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Multimodality prehabilitation is a complex intervention that can enhance fitness, nutrition, and psychological resilience, with emerging evidence showing an improvement in perioperative and oncological outcomes (1). Personalised prehabilitation also has the potential to meet the widely adopted triple aim of health care: improving individuals’ experience of care, improving population health, and providing value for money to the taxpayer (2). The contemporary prehabilitation model has adopted a multimodal approach, which attempts to address complex needs in patients having complex treatment pathways. Multimodal prehabilitation incorporates intervention components specifically selected for their potential synergistic effects on health outcomes. Prehabilitation enables people with cancer prepare for treatment through promoting healthy behaviours and through needs-based prescribing of exercise, nutrition, and psychological interventions, aiming to empower patients to maximise resilience to treatment and improve long-term health outcomes (3). In this Research Topic entitled ‘Personalised Multimodal Prehabilitation in Cancer’ a collection of articles demonstrate how prehabilitation is now regarded as an integral part of a continuum spanning from cancer diagnosis to rehabilitation.

Among Crotalaria L. species, Crotalaria spectabilis stands out for its good adaptation to various production systems in the Brazilian cerrado, high nutrient cycling, reduction of weeds incidence, and antagonistic action on the nematode population. Thus, the aim of this study was to characterize dry matter production and macronutrient accumulation in plant shoots at different growth and development stages. The experimental design consisted of random blocks, with 12 cutting times and 5 repetitions. At each collection, the plants were divided into leaves, stems + branches, pods, and seeds, for macronutrient level determination. The stem + branches are the primary drain on nutrients during the formation of reproductive structures. Macronutrient concentration in the shoots exhibited the following order: K > N>Ca > P>Mg > S and the order of nutrient export in seeds was N > K>P > Ca > S>Mg. Cutting aimed at nutrient supply to the soil should be conducted before pod formation, and at the end of the cycle ...

Background: This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.Methods: A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to GRADE Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.Results: All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials, meta-analyses of good quality trials or large cohort studies. The level of evidence for the use of each item is presented accordingly.Conclusions: The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

RESUMO Com base em dois níveis de contagem de células somáticas (CCS) do leite utilizado como matéria-prima, determinou-se influência no rendimento e na eficiência de fabricação do queijo colonial, em escala industrial. Os dois níveis de CCS foram formados do leite captado pela indústria, baixa CCS (

This is the fourth updated Enhanced Recovery After Surgery (ERASA wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.All recommendations on ERASThe evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS

The aim of this study was to evaluate the clinical and radiographic outcome of traumatic craniodor - sal hip luxation in a cat, treated with the application of a Mini TightRope (mTR) implant. A caudal approach was carried out in order to expose the hip joint and the sciatic nerve preserving the muscle masses. Clinical follow-up and radiographic recheck were performed at 10 days, one, three, six and 12 months after surgery. Orthopaedic examination was normal 1 month after surgery while the revisit radiographs showed only mild to moderate signs of osteoarthritis (OA) one year later.

Background Clinical studies have shown opioid-sparing effects of β-adrenergic antagonists perioperatively and β-blockers are being investigated for chronic musculoskeletal pain. However, the direct analgesic effects of β-blockers have rarely been examined in healthy humans. Methods In a randomized, counter-balanced, double-blind, within-subject crossover design, we tested the effect of the lipophilic β-blocker propranolol (0.035 mg/kg body weight i.v.) on heat pain sensitivity in 39 healthy males, compared with placebo. To test for peripheral versus central effects, the peripherally acting β-blocker sotalol was also examined. Experimental stimuli were brief superficial noxious heat stimuli applied to the volar forearm. Non-painful cold stimuli were included to test for specificity. Sedation, mood and anxiety were assessed to investigate potential mechanisms underlying any analgesic effect. β-blocker effects on blood pressure were incorporated into the analysis because of a known inverse relationship between pain sensitivity and systolic blood pressure. Results Propranolol significantly decreased perceived intensity of heat pain stimuli but only in participants with small propranolol-induced blood pressure decreases. Even in this group, the effect was small (4%). Propranolol did not influence perceived intensity of non-noxious stimuli and had no effect on sedation, anxiety or mood. Sotalol did not influence heat pain sensitivity. Conclusions Propranolol decreased pain sensitivity but its analgesic effects were small and counteracted by blood pressure decreases. The analgesic effects were not mediated by peripheral β-receptor blockade, sedation, mood or anxiety. The small effect indicates that the utility of β-blockers for clinical pain must be related to factors that do not play a significant role for experimental pain.

This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol.Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group.For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate).Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.

Introduction Vancomycin is the antibiotic of choice in β-lactam allergic adults undergoing surgical antibiotic prophylaxis. Because it is a suboptimal option, in 2015 a pre-operative drug allergy screening program began at the Montreal General Hospital (MGH). It de-labeled 94 % of patients evaluated, reducing vancomycin use to 3 %. To validate the program effectiveness a prospective study comparing the Royal Victoria Hospital (RVH), which lacked de-labeling was undertaken.The aim of the study was to determine the effect of a de-labeling program on vancomycin use. Methods From Jan 1st to Dec 31st 2017 pre-surgical patients suspected of penicillin allergy at both hospitals were studied. Variables captured included; gender, age, time, type, place of surgery, prophylactic antibiotics and number/type of postoperative infections. Results Among 618 RVH patients with suspected β-lactam allergy, 385 received peri-operative antibiotics and 175 got vancomycin (only one had Methicillin Resistant Staphylococcus Aureus (MRSA)). Of the 31 post-operative infectious complications, 20 (65%) occurred in those administered vancomycin. Among the 658 MGH patients with suspected β-lactam allergy 116 had pre-operative allergy assessments of which 98 got antibiotics. Vancomycin was given peri-operatively to 4 patients (none MRSA positive). Cefazolin in 84 and no antibiotics in 18.Only 3 patients (3 %) had post-operative complications but none on vancomycin. Vancomycin prophylaxis was higher at the RVH (175 of 385,45.45%) versus MGH (4 of 98,4.08%), with a difference of 41.37% (95%CI, 34.40%, 48.34 %). Conclusions Lack of β-lactam allergy screening was associated with a significantly higher frequency of vancomycin use and higher rates of post-operative complications.

With the changes in health care dictated by economic pressure, there has been a realization that hospital stay could be shortened without compromising quality of care. Advances in surgical technology and anesthetic drugs have made an impact in the way perioperative care is delivered with some emphasis on multidisciplinary approach. From the expansion of ambulatory care, lessons were learnt how to apply same concepts to major surgery with the understanding that interventions to attenuate the surgical stress would facilitate the return to "baseline". Beside minimal invasive approach to surgery, anesthesia interventions are arranged with the intent to decrease the negative effects of surgical stress and pain, to minimize the side effects of drugs and at the same time to facilitate the recuperation which follows after surgery. Fast-track or accelerated care encompasses many aspects of anesthesia care, not only preoperative preparation and prehabilitation, but intraoperative attenuation of surgical stress and postoperative rehabilitation. The anesthesiologist is part of this team with the specific mission to use medications and techniques which have the least side effects on organ functions, provide analgesia which in turn facilitates the intake of food and mobilization out of bed. This chapter has been conceived with the intention to direct the clinician towards procedure-specific protocols where the choice of medications and techniques is based on published evidence. The success of implementing fast-track depends more on dynamic harmony amongst the various participants (surgeons, anesthesiologists, nurses, nutrtionists, physiotherapists) than on reaching an optimum level of excellence at each separate organization level.

The aim of this research was to improve the oral bioavailability of Oxytetracycline hydrochloride, a broad spectrum antibiotic having poor oral bioavailability, through the formulation of double o/w/o microemulsion systems. The range of compositions forming a clear one-phase region (primary o/w microemulsion) was evaluated through the construction of the ternary diagram and then three different types of double microemulsions were prepared using the "two-step technology". The formulations were characterized for droplet size and zeta potential. DSC was used for determining the type of microemulsion and to verify the formation of double microemulsion systems. The physical characterization gave satisfactory results that were compatible with double microemulsion systems. Finally, the pharmacokinetics of microemulsions was evaluated after oral administration on rats and compared to that of an aqueous and an oily solution. Results indicated an oral bioavailability enhancement of 5.7 and 2 times over the aqueous and oily solutions, respectively.

In this paper, we illustrate the design and testing of new silicon microstructures, fabricated by means of a conventional planar process. These "Venetian-blind" structures consist of arrays of narrow, rectangular suspended masses (width =31 /spl mu/m, length =400 /spl mu/m, thickness =15 /spl mu/m), which can be tilted using electrostatic actuation. Characterization of their static and dynamic behavior was performed with optical methods. The diffraction patterns in monochromatic light were analyzed and vibration measurements were performed by means of semiconductor laser feedback interferometry: experimental data on the tilt angle as a function of the applied voltage and on the resonance frequencies are reported. A maximum tilt angle of approximately 1.9/spl deg/ was obtained with a driving voltage in the range of 70-95 V. All the tested devices showed resonance frequencies higher than 80 kHz, which is fast enough (i.e., switching time in the millisecond range) for future use in optical interconnections. Numerical analyses were performed to evaluate the coupled electromechanical behavior of the microstructures, confirming the observed experimental behavior.

Leiomyosarcoma of the broad ligament is a rare tumor, since only 12 cases have been reported so far in the literature. A 53-year-old patient was diagnosed with leiomyosarcoma of the broad ligament at the Department of Gynecology Oncology of the National Cancer Research Institute in Genoa. The tumor had low mitotic activity and less than ten mitotic figures were found for ten high-power fields. The treatment consisted of total abdominal hysterectomy and bilateral salpingo-oophorectomy with bilateral ureteral neoanastomosis and omentectomy. The patient has not received either radiotherapy or chemotherapy, considering the low grade of malignancy, but she is only followed up on an outpatient basis. No evidence of metastasis has been noted after a follow-up of 13 months. It is concluded that low-grade leiomyosarcoma of the broad ligament should be treated only with surgery.

The nanoemulsified composite (NEC(TM)) delivery system is a patented technology based on the incorporation of a double microemulsion into microporous carrier. This approach was applied on the very water insoluble ubidecarenone drug. The resulting composite powder showed good technological properties such as flowability; also good stability was evidentiated, with size of the nano-droplets released from the systems maintained equal to the starting size also after a long storage. Furthermore very good biopharmaceutical properties were originated, with water solubility concentrations up to 50-fold higher than pure ubidecarenone and oral absorption in rats up to three-fold greater than standard commercial products in terms of plasma levels and AUC. (C) 2004 Elsevier B.V. All rights reserved.

Regional anesthesia is associated with recognized physiological advantages; however trials evaluating its impact on postoperative outcomes have shown contrasting results, probably because these effects have not been utilized in a multimodal perioperative care program. Enhanced recovery has attracted clinical interest because of its standardized, coordinated, multidisciplinary perioperative care plan that incorporates several evidenced-based interventions with positive influence on postoperative patient recovery. A critical analysis of the published evidence is here presented in order to understand the role of regional anesthesia and analgesia as part of the multidisciplinary components of the enhanced recovery program. Clearly, there are synergistic benefits derived from integrating specific regional anesthetic and analgesic techniques with other perioperative elements characteristic of a particular surgical procedure. This challenge requires a team approach in delivering such integrated care, ultimately providing the best cure for patient.

Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy.An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'.The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations.The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.

A photographic version of the Mallampati test was developed and applied to 242 pregnant patients at 12 weeks' gestation and again at 38 weeks' gestation. At 38 weeks the number of grade 4 cases had increased by 34% (P < 0.001). This is in agreement with other evidence which suggests that difficult laryngoscopy is slightly more frequent in obstetrics (1.7%) than in general surgery (1.3%). The increase in Mallampati score correlated with gain in body weight (r = 0.3, P < 0.001), which gives some support to the concept that fluid retention is the underlying cause. We conclude that pharyngeal oedema causes some hindrance to tracheal intubation in obstetrics, but not enough to explain the high failure rate reported. A case is made for rationalizing the management of difficult intubation. Our data also show that more research is needed on factors which affect Mallampati's test, particularly neck extension.

Clinical studies have shown opioid-sparing effects of β-adrenergic antagonists perioperatively and β-blockers are being investigated for chronic musculoskeletal pain. However, the direct analgesic effects of β-blockers have rarely been examined in healthy humans.In a randomized, counter-balanced, double-blind, within-subject crossover design, we tested the effect of the lipophilic β-blocker propranolol (0.035 mg/kg body weight i.v.) on heat pain sensitivity in 39 healthy males, compared with placebo. To test for peripheral versus central effects, the peripherally acting β-blocker sotalol was also examined. Experimental stimuli were brief superficial noxious heat stimuli applied to the volar forearm. Non-painful cold stimuli were included to test for specificity. Sedation, mood and anxiety were assessed to investigate potential mechanisms underlying any analgesic effect. β-blocker effects on blood pressure were incorporated into the analysis because of a known inverse relationship between pain sensitivity and systolic blood pressure.Propranolol significantly decreased perceived intensity of heat pain stimuli but only in participants with small propranolol-induced blood pressure decreases. Even in this group, the effect was small (4%). Propranolol did not influence perceived intensity of non-noxious stimuli and had no effect on sedation, anxiety or mood. Sotalol did not influence heat pain sensitivity.Propranolol decreased pain sensitivity but its analgesic effects were small and counteracted by blood pressure decreases. The analgesic effects were not mediated by peripheral β-receptor blockade, sedation, mood or anxiety. The small effect indicates that the utility of β-blockers for clinical pain must be related to factors that do not play a significant role for experimental pain.

A recent study showed that the removal of a bladder catheter is safe in presence of thoracic epidural analgesia (TEA). However, the ability to void satisfactorily can be affected. The aim of this investigation is to determine whether patients with TEA are able to recover the micturition process.On the morning after the surgery patients were randomised into two groups: the early removal group (ERG) (n = 101), with the bladder catheter removed at the same time, and the standard group (SG) (n = 104), where the bladder catheter was kept as long as TEA was functioning (on average 3-5 days after surgery). Following the first micturition, patients underwent regular ultrasound scanning of the bladder until a post-void residual (PVR) less than 200 ml was reached.All of the patients in the ERG and in the SG started to void and recovered satisfactorily their ability to void, reaching a PVR200 ml without requiring a transurethral catheterisation. However, the length of time to reach a PVR200 ml in the ERG was significantly longer compared with the SG (345 min ± 169 vs. 207 min ± 122, P0.0001).In the presence of TEA, the removal of the bladder catheter on the morning after surgery leads to a transient impairment of the lower urinary tract function with no need for re-catheterisation.

Postoperative urinary retention (POUR) following lower limb arthroplasty is a common complication. The aim of this observational study was to establish the incidence of POUR and assess the usefulness of an ultrasonographic nurse-driven protocol, thereby avoiding elective bladder catheterization.Two-hundred and eighty six consecutive patients undergoing elective hip and knee arthroplasty were retrospectively studied. None of the patients received elective bladder catheterization. Data on risk factors for POUR, urinary tract infections, length of hospital stay and analgesia were collected. Student's t, Wilcoxon rank-sum, ANOVA and Kruskall-Wallis tests were performed for comparison among two or more groups. Categorical variables were studied using Pearson's χ2 test. Results were considered significant when the P value0.05.Of the 286 patients studied, 49 (17%) required indwelling catheter for 24-48 h. Patients who had POUR had more risk factors (P0.05) and had longer hospital stays (P0.05). When comparing analgesia, continuous peripheral nerve block (CPNB) had the least impact on POUR (15.8%), while epidural analgesia had the greatest impact (48.1%).Bladder scanners timely detect POUR following lower joint arthroplasty, making elective bladder catheterization unnecessary.

Fast-track methodology has been developed with the aim of improving postoperative recovery and reducing perioperative morbidity and mortality. A multidisciplinary approach involving surgeons, anesthesiologists, nurses and physiotherapists is necessary. While the surgical community has revised many of the standard principles used in clinical practice, anesthesiologists still need to contribute more to further optimize and facilitate recovery after surgery.

We have examined the efficacy, duration of action and side effects of extradural diamorphine alone and in combination with 1:200,000 adrenaline in a randomized, double-blind controlled study of 45 patients who underwent Caesarean section under spinal anaesthesia. Saline 10 ml, diamorphine 2.5 mg in saline 10 ml or diamorphine 2.5 mg in 1:200,000 adrenaline 10 ml were administered via the extradural route at delivery of the baby. Both diamorphine and diamorphine with adrenaline provided significantly prolonged analgesia compared with control (mean time to next analgesia (95% confidence interval) 17.3 h (12.0, 22.1 h), 15.9 h (10.6, 21.1 h), 5.7 h (1.5, 9.9 h), respectively) (P0.01). The addition of adrenaline increased the quality of analgesia 8 h after operation, but had no effect on the total amount of i.m. morphine administered during the first 24 h. The incidence of side effects was similar in all groups.

Twelve healthy, unpremedicated women scheduled for total abdominal hysterectomy were given either isoflurane (n = 6) or halothane (n = 6) anaesthesia. They all received general anaesthesia for a period of 3 h, with surgery being carried out only in the last hour. The anaesthesia consisted of thiopentone, pancuronium and a mixture of oxygen-enriched air (FiO2 = 34%) supplemented with 1 MAC of either isoflurane or halothane. The patients were maintained normothermic, and with an arterial SaO2 above 95% throughout the period of the study. The following measurements were made before, during and after anaesthesia (with and without surgery): oxygen consumption (VO2), carbon dioxide production (VCO2); circulating concentrations of various hormones (insulin, growth hormone and cortisol); various metabolites; selected amino acids and albumin; forearm arterio-venous concentration difference of glucose, lactate, free fatty-acids and selected amino acids (four patients in each group). Whole body VO2 decreased significantly by over 20% during anaesthesia (with or without surgery), P < 0.05). Although the circulating concentration of most amino acids showed little or no change during anaesthesia alone, there was a tendency for the flux of most metabolites to decrease, and this persisted during surgery (P < 0.05). During anaesthesia alone there was a twofold reduction in the plasma cortisol concentration (P < 0.05), and a decrease in albumin concentration (P < 0.01). With the onset of surgery, plasma cortisol concentration increased rapidly (in association with several other hormones and metabolites) but hypoalbuminemia persisted.

Postoperative urinary retention (POUR) occurs after lower joint arthroplasty with an incidence between 0% and 75%. This vast range reflects the differences in diagnosis and management of POUR. At present, clinical practice includes either preoperative insertion of an indwelling catheter to be removed after 24-48 postoperative hours or postoperative intermittent in-and-out catheterization performed either at scheduled times (every 6-8 hours) or as necessary. Although the most effective approach remains an issue of debate, there is a growing consensus that postoperative intermittent catheterization guided by ultrasound could decrease the incidence of complications related to POUR. The purpose of the present article is to review the published data on the effects of analgesia techniques on the development of POUR after hip and knee arthroplasty. General and regional anesthesia are implicated in the etiology of POUR; however, type and duration do not correlate with its incidence. Of the different postoperative analgesic techniques currently used, continuous peripheral nerve block has the least impact on POUR.

Body temperature, respiratory gas exchange, and plasma catecholamines were determined before and after surgery in three groups [control (C), warmed (W), and epidural (E) who received local anesthetic at T4-S5 dermatomes during and for 24 h after surgery] of patients undergoing colonic surgery under general anesthesia. At the end of surgery, group W were nursed in an ambient temperature of 28-30 degrees C, whereas the others were at 20-23 degrees C for a period of 24 h. Core (Tc) and dorsal hand temperature decreased during surgery in both C and E (P less than 0.05) but not in W. After surgery, Tc increased similarly in C and E and by a smaller amount in W. Plasma catecholamine concentrations increased significantly in C and W but not in E (P less than 0.001), with the greatest response occurring in C. Postoperative oxygen consumption and carbon dioxide production exceeded preoperative values (P less than 0.01) in C but not in W or E. After surgery, plasma albumin fell and C-reactive protein increased similarly in all three groups. Thus body heat conservation or epidural blockade attenuates or abolishes the rise in plasma catecholamines and oxygen consumption postoperatively but does not prevent the increase in Tc or the acute phase protein response.

In a randomised double-blind study, the efficacy, duration of action and side effects of five diamorphine analgesia regimens following Caesarean section are described. The time to next analgesia was shorter in the 5 mg intramuscular group (3.53 hours) than in any of the four epidural groups: 5 mg (5.7 hours, p = 0.007), 2.5 mg (4.76 hours, p = 0.103), 5 mg with adrenaline 1/200,000 (7.2 hours, p = 0.001) and 2.5 mg with adrenaline 1/200,000 (6.05 hours, p = 0.007). Multiple regression analysis showed that the addition of adrenaline significantly increased the duration of action of epidural diamorphine (p less than 0.05). The 5 mg dose with adrenaline showed no advantage when compared with 2.5 mg with adrenaline (p = 0.16). No serious side effects were reported in any group.

The metabolic effects of enflurane anaesthesia (1MAC) in air/oxygen were investigated in six healthy unpremedicated women scheduled for total abdominal hysterectomy (TAH). The changes in acid-base status, CO2 production, and circulating concentration of total protein, albumin and a variety of metabolites (glucose, lactate, glycerol and alanine) were measured before and during a 2-h period of anaesthesia alone, during 1 h of anaesthesia plus surgery, and in the recovery period. The subjects were maintained normothermic (36.5 +/- 0.3 degrees C), and with an arterial SaO2 above 95% throughout the period of study. The circulating concentration of all metabolites changed little as a result of anaesthesia alone, but the glucose and lactate levels rose rapidly after the onset of surgery (P less than 0.05). Plasma albumin and total protein concentration decreased during the study, reaching values that were significantly lower than the pre-anaesthetic values (P less than 0.05). CO2 production decreased by 9% during anaesthesia and surgery, but returned towards preoperative values during recovery. This study provides no evidence of any significant effect of enflurane anaesthesia alone on human intermediary metabolism. Most of the changes in circulating metabolite concentrations observed during and after anaesthesia and surgery are likely to be due to the surgical stress.

We have studied the effect of intraoperative body heat conservation and 24-h thermoneutrality on postoperative whole body protein turnover using stable isotope methodology in a group of elderly patients undergoing colorectal surgery for rectosigmoid adenocarcinoma. Two groups of eight patients were studied. One group (control, or cold) received routine intraoperative and postoperative care. All patients in the second group (warmed) were maintained at normothermia during anaesthesia and surgery; these patients were nursed after surgery in a warm room (ambient temperature 28-30 degrees C) for a period of 24 h. General anaesthesia, surgical care and nutritional support were similar in both groups. A constant nutritional intake, based on nitrogen 0.1 g kg-1 day-1 and energy 20 kcal kg-1 day-1, was provided orally for 7 days before surgery and i.v. after operation for 4 consecutive days. Whole body protein breakdown and synthesis, as assessed by stable isotope methodology, increased significantly 2 and 4 days after surgery in both groups (P less than 0.01), but the increase in protein breakdown in the warmed group on day 2 was significantly less than that in the cold group (P less than 0.05). The increase in leucine oxidation in the warmed group on the 2nd day after surgery was not significant, and was less than the increase observed in the cold group (P less than 0.05). However, by the 4th day, leucine oxidation was enhanced significantly in both groups (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Studies of regional anesthesia are increasing in popularity not only for the purpose of technical advancement, but also to better understand the effects of neural deafferentation on the function of various organs. Thoracic epidural anesthesia (TEA) is one of the most versatile and widely utilized neural deafferentation techniques. The aim of this article is to critically review published data regarding the most relevant effects of TEA on the cardiovascular, respiratory and gastrointestinal systems. In the cardiovascular system, TEA modifies the electrical activity of the heart in addition to ventricular function and wall motion. Improvements in regional blood flow and a reduction of the major determinants of cardiac oxygen consumption lead to less severity of the ischemic injury. Although TEA negatively affects the performance of intercostal muscles, it spares diaphragmatic function and, when it is limited to the first five thoracic segments, affects pulmonary volumes to a lesser extent. TEA can be safely used in patients with compromised respiration. Splanchnic sympathetic block is achieved when thoracic fibers from T5 to T12 are affected in a dose-dependent manner. Improved gastrointestinal blood flow and motility are clear in animals, and in clinical studies, TEA has been shown to improve recovery after major abdominal surgery. TEA thus presents a powerful tool available to anesthesiologists for perioperative intervention, but its use alone cannot prevent postoperative morbidity and mortality. It is therefore necessary to address its use in the context of multimodal intervention.

To determine if general anaesthesia alone or in conjunction with surgery alters body protein turnover, we studied six healthy, unpremedicated females undergoing elective total abdominal hysterectomy. Changes in protein metabolism, synthesis and breakdown were estimated by an isotope dilution technique using a continuous infusion of the stable isotope tracer, L-[1-13C]leucine, before anaesthesia (4 h), during anaesthesia alone (1 h), during anaesthesia and surgery (1 h) and in the recovery period (2 h). General anaesthesia comprised thiopentone, pancuronium, enflurane (1 MAC) and oxygen-enriched air. An isotopic steady state in plasma 13C-alpha-ketoisocaproate (13C alpha-KIC) and expired 13C-carbon dioxide were obtained during the four periods. Collections of plasma and expired air were made during the steady state periods and plasma alpha-KIC enrichment measured to indicate precursor pool labelling from which leucine flux (equal to protein breakdown in the post-absorptive state) and oxidation were calculated, and whole body protein synthesis was derived. Whole body protein breakdown did not change with anaesthesia, but decreased with both surgery and during the acute recovery period (P less than 0.05). Protein synthesis did not change with anaesthesia and surgery, but decreased significantly after surgery (P less than 0.05).