Unintentional hypothermia is associated with postoperative myocardial ischemia. The Perioperative Ischemia Randomized Anesthesia Trial Study Group

BACKGROUND

Hypothermia occurs commonly during surgery and can be associated with increased metabolic demands during rewarming in the postoperative period. Although cardiac complications remain the leading cause of morbidity after anesthesia and surgery, the relationship between unintentional hypothermia and myocardial ischemia during the perioperative period has not been studied.

METHODS

One hundred patients undergoing lower extremity vascular reconstruction received continuous Holter monitoring throughout the first 24 h postoperatively. Myocardial ischemia was determined by a cardiologist masked to clinical variables. The patient's sublingual temperature on arrival at the intensive care unit immediately after the surgical procedure was used to divide the patients into two groups: hypothermic (temperature, < 35 degrees C; n = 33) and normothermic (temperature, > or = 35 degrees C; n = 67). The relationship between intentional hypothermia and myocardial ischemia occurring during the first postoperative day was evaluated by univariate and multivariate analyses.

RESULTS

A greater percentage of patients had electrocardiographic changes consistent with myocardial ischemia in the hypothermic group (36%, 12 of 33) compared with those in the normothermic group (13%, 9 of 67, P = 0.008). Preoperative risk factors for perioperative cardiac morbidity were similar between the two groups, except for patient age. The mean age was 70 +/- 2 yr and 62 +/- 1 yr in the hypothermic and normothermic groups, respectively (P = 0.001). When subgroup and multivariate analyses were used to adjust for differences in age, temperature remained an independent predictor of ischemia (odds ratio, 1.82 per degree Celsius; 95% confidence interval, 1.09-3.02). The incidence of postoperative angina was greater in the hypothermic group (18%, 6 of 33) than in the normothermic group (1.5%, 1 of 67, P = 0.002). The incidence of PaO2 < 80 mmHg in the arterial blood was greater in the hypothermic group (52%, 17 of 33) than in the normothermic group (30%, 20 of 67, P = 0.03).

CONCLUSIONS

Unintentional hypothermia is associated with myocardial ischemia, angina, and PaO2 < 80 mmHg during the early postoperative period in patients undergoing lower extremity vascular surgery.

Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Perioperative Ischemia Randomized Anesthesia Trial Study Group

BACKGROUND

Perioperative morbidity may be modifiable in high risk patients by the anesthesiologist's choice of either regional or general anesthesia. This clinical trial compared outcomes between epidural (EA) and general (GA) anesthesia/analgesia regimens in a group of patients at high risk for cardiac and other morbidity who were undergoing similarly stressful surgical procedures.

METHODS

One hundred patients scheduled for elective vascular reconstruction of the lower extremities were randomized to receive either EA for surgery followed by epidural analgesia, or GA for surgery followed by intravenous patient-controlled analgesia. Hemodynamic monitoring, blood pressure, and heart rate limits were determined prior to randomization. Management of anesthesia in the immediate postoperative period was standardized. The data collected included continuous electrocardiographic monitoring from the day before surgery through the third postoperative day, serial electrocardiograms, and cardiac enzymes. Cardiac ischemia, myocardial infarction, unstable angina, and cardiac death were identified by a cardiologist blinded to the type of anesthesia received. Other major morbidity was determined at the time of hospital discharge and at 1 and 6 months after surgery.

RESULTS

Eleven patients who received GA required regrafting or an embolectomy during their hospital stay, compared with two patients who received EA. This association of GA with reoperation remained significant after adjustment for baseline differences. Cardiac outcomes were similar in the two groups with respect to perioperative death (1 EA and 1 GA), death within 6 months (4 EA and 3 GA), nonfatal myocardial infarction within 7 days (2 EA and 2 GA), unstable angina (0 EA and 2 GA), and myocardial ischemia following randomization (17 EA and 23 GA). Rates of major infections in the two groups (1 EA and 2 GA), renal failure (3 EA and 3 GA), and pulmonary complications (3 EA and 7 GA) also were similar.

CONCLUSIONS

Carefully conducted epidural and general anesthesia appear to be associated with comparable rates of cardiac and most other morbidity in patients undergoing lower extremity vascular surgery. However, compared with general anesthesia, epidural anesthesia is associated with a lower incidence of reoperation for inadequate tissue perfusion and, therefore, may be advantageous for this surgical population.

Epidural versus general anesthesia, ambient operating room temperature, and patient age as predictors of inadvertent hypothermia

To elucidate the multifactorial nature of perioperative changes in body temperature, the influence of several clinical variables, including anesthetic technique, ambient operating room temperature, and age, were evaluated. Perioperative oral sublingual temperatures were measured in 97 patients undergoing lower extremity vascular surgery randomized to receive either general (GA) or epidural (EA) anesthesia. Surgery and anesthesia were performed in operating rooms (OR) with a relatively warm mean ambient temperature (24.5 +/- 0.4 degrees C) (GA, n = 30; EA, n = 33) or relatively cold mean ambient temperature (21.3 +/- 0.3 degrees C) (GA, n = 21; EA, n = 13). Patients were 35-94 yr old, with a mean age of 64.5 +/- 1.1 yr. A regression analysis was performed to determine the variables that correlated with intraoperative decrease in temperature and postoperative rewarming rate. The major correlates of greater intraoperative decrease in temperature were 1) GA (P = 0.003); 2) cold ambient OR temperature (P = 0.07); and 3) advancing patient age (P = 0.03). There was significant interaction between ambient OR temperature and type of anesthesia (P = 0.03): there was a greater intraoperative decrease in temperature with GA compared to EA in a cold OR but a similar decrease with GA and EA in a warm OR. The data also suggest an interaction between type of anesthesia and patient age (P = 0.06), showing a greater decrease in temperature with GA compared to EA in the younger patients, but a similar decrease between GA and EA in older patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of different anesthetic regimens on fibrinolysis and the development of postoperative arterial thrombosis. Perioperative Ischemia Randomized Anesthesia Trial Study Group

BACKGROUND

The purpose of this clinical trial was to compare the effects of different anesthetic and analgesic regimens on hemostatic function and postoperative arterial thrombotic complications.

METHODS

Ninety-five patients scheduled for elective lower extremity vascular reconstruction were randomized to receive either epidural anesthesia followed by epidural fentanyl (RA) or general anesthesia followed by intravenous morphine (GA). Intraoperative and postoperative care were controlled by protocol using predetermined limits for heart rate, blood pressure, and other monitoring criteria. Data collection included serial physical examinations, electrocardiograms, and cardiac isoenzymes to detect arterial thrombosis (defined as unstable angina, myocardial infarction, or vascular graft occlusion requiring reoperation). Fibrinogen, plasminogen activator inhibitor-1 (PAI-1), and D-dimer levels were measured preoperatively and at 24 and 72 h postoperatively.

RESULTS

Preoperative fibrinogen levels were similar in both groups, remained unchanged after 24 h, and increased equally (45%) in the first 72 h postoperatively. PAI-1 levels in the GA group increased from 13.6 +/- 2.1 activity units (AU)/ml to 20.2 +/- 2.6 AU/ml at 24 h and returned to baseline at 72 h. In contrast, PAI-1 levels in the RA group remained unchanged over time. Twenty-two of 95 patients (23%) had postoperative arterial thrombosis, 17 of whom had received GA and 5 of whom, RA. Preoperative PAI-1 levels were higher in patients who developed postoperative arterial thrombosis (20.5 +/- 3.6 AU/ml vs. 11.2 +/- 1.4 AU/ml). Multiple logistic regression analysis indicated that GA and preoperative PAI-1 levels were predictive of postoperative arterial thrombotic complications.

CONCLUSIONS

Impaired fibrinolysis may be related causally to postoperative arterial thrombosis. Because RA combined with epidural fentanyl analgesia appears to prevent postoperative inhibition of fibrinolysis, this form of perioperative management may decrease the risk of arterial thrombotic complications in patients undergoing lower extremity revascularization.

Determinants of catecholamine and cortisol responses to lower extremity revascularization. The PIRAT Study Group

BACKGROUND

Surgical trauma elicits diffuse changes in hormonal secretion and autonomic nervous system activity. Despite studies demonstrating modulation of the stress response by different anesthetic/analgesic regimens, little is known regarding the determinants of catecholamine and cortisol responses to surgery.

METHODS

Plasma catecholamines and cortisol secretion data were obtained from 60 patients undergoing lower extremity revascularization. Patients were randomized to receive either general anesthesia combined with patient-controlled intravenous morphine (GA) or epidural anesthesia combined with epidural fentanyl analgesia (RA). All aspects of intra- and postoperative clinical care were defined by written protocol. Plasma catecholamines were measured before induction, intraoperatively, and for the first 18 h postoperatively (by HPLC). Urine cortisol was measured intra- and postoperatively using RIA. Data were evaluated using univariate and multivariate analyses to evaluate demographic and perioperative variables as determinants of stress hormone secretion.

RESULTS

Plasma catecholamines increased during skin closure in the GA group, and remained higher relative to the RA group in the postoperative period. Multivariate analysis indicated that age and anesthetic regimen predicted increases in catecholamines during skin closure (P < 0.005), although duration of surgery, blood loss, and body temperature were not correlated. Early postoperative norepinephrine concentrations were correlated with pain score and duration of surgery (P < 0.004), but not with anesthetic management, blood loss, or body temperature. All postoperative norepinephrine levels were highly correlated (r = 0.7) with norepinephrine levels during skin closure. Cortisol excretion was higher postoperatively than intraoperatively. No patient or perioperative variable predicted cortisol excretion, and cortisol excretion was not correlated with catecholamine levels at any time.

CONCLUSIONS

These data indicate that patient factors, such as age and inherent sympathetic responsivity, are important determinants of the catecholamine response to surgery. Modulation of the norepinephrine response by regional anesthesia/analgesia appears to be related, in part, to superior analgesia. The lack of correlation between catecholamine and cortisol secretion indicates that the stress response may consist of discrete systems responding to different stimuli.

Catecholamine and cortisol responses to lower extremity revascularization: correlation with outcome variables. Perioperative Ischemia Randomized Anesthesia Trial Study Group

OBJECTIVE

To determine whether catecholamine and cortisol secretory responses to surgery contribute to postoperative complications.

DESIGN

Prospective, randomized, case series.

SETTING

A university hospital operating suite and surgical intensive care unit.

PATIENTS

Sixty patients undergoing lower extremity vascular surgery.

INTERVENTIONS

Patients were randomized to receive either epidural anesthesia/epidural opiate analgesia (regional anesthesia) or general anesthesia/intravenous patient-controlled analgesia (general anesthesia).

MEASUREMENTS AND MAIN RESULTS

Anesthesia was managed according to a prospectively designed protocol. Hemodynamic parameters and plasma catecholamine concentrations were determined at specific intraoperative and postoperative time points. Intraoperative and postoperative urine samples were collected and analyzed for free cortisol concentrations. Outcomes evaluated were cardiac (nonfatal myocardial infarction and cardiac death) and surgical (graft occlusion). Mean arterial pressure during emergence from anesthesia and in the early postoperative period correlated positively with plasma norepinephrine concentration (p < .01). In addition, plasma catecholamine concentrations were higher in patients with postoperative hypertension. Plasma norepinephrine concentrations at the time of emergence from anesthesia and postoperatively were also higher in patients requiring repeat surgery for graft revision, thrombectomy, or amputation (p < .05). Multivariate analysis indicated that the norepinephrine concentration at the time of emergence, but not type of anesthesia, correlated with reoperation for graft occlusion, suggesting that the previously reported beneficial effect of regional anesthesia may be due to modulation of the stress response. Myocardial infarction or cardiac death occurred in three patients. These patients had markedly increased catecholamine concentrations.

CONCLUSIONS

The catecholamine response to lower extremity vascular surgery contributes to the development of postoperative hypertension and may also be important in the development of thrombotic complications.

Perioperative ischemia and cardiac complications in major vascular surgery: importance of the preoperative twelve-lead electrocardiogram

PURPOSE

To investigate the associations between specific preoperative 12-lead electrocardiogram (ECG) abnormalities, perioperative ischemia, and postoperative myocardial infarction or cardiac death in major vascular surgery.

METHODS

Two prospective studies on perioperative myocardial ischemia performed in two tertiary university hospitals were combined to include 405 patients. All preoperative ECGs were analyzed according to the Sokolow-Lyon criteria for left ventricular hypertrophy by investigators who were blinded to the patients' perioperative clinical course. Perioperative myocardial ischemia was detected by continuous ECG recording, and postoperative cardiac complications included myocardial infarction and cardiac death.

RESULTS

A total of 19 postoperative cardiac complications occurred (two cardiac deaths and 17 myocardial infarctions). Voltage criteria for left ventricular hypertrophy (78 patients, 19%) and ST segment depression greater than 0.5 mm (98 patients, 24.2%) on preoperative ECGs were both significantly associated with postoperative myocardial infarction or cardiac death (odds ratio, 4.2 and 4.7; p = 0.001 and 0.0005, respectively) and with longer intraoperative and postoperative myocardial ischemia. In each of the two study groups, a preoperative ECG abnormality that involved voltage criteria, ST segment depression, or both (134 patients, 33.1%) was more predictive of postoperative cardiac complications than any other preoperative clinical variable, including a history of myocardial infarction or angina pectoris, diabetes mellitus, pathologic Q-wave by ECG, or preoperative myocardial ischemia. The combined duration of intraoperative and postoperative ischemia and the preoperative ECG with either voltage criteria or ST segment depression were the only independent factors associated with adverse cardiac events by multivariate analysis (p < or = 0.0001 and p = 0.02, respectively).

CONCLUSION

Left ventricular hypertrophy and ST segment depression on preoperative 12-lead ECGs are important markers of increased risk for myocardial infarction or cardiac death after major vascular surgery.

The effect of cold exposure of sheep on digestion, rumen turnover time and efficiency of microbial synthesis

1. Six closely shorn sheep were given brome grass (Bromus inermis) pellets at 1 h intervals and maintained at ambient temperatures of --I to Idegree and 18--21degrees for 28 d. Measurements of digestion were made during the last 10 d of temperature exposure. 2. Cold exposure resulted in a reduction in apparent dry matter (DM) digestibility from 0-482 to 0-450, and of apparent digestibility of organic matter (OM) from 0-511 to 0-477. Neither apparent digestibility nor retention of nitrogen was affected. 3. Apparent digestibility of OM in the rumen decreased from 0-300 to 0-242 with cold exposure, and was highly correlated with turnover time in the rumen of 103Ru, which was used as a particulate marker. 4. The efficiency of microbial synthesis (g N incorporated into microbial cells/kg OM apparently digested) was correlated with the dilution rate of the solute marker (51Cr) and with the turnover time of the particulate marker (103Ru) in the rumen. 5. Digestion in the intestine of DM and OM accounted for significantly more of apparent digestion in the whole gastrointestinal tract for sheep kept in the cold than for sheep kept in the warm. The apparent digestibilities of DM and OM entering the intestine were similar in sheep on both treatments, but significantly more non-ammonia-N was digested in the intestines of cold-exposed sheep. 6. The influence of dilution rate of rumen fluid on the efficiency of synthesis of microbial cells in the rumen is discussed.

Nonnutritive sucking by the calf and postprandial secretion of insulin, CCK, and gastrin

Early weaned calves were allowed to suck on a dry rubber teat after drinking milk, and samples of blood from the hepatic portal vein and from the jugular vein were assayed for insulin, CCK, and gastrin to determine if nonnutritive sucking affected digestive hormone secretion. Postprandial changes in concentrations of all hormones showed a biphasic response with an initial rapid increase, later followed by a slower increase. In the portal vein, peak postprandial concentrations of insulin and concentrations of CCK 60 min after the meal were higher when the calves could suck the teat after the meal. There was a positive correlation between the time spent sucking the teat and the increase in insulin and CCK concentrations. Nonnutritive sucking did not significantly increase gastrin concentrations, nor were concentrations of insulin and CCK in the jugular vein affected. The performance of normal appetitive feeding behavior can directly affect digestive hormone secretion even if nutrient intake is not affected. Deprivation of normal sucking behavior cannot be assumed to be inconsequential for the well being of calves.

Effects of cold exposure on feed protein degradation, microbial protein synthesis and transfer of plasma urea to the rumen of sheep

1. Three diets of barley-canola-seed (Brassica campestris), lucerne (Medicago sativa) or chopped brome-grass (Bromus inermis) were given at intervals of 3 h to closely-shorn Suffolk wethers held at a temperature of 1-5 degree (cold) or 22-24 degree (warm). Apparent digestibility of organic matter (OM) and nitrogen was reduced by 0.08-0.05 and 0.04 units respectively for lucerne and brome-grass diets given to cold-exposed sheep, but no treatment effects on digestibility were observed for the barley-CSM diet. Measurements achieved using infusion of the digesta markers 58Co-EDTA and 103Ru-phenanthroline (103Ru-P) showed that cold exposure depressed apparent OM digestion in the stomach and intestines by 33 and 42 g/d for the lucerne diet, and 13 and 35 g/d for the brome-grass diet respectively. 2. The turnover time (h) of the 103Ru-P marker in the rumen of warm sheep was 38.9 for barley-CSM, 18.4 for lucerne, and 15.6 for brome-grass. In cold-exposed sheep, 103Ru-P turnover time (h) tended to be reduced to 32.3, 12.3 and 15.3 for the three diets, respectively. OM fermentation in the stomach was highly related to 103RU-P turnover time for lucerne and brome-grass diets. 3. Cold exposure increased the escape of dietary N from the abomasum by 0.04 and 0.09 of dietary N intake for sheep given lucerne and brome-grass diets respectively. Dietary N degradation was closely related to 103Ru-P turnover time for lucerne, and to the proportion of large particles in rumen digesta for the brome-grass diet. Estimates of feed N degradation made by use of information on the rate of fermentation of the diet in nylon bags and 103Ru-P turnover time were consistently lower than those observed in vivo for barley-CSM and lucerne diets. Intestinal digestibility of non-ammonia N was not significantly changed by cold exposure. 4. Transfer of urea from plasma to the rumen was 1.4-2.5 g N/d for the barley-CSM and lucerne diets, but the value for brome-grass was 4.5-4.9 g N/d. Cold exposure did not affect urea transfer. The production of ammonia from feed and endogenous protein was approximately 0.66 and 0.47 g N/g N intake of barley-CSM and lucerne diets, with no effect of cold exposure. Cold exposure reduced the value from 0.57 to 0.38 for brome-grass. 5. The results are compared with those obtained previously with pelleted hay, and the importance of large particle breakdown in the prediction of OM and N fermentation using nylon bags is discussed.

Right- and left-arm blood pressure discrepancies in vascular surgery patients

To identify a relationship between atherosclerotic vascular disease and differences in blood pressure between the right and left arms, blood pressure differences between arms were measured in patients with peripheral vascular disease (PVD, n = 58), in patients with coronary artery disease (CAD, n = 38), and in patients with no evidence of atherosclerotic disease, who served as a control group (n = 38). The incidence and magnitude of right and left arm pressure difference determined by the oscillometric technique were compared between the patient groups. The incidence of systolic pressure difference greater than or equal to 20 mmHg between arms in patients with PVD (21%) was greater than that in either those with CAD (3%) (P less than or equal to 0.05) or control subjects (0%) (P less than 0.01). The incidence of systolic pressure difference greater than or equal to 45 mmHg between arms in patients with PVD (10%) was greater than that in either those with CAD (0%) (P less than 0.05) or control subjects (0%) (P less than 0.05). Patients with PVD also had a greater incidence of right and left arm difference than did those with CAD or controls for mean and diastolic blood pressures. Of all patients with a systolic difference greater than 10 mmHg, neither the right nor the left arm blood pressure was consistently higher: 21 of 35 (60%) had a higher pressure in the right arm, and 14 of 35 (40%) had a higher pressure in the left arm (P = 0.33). Gender, diabetes, hypertension, smoking, and age were not associated with a difference in blood pressure between the right and left arms.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes during eating in oxygen consumption, cardiac function and body fluids of sheep

1. A study was made of the changes taking place in O(2) consumption, cardiac function and the volume and composition of the body fluids of sheep while they consumed a meal of hay.2. During eating P(a, CO2) and P(v, CO2) both increased, pH decreased and free plasma [HCO(3) (-)] increased. Venous haematocrit increased sharply at the beginning of the meal, and declined slowly after feed was removed.3. Arterial P(O2) did not change significantly during eating. However P(v, O2) fell slightly but significantly. The O(2) saturation of venous blood fell due to the decline in pH. Estimated CO(2) in arterial blood increased as a consequence of increased haemoglobin content. The net effect was to increase arteriovenous difference in O(2) content from 4.4 ml./100 ml. before eating to 6.0 ml./100 ml. at the end of the meal.4. O(2) consumption increased about 60% during eating and fell rapidly thereafter. Heart rate followed a similar pattern. Cardiac output however increased only about 17%, from 6 to 7 l./min. Consequently stroke volume declined throughout the meal from 76 to 52 ml./beat.5. Plasma volume, estimated from measurements of T-1824, declined sharply by about 300 ml. at the beginning of the meal and recovered slowly after feed was removed. Blood volume declined less because of a rise in circulating erythrocytes.6. Extracellular fluid volume was estimated from measurements of thiocyanate and thiosulphate spaces. Thiocyanate space measurements were abandoned after thiocyanate was found to be concentrated in saliva. Considerable random variation occurred in measurements of changes in extracellular fluid from thiosulphate disappearance but the results did reveal a significant fall of 1000-1500 ml. in extracellular fluid volume during eating.7. The significance of these interrelated changes is discussed in relation to the maintenance of homoeostasis during eating in the sheep.

Effect of prolonged thermal exposure on heat production, reticular motility, rumen-fluid and -particulate passage-rate constants, and apparent digestibility in steers

Six steers fitted with permanent rumen cannulae and fed alfalfa-grass hay were kept at either −10, 10 or 28 °C for 21 d to evaluate the effects of prolonged thermal exposure on heat production (HP) and digestive responses. HP was lowest at 28 °C and increased significantly (P < 0.05) as the temperature was reduced to −10 °C. The duration of the biphasic reticular contraction during resting was significantly (P < 0.05) reduced at −10 °C (5.4 s) compared with that at 10 °C (5.7 s) and 28 °C (5.7 s) whereas duration and amplitude of biphasic reticular contractions during rumination were elevated at −10 °C (P < 0.05). Apparent digestibilities of dry matter, organic matter, neutral detergent fibre and crude protein on average were 11% (range 9–16%) higher (P < 0.05) at 28 than at 10 °C. The particulate passage-rate constant was higher at −10 °C (P < 0.05) than at 10 and 28 °C (0.046 vs. 0.038 and 0.034, respectively). The fluid passage-rate constant showed a quadratic response to temperature and was inversely related to digestibility. This study suggests that thermal exposure not only affects rumen particulate and fluid kinetics but also influences the form and pattern of reticular contractions. Further, the temperature-induced changes in duration and amplitude of reticular contractions during rumination were associated with changes in particulate passage-rate constants. Key words: Environmental temperature, reticulum, motility, fluid and particulate passage rates, digestibility, steer

Control of blood pressure and heart rate in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Perioperative Ischemia Randomized Anesthesia Trial (PIRAT) Study Group

STUDY OBJECTIVE

To examine the degree of success at maintaining patients randomized to epidural or general anesthesia for peripheral vascular surgery within predetermined blood pressure (BP) and heart rate (HR) limits. To investigate associations between such hemodynamic control and intraoperative myocardial ischemia and postoperative major cardiac morbidity.

DESIGN

Prospective randomized clinical trial.

SETTING

University-affiliated hospital.

PATIENTS

100 patients undergoing elective lower extremity revascularization for atherosclerotic peripheral vascular disease.

INTERVENTIONS

Patients were randomized to receive either epidural anesthesia or general anesthesia. Blood pressure and HR limits were determined prior to randomization. Hemodynamic monitoring and management of anesthesia was standardized. Myocardial ischemia and major cardiac morbidity were diagnosed by a blinded cardiologist, based on continuous ambulatory ECG monitoring, cardiac enzymes, and 12 lead ECGs. Intraoperative BP and HR date were analyzed by investigators masked to the type of anesthesia given.

MEASUREMENTS AND MAIN RESULTS

A greater percentage of patients randomized to general anesthesia had intraoperative BPs more above their limit (95% vs 72%, p = 0.002) and/or more rapid changes in HR (75% vs 48%, p = 0.008) or BP (100% vs 93%, p = 0.04) than those randomized to epidural anesthesia. Intraoperative ischemia and major cardiac morbidity were similar in the two anesthesia groups. Patients experiencing intraoperative ischemia, regardless of anesthetic type, more frequently had BPs greater than 10% above their upper limit (90% vs 60% p = 0.04) and/or more rapid HR changes (90% vs 58%, p = 0.03) compared with patients without ischemia. These vital sign abnormalities, however, were not necessarily temporally related to the ischemic episodes. Patients experiencing subsequent major cardiac morbidity were not different from other patients with respect to excursions out of BP on HR limits.

CONCLUSIONS

Prevention of elevated intraoperative BP and/on rapid changes in BP or HR may be more successful with epidural than with general anesthesia. Such vital sign abnormalities may occur more frequently in patients who have had intraoperative ischemia or are at risk for having it later in the procedure.

Lack of class I major histocompatibility antigens on trophoblast of periimplantation blastocysts and term placenta in the pig

In this study, the pattern of expression of class I major histocompatibility (MHC) antigens and mRNA on periimplantation blastocysts and term placental tissue was determined for the pig. Class I MHC antigens could not be detected immunohistochemically either on extra-embryonic membranes or on the embryonic portion of Day 14, 16, 22, and 25 blastocysts. Nor could class I MHC antigens be detected on the outer trophoblast epithelium and inner endodermal surface of the chorioallantoic membrane or on the outer and inner surfaces of the amnion at term. However, MHC class I antigens were detected on the vascular mesoderm found in both the chorion and amnion at term, and in Day 25 extra-embryonic membranes. Uterine endometrial cells and tissues and maternal peripheral blood leukocytes stained strongly for class I MHC antigens. There was a large difference in the intensity of class I MHC mRNA signal, detected by Northern blot analysis, in embryo/fetus-derived tissues compared to that in maternal tissues. The embryos appeared to express even less class I MHC mRNA than did the extra-embryonic membranes. In addition, in situ hybridization of Day 16 blastocysts indicated class I MHC mRNA to be ubiquitously expressed at low levels in embryos and extra-embryonic tissues compared to uterine endometrial tissue controls. Taken together, these results indicate that class I MHC antigens are either not expressed on the surface of the extra-embryonic/fetal membranes during gestation in the pig or are expressed at very low levels, and that specific mRNA is expressed at correspondingly low levels.

Capillary gas chromatographic analysis of amino acids in blood and protein hydrolysates as tert.-butyldimethylsilyl derivatives

A method is given for a one-step derivatization and gas chromatography of amino acids in blood and protein hydrolysates. Blood samples are partially purified by solvent extraction. Protein hydrolysates are neutralized with a triethylamine solution. Then tert.-butyldimethylsilyl derivatives of the amino acids are prepared in a one-step procedure and separated on a 30-m fused-silica SE-30 capillary column. Except for tryptophan and cystine, amino acids are eluted within 30 min. Amino acids are derivatized more rapidly than their corresponding trimethylsilyl derivatives and do not degrade on the long fused-silica columns.

A porcine trophoblast cell line that secretes growth factors which stimulate porcine macrophages

We have previously described experiments in both the mouse and the human indicating that cytokines capable of activating macrophages (colony-stimulating factor-1 [CSF-1], granulocyte-macrophage colony-stimulating factor [GM-CSF], and interleukin-3 [IL-3]) are produced by, and/or stimulatory of, trophoblast cells in these species. In contrast to the complex hemochorial placenta of the mouse and humans, the pig has a simple diffuse type of placenta, designated as epitheliochorial. To determine whether similar phenomena might not apply to the porcine pregnancy, we have isolated a cell line, designated Jag-1, from the trophoblastic tips of Day 14 porcine embryos. We report here that this cell line is cytokeratin-positive, vimentin-negative, and therefore of epidermal origin. It also shares various morphological characteristics with porcine trophoblast as demonstrated at both the light and electron microscopic levels. In addition, Jag-1 cells and primary trophoblast tissue from Day 14 blastocyst do not express classical major histocompatibility (MHC) class I and class II antigens, a unique feature of trophoblast in many species. To determine the ability of this cell line to produce cytokines, we have developed an assay for porcine macrophage growth factors that utilizes uptake of tritiated thymidine. This assay responds positively to recombinant bovine GM-CSF and, more importantly, detects a similar activity in supernatants of the porcine trophoblast cell line and of Day 14 blastocysts. Thus porcine trophoblast cells, like their murine and human counterparts, produce and potentially interact with lymphohematopoietic cytokines that are traditionally associated with macrophages.

Perioperative rate-related silent myocardial ischemia and postoperative death

A case is presented that demonstrates heart rate (HR)--related silent myocardial ischemia occurring preoperatively, subsiding intraoperatively, then recurring and leading to a post-operative cardiac death in a patient undergoing peripheral vascular surgery. This case illustrates that patients may have an ischemic threshold for HR whereby recurrent depression of the ST segment may occur during increase of HR to rates as low as 80 to 85 beats per minute (bpm), even in the absence of acute blood pressure (BP) changes. Myocardial ischemia may be HR related; however, the authors are not aware of a case that demonstrates repeated episodes of rate-related ischemia occurring at HRs well below the 100 bpm traditional definition of tachycardia. The authors conclude that patients at risk for perioperative myocardial ischemia should be identified and the hemodynamic management of these patients should include control of HR. This implies control of the physiologic variables that influence HR, along with the use of beta-adrenergic blockers. This case also demonstrates the value of Holter monitoring for ischemia, which, when done preoperatively, can detect patients at risk for unfavorable cardiac outcomes. Ischemia monitoring also may be useful during the intraoperative and postoperative periods, a time when ischemia is often silent and undetected. The early recognition of ischemia would allow for anti-ischemic interventions, which could decrease the morbidity and mortality of patients at risk for perioperative cardiac complications.

Metabolic and endocrine responses to cold and feed restriction in ruminants

Twenty-four wether lambs were assigned to different temperature and feeding levels to assess their metabolic and endocrine profiles and to test the hypothesis that energy conservation responses of sheep to feed restriction occur in warm but not cold environments. Lambs were kept in warm (W; 23 ± 2 °C) or cold (C; 0 ± 2 °C) environments and received either an ad libitum (A) or a restricted (1.35 × maintenance) (R) level of feed intake, thus creating four treatment groups (WA, WR, CA and CR). Average daily gain (ADG), feed intake, metabolic rates, rectal temperature, and plasma levels of insulin, thyroxine (T4), triiodothyronine (T3) and cortisol were recorded during three periods of 5 wk each. The ADG was lower (P < 0.001) in feed-restricted groups. Cold exposure reduced the ADG along with feed efficiency in the first period (P < 0.01). Metabolic rate was lowered by feed restriction (P < 0.01) in periods 1 and 3, but was increased by cold exposure in ad libitum-fed sheep during period 1 (P < 0.05). Both cold exposure and feed restriction lowered rectal temperature (P < 0.001). Plasma insulin concentration was lowered by feed restriction (P < 0.05) and was increased (P < 0.05) by cold exposure during periods 2 and 3. Plasma T3 concentration was reduced (P < 0.05) by feed restriction and was increased by cold exposure during periods 1 and 2. Plasma T4 level remained unaltered (P > 0.05) while plasma cortisol concentration was increased by both cold exposure and feed restriction (P < 0.01). The results indicate that lambs show metabolic and physiological responses to feed restriction, which conserve energy in a cold as well as a warm environment. Key words: Sheep, hormone, cold-exposure, feed-restriction.

Current understanding of the role of the reticulum and reticulo-omasal orifice in the control of digesta passage from the ruminoreticulum of sheep and cattle

Simultaneous abolition of the motility of the ruminoreticulum (RR) and digesta passage from the RR by bilateral vagotomy indicate that the motility of the RR coordinated with quiescence of the reticulo-omasal orifice (ROO) are prerequisite for caudal movement of digesta from the RR and forestomach. Rate of passage is of importance in ruminant animals since it is related to maximal voluntary feed intake, extent of digestion of the diet, amount of protein which bypasses the rumen, efficiency of microbial growth, extent of methane loss, and susceptibility of animals to bloat. In a series of studies, we clarified the roles of frequency, pressure and duration of reticular contractions and the function of the ROO in controlling digesta flow from the rumen in response to changes in diets, environmental conditions and physiological status. Variability in amount of NDF and OM transferred per contraction suggests that frequency of reticular contraction is not the rate-limiting step in digesta passage from the rumen. This concept is supported by our finding that the relaxation of the ROO is not always coincidental with reticular electromyographic activity in solid meal-fed relative to milk fed sheep. The magnitude of reticular pressure may not precisely control digesta passage through the ROO as the amount of OM and NDF associated with each centimetre of pressure during contraction varies from 1.2 to 1.4 and from 0.9 to 2.5 g. On the other hand, the amount of OM and NDF passed per second of reticulum contraction varies only from 0.3 to 0.6 and from 0.2 to 0.3 g, respectively, in cattle. In addition, a 38% decrease in mean retention time of particulate matter in the rumen was associated with a 14% increase in duration of reticular contraction in cattle. Similarly, quiescence of the ROO increased from 2.9 to 3.3 s in sheep when feed intake increased from maintenance to twice maintenance. We suggest that duration of reticular contractions may be more closely related to digesta flow than is either frequency or pressure changes. We also suggest that the ruminant animal can influence reticular contraction characteristics and duration of the quiescence of the ROO in response to various stimuli and that reticular contractions are coordinated with other diet and physiological demands for optimal transfer efficiency of digesta from the RR. Key words: Digesta passage, reticular contractions, reticulo-omasal orifice, electromyographic activity

The effect of a cold environment on protein and energy metabolism in calves

Eleven Holstein bull calves 35 d of age were assigned to one of three treatment groups: (1) W72, warm environment (20 degrees), 72 g feed/kg body weight (BW)0.75 per d, (2) C72, cold environment (-5 degrees), 72 g feed/kg BW0.75 per d, or (3) C90, cold environment (-5 degrees), 90 g feed/kg BW0.75 per d. Fractional synthesis rates (FSR) of protein in the rumen wall, rumen papillae, omasum, duodenum, kidney, liver, heart, longissimus dorsi, biceps femoris and skin were determined following a continuous infusion of [3H]phenylalanine. Phenylalanine flux was elevated in both groups of cold-adapted calves. FSR of protein in the two muscles and skin were reduced along with N retention in the calves in the C72 group compared with the other two groups. Muscle protein degradation, estimated from urinary N tau-methylhistidine excretion, tended to be elevated in both groups of cold-adapted calves. Reduced protein synthesis and increased protein degradation in the C72 group contributed to reduced muscle protein gain. It appears that when feed intake is limited in cold-adapted animals, muscle and skin have a lower priority for nutrients than other organs and tissues, resulting in reduced protein synthesis. It seems unlikely that thermogenesis due to enhanced protein synthesis contributed to the increased heat production in the cold.