (Group 2), lidocaine 30 mg and thiopental 5 mg kg(-1) (Group 3), etomidate 0.3 mg kg(-1) (Group 4), or lidocaine 30 mg and etomidate 0.3 mg kg(-1) (Group 5). After loss of consciousness, succinylcholine 0.6 mg kg(-1) was given i.v. followed by direct laryngoscopy and tracheal intubation after 60 s. Measurements included intubation conditions recorded during laryngoscopy 60 s after succinylcholine administration, and apnoea time. RESULTS Overall, clinically acceptable intubation conditions were met in 168 out of the 175 patients studied (96%). They were met in 35/35 patients in Group 1, 33/35 patients in Group 2, 34/35 patients in Group 3, 33/35 patients in Group 4, and 33/35 patients in Group 5. Mean (SD) apnoea time was 4.0 (0.4), 4.2 (0.3), 4.2 (0.6), 4.1 (0.2) and 4.1 (0.2) min respectively in Groups 1-5. There were no differences in the intubation conditions or apnoea times between the groups. CONCLUSIONS The use of succinylcholine 0.6 mg kg(-1) produced the same favourable intubation conditions and a short apnoea time regardless of the induction drug used.
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Affiliation(s)
- M I El-Orbany
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA.
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Hu G, Salem MR, Crystal GJ. Role of Adenosine Receptors in Volatile Anesthetic Preconditioning against Neutrophil-induced Contractile Dysfunction in Isolated Rat Hearts. Anesthesiology 2005; 103:287-95. [PMID: 16052111 DOI: 10.1097/00000542-200508000-00012] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background
The authors tested the hypothesis that adenosine receptors in polymorphonuclear neutrophils and the heart mediate the preconditioning effects of volatile anesthetics against neutrophil-induced contractile dysfunction.
Methods
Studies were conducted in buffer-perfused and paced isolated rat hearts. Left ventricular developed pressure served as index of contractility. Neutrophils and platelet-activating factor were added to perfusate for 10 min followed by 30 min of recovery. The effect of selective pretreatment of the neutrophils and the hearts with 1.0 minimum alveolar concentration isoflurane or sevoflurane on the neutrophil-induced contractile dysfunction was assessed. Studies were performed in the absence and presence of the nonselective adenosine receptor antagonist 8-phenyltheophylline (10 microM). Neutrophil retention was determined from difference between those administered and collected in coronary effluent and from myeloperoxidase concentration in myocardial samples. Superoxide production of neutrophils was measured by spectrophotometry.
Results
Under control conditions (no anesthetic pretreatment), activated neutrophils caused marked and persistent reductions in left ventricular developed pressure, associated with increases in neutrophil retention and myeloperoxidase activity. Pretreatment of the neutrophils or the heart with either isoflurane or sevoflurane abolished these effects. Pretreatment of the neutrophils also reduced the platelet-activating factor-induced increase in superoxide production by 29 and 33%, respectively. 8-Phenyltheophylline blunted the effects of anesthetic pretreatment of the neutrophils, whereas it did not alter the effects of anesthetic pretreatment of the heart.
Conclusion
An activation of adenosine receptors in neutrophils, but not in the heart, plays a role in the preconditioning effects of volatile anesthetics against neutrophil-induced contractile dysfunction.
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Affiliation(s)
- Guochang Hu
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois 60657-5193, USA
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Affiliation(s)
- M El-Orbany
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL
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Abstract
UNLABELLED Succinylcholine 1.0 mg/kg usually produces excellent tracheal intubation conditions in 60 s. Recovery of respiratory muscle function after this dose, however, is not fast enough to forestall oxyhemoglobin desaturation when ventilation cannot be assisted. In this study, we investigated whether smaller doses of succinylcholine can produce satisfactory intubation conditions fast enough to allow rapid sequence induction with a shorter recovery time. Anesthesia was induced with fentanyl/propofol and maintained by propofol infusion and N(2)O in O(2). After the induction, 115 patients were randomly allocated to five groups according to the dose of succinylcholine (0.3 mg/kg, 0.4 mg/kg, 0.5 mg/kg, 0.6 mg/kg, or 1.0 mg/kg). Evoked adductor pollicis responses to continuous 1-Hz supramaximal ulnar nerve stimulation were recorded using acceleromyography. Tracheal intubation conditions were graded 60 s after succinylcholine administration. Onset time, maximal twitch depression, time to initial twitch detection after paralysis, and to 10%, 25%, 50%, and 90% twitch height recovery were recorded. Time to initial diaphragmatic movement as well as time to resumption of regular spontaneous respiratory movements were calculated. Onset times ranged between 82 s and 52 s, decreasing with increasing doses of succinylcholine but not differing between 0.6 and 1 mg/kg. Maximum twitch depression was similar after 0.5, 0.6, and 1 mg/kg (98.2%-100%). Recoveries of twitch height and apnea time were dose-dependent. Intubation conditions were often unacceptable after 0.3- and 0.4-mg/kg doses. Acceptable intubation conditions were achieved in all patients receiving a 0.5, 0.6, and 1 mg/kg dose of succinylcholine. Intubation conditions in patients receiving 0.6 and 1 mg/kg were identical, whereas times to T(1) = 50% and 90% and time to regular spontaneous reservoir bag movements were significantly shorter in the 0.6-mg/kg dose group (5.78, 7.25, and 4.0 min, respectively) versus patients receiving 1 mg/kg (8.55, 10.54, and 6.16 min, respectively). The use of 0.5 to 0.6 mg/kg of succinylcholine can produce acceptable intubation conditions 60 s after administration. The conditions achieved after 0.6 mg/kg are similar to those after 1.0 mg/kg. These smaller doses are associated with faster twitch recovery and shorter apnea time. IMPLICATIONS In normal healthy patients, succinylcholine 0.6 mg/kg produces clinical intubation conditions identical to the traditional 1.0-mg/kg dose but is associated with a shorter recovery time.
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Affiliation(s)
- Mohammad I El-Orbany
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
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Abstract
Background
The authors tested the hypothesis that pretreatment with isoflurane or sevoflurane can protect the heart against neutrophil-induced contractile dysfunction.
Methods
Studies were conducted in buffer-perfused and paced isolated rat hearts. Left ventricular developed pressure served as an index of contractility. Pretreatment consisted of administration of 1.0 minimum alveolar concentration isoflurane or sevoflurane for 15 min followed by a 10-min washout and was performed in the absence and presence of the adenosine triphosphate-sensitive potassium channel inhibitor glibenclamide (10 microM). Polymorphonuclear neutrophils and platelet-activating factor were then added to the perfusate for 10 min, followed by 30 min of recovery. Neutrophil retention was assessed from the difference between those administered and collected in coronary effluent and measurements of myeloperoxidase in myocardial samples. Isolated hearts were also used to assess the effect of volatile anesthetic pretreatment on cardiac dysfunction caused by enzymatically generated superoxide. In additional studies, the authors evaluated the effect of volatile anesthetic pretreatment on the adherence of neutrophils to isolated rat aortic segments.
Results
Platelet-activating factor-stimulated neutrophils caused marked and persistent reductions (> 50%) in left ventricular developed pressure. Pretreatment with either isoflurane or sevoflurane abolished these effects, as well as the associated increases in neutrophil retention. Glibenclamide did not alter these actions of the anesthetics. Pretreatment with either volatile anesthetic attenuated the reductions in left ventricular developed pressure caused by exogenous superoxide and abolished the increases in neutrophil adherence in the aortic segments.
Conclusion
Isoflurane and sevoflurane preconditioned the heart against neutrophil-induced contractile dysfunction. This action was associated with an inhibition to neutrophil adherence and likely involved an increased resistance of the myocardium to oxidant-induced injury; the adenosine triphosphate-sensitive potassium channels played no apparent role.
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Affiliation(s)
- Guochang Hu
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago 60657-5193, USA
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El-Orbany MI, Joseph NJ, Salem MR. The relationship of posttetanic count and train-of-four responses during recovery from intense cisatracurium-induced neuromuscular blockade. Anesth Analg 2003; 97:80-4, table of contents. [PMID: 12818947 DOI: 10.1213/01.ane.0000063825.19503.49] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Posttetanic count (PTC) has been used to quantify intense degrees of nondepolarizing neuromuscular blockade. Our objective in the present investigation was to discern whether PTC correlates with recovery from intense cisatracurium-induced neuromuscular blockade under both inhaled and IV anesthesia. In 60 patients, anesthesia was induced with propofol 2 mg/kg and fentanyl 1.5 micro g/kg IV. Recovery from intense neuromuscular blockade induced by cisatracurium (0.15 mg/kg) was studied in 2 groups. Group 1 (n = 30) had anesthesia maintained with propofol 100-200 micro g x kg(-1) x min(-1) and 60% N(2)O in O(2), whereas Group 2 (n = 30) had anesthesia maintained with isoflurane (end-tidal concentration 0.8%) and 60% N(2)O in O(2). Neuromuscular functions were monitored using acceleromyography. Cycles of posttetanic stimulation were repeated every 6 min with train-of-four (TOF) stimulation in between. Measurement included times to posttetanic responses and to the first response to TOF stimulation (T(1)), as well as the correlation between PTC and T(1). In Group 1, the mean times to PTC(1) and T(1) were 35.6 +/- 7.5 and 46.9 +/- 6.5 min, respectively. Corresponding times in Group 2 were 39.5 +/- 6.8 and 56.7 +/- 5.4 min, respectively. There was a good time correlation, r = 0.919 for propofol (Group 1) and r = 0.779 for isoflurane (Group 2), between PTC and T(1) recovery in both groups. The PTC when T(1) appeared ranged between 8 and 9 in Group 1 and 8 and 14 in Group 2. Conforming to original observations with other neuromuscular blocking drugs, there is a correlation between PTC and TOF recovery from intense cisatracurium-induced neuromuscular blockade allowing better monitoring of this intense degree of blockade during both IV (propofol) and isoflurane anesthesia. IMPLICATIONS Monitoring posttetanic count during intense neuromuscular blockade allows the clinician to estimate the intensity of the blockade and estimate recovery time. The relationship between posttetanic count and train-of-four recovery from intense cisatracurium-induced neuromuscular blockade was documented under both IV and inhaled anesthesia.
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Affiliation(s)
- Mohammad I El-Orbany
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago 60657, USA.
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El-Orbany MI, Klimas-Osolkowski K, Salem MR. Use of the Cook airway exchange catheter to facilitate fiberoptic intubation: are we trying to solve a problem that we created? Anesthesiology 2003; 98:1293; author reply 1293. [PMID: 12717157 DOI: 10.1097/00000542-200305000-00038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Volatile anesthetics can precondition the myocardium against functional depression and infarction following ischemia-reperfusion. Neutrophil activation, adherence, and release of superoxide play major roles in reperfusion injury. The authors tested the hypothesis that pretreatment of neutrophils with a volatile anesthetic, i.e., simulated preconditioning, can blunt their ability to cause cardiac dysfunction. METHODS Studies were performed in 60 buffer-perfused and paced isolated rat hearts. Left ventricular developed pressure served as an index of myocardial contractility. Polymorphonuclear neutrophils and/or drugs were added to coronary perfusate for 10 min, followed by 30 min of recovery. Platelet-activating factor was used to stimulate neutrophils. Pretreatment of neutrophils consisted of incubation with 1.0 minimum alveolar concentration (MAC) isoflurane or sevoflurane for 15 min, followed by washout. Additional studies were performed with 0.25 MAC isoflurane. Effects of superoxide dismutase were compared to those of volatile anesthetics. Superoxide production was measured by spectrophotometry. Neutrophil adherence to coronary vascular endothelium was estimated from the difference between neutrophils administered and recovered in coronary venous effluent. RESULTS Activated neutrophils caused marked, persistent reduction (> 50%) in left ventricular developed pressure. Isoflurane and sevoflurane at 1.0 MAC and superoxide dismutase abolished this effect. Isoflurane and sevoflurane reduced superoxide production of activated neutrophils by 29% and 33%, respectively, and completely prevented the platelet-activating factor-induced increases in neutrophil adherence. Isoflurane at 0.25 MAC blunted, but did not abolish, the neutrophil-induced decreases in left ventricular developed pressure. CONCLUSION Neutrophils pretreated with 1.0 MAC isoflurane or sevoflurane lost their ability to cause cardiac dysfunction, while those pretreated with a concentration of isoflurane as low as 0.25 MAC were partially inhibited. This action of the volatile anesthetics was associated with reductions in superoxide production and neutrophil adherence to the coronary vascular endothelium. Our findings suggest that inhibitory actions on neutrophil activation and neutrophil-endothelium interaction may contribute to the preconditioning effects of volatile anesthetics observed in vivo during myocardial ischemia-reperfusion.
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Affiliation(s)
- Guochang Hu
- Advocate Illinois Masonic Medical Center, and Department of Anesthesiology, University of Illinois College of Medicine, Chicago 60657-5193, USA
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El-Orbany MI, Wafai Y, Joseph NJ, Salem MR. Does the choice of intravenous induction drug affect intubation conditions after a fast-onset neuromuscular blocker? J Clin Anesth 2003; 15:9-14. [PMID: 12657404 DOI: 10.1016/s0952-8180(02)00473-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVES To compare intubation conditions and hemodynamic effects resulting from thiopental-rapacuronium, propofol-rapacuronium, and etomidate-rapacuronium intravenous (IV) induction. DESIGN Randomized, blinded study. SETTING Operating suites of a large university-affiliated medical center. PATIENTS 60 ASA physical status I and II adult patients without airway abnormalities, who were scheduled for elective surgery requiring endotracheal intubation. Patients were randomly allocated to receive IV thiopental sodium 5 mg/kg (Group 1), propofol 2 mg/kg (Group 2), or etomidate 0.3 mg/kg (Group 3) followed by rapacuronium 1.5 mg/kg. Fifty seconds later, an anesthesiologist, who had no knowledge of the induction drug used, entered the operating room and attempted laryngoscopy and intubation. MEASUREMENTS Intubation conditions were graded as excellent, good, poor, or impossible according to Good Clinical Research Practice criteria. Arterial blood pressure and heart rate changes accompanying both induction techniques were also monitored and recorded. MAIN RESULTS All patients were intubated within 55 to 70 seconds. Clinically acceptable intubation conditions were not statistically different among the three groups. Moderate tachycardia after induction was seen in all three groups, and blood pressure was significantly lower in Group 2 than in Groups 1 or 3. CONCLUSIONS Clinically acceptable intubation conditions are similar after either thiopental, propofol, or etomidate when a fast-onset neuromuscular blocking drug (rapacuronium 1.5 mg/kg) is used to facilitate tracheal intubation.
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Affiliation(s)
- Mohammad I El-Orbany
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago 60657, USA
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Abstract
UNLABELLED Compensatory increases in oxygen extraction (EO(2)) during acute normovolemic hemodilution (ANH) have the effect of decreasing tissue oxygen tension values, thus increasing the threat of tissue hypoxia. We hypothesized that if the beta-adrenergic agonist isoproterenol (ISOP) could augment cardiac output (CO) during ANH, it could reverse the increases in EO(2) and restore the margin of safety for tissue oxygenation. Studies were performed in seven anesthetized (isoflurane) dogs. CO was measured by using thermodilution, and regional blood flow (RBF) was measured by using radioactive microspheres. Systemic oxygen delivery (DO(2)), oxygen consumption (OV0312;O(2)), and EO(2), as well as regional DO(2), were calculated. Measurements were obtained under the following conditions in each dog: 1) baseline-1, 2) ISOP (0.1 micro g. kg(-1). min(-1) IV), 3) baseline-2, 4) ANH, and 5) ISOP during ANH. Hematocrit was 45% +/- 3% under baseline conditions and 18% +/- 3% during ANH. Before ANH, ISOP caused parallel increases in CO and systemic DO(2), which, in the presence of an unchanged OV0312;O(2), reduced EO(2). RBF increased in myocardium and spleen, decreased in pancreas, and did not change in brain, spinal cord, or other tissues. ANH caused increases in CO, which were insufficient to offset the decrease in arterial oxygen content, and thus systemic DO(2) declined; systemic OV0312;O(2) was maintained by an increase in EO(2). ANH-related increases in RBF maintained DO(2) in myocardium, brain, duodenum, and pancreas, whereas DO(2) declined in kidney and spleen. ISOP during ANH increased CO and systemic DO(2), which returned systemic EO(2) to baseline, and it increased RBF in myocardium, kidney, duodenum, and spleen. We conclude that 1) beta-adrenergic stimulation with ISOP restored the systemic EO(2) reserve during ANH, without apparent adverse effects in the individual body tissues, and that 2) the use of inotropic drugs, such as ISOP, may extend the limit to which hematocrit can be reduced safely during ANH. IMPLICATIONS By restoring the oxygen extraction reserve, isoproterenol and other inotropic drugs can enhance the margin of safety and extend the limit to which hematocrit can be reduced safely during acute normovolemic hemodilution. The use of this approach will depend on the degree of hemodilution, the extent of mixed venous oxygen desaturation, and whether increases in cardiac output are possible or desirable.
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Affiliation(s)
- George J Crystal
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois 60657, USA.
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