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Background and Objective: Parenteral nutrition including lipids might be associated with liver disease. The cause leading to parenteral nutrition-related liver dysfunction remains largely unknown but is likely to be multifactorial. The study was performed to assess the effects of a lipid emulsion based on soybean oil, medium-chain triglycerides, olive and fish oil (SMOFlipid20%) compared with a lipid emulsion based on olive and soybean oil on hepatic integrity.Methods: In a prospective, randomized, double-blinded trial, 44 postoperative patients with an indication for parenteral nutrition were allocated to one of two regimens: group A (n = 22) received SMOFlipid, group B (n = 22) a lipid emulsion based on olive and soybean oil for 5 days. Aspartate aminotransferase, alanin-aminotransferase, and serum alpha-glutathion S-transferase were measured before the start of parenteral nutrition (d0), at day 2 (d2), and day 5 (d5) after the start of parenteral nutrition. The significance level was defined at a P value of less than 0.05.Results: There was no significant difference at d0, but at d2 and d5, significantly lower aspartate aminotransferase (d2: group A: 27 +/- 13 vs. group B: 47 +/- 36 U l(-1); d5: A: 31 +/- 14 vs. B: 56 +/- 45 U l(-1)), alanin-aminotransferase (d2: A: 20 +/- 12 vs. B: 42 +/- 39 U l(-1); d5: A: 26 +/- 15 vs. B: 49 +/- 44 U l(-1)), and alpha-glutathion S-transferase levels (d2: A: 5 +/- 6 vs. B: 17 +/- 21 U l(-1); d5: A: 6 +/- 7 vs. B: 24 +/- 27 microg l(-1)) were found in soybean oil, medium-chain triglycerides, olive and fish oil group compared with the control group.Conclusion: Hepatic integrity was well retained with the administration of SMOFlipid whereas in patients receiving a lipid emulsion based on olive and soybean oil liver enzymes were elevated indicating a lower liver tolerability. [ABSTRACT FROM AUTHOR]

Background: S(+)-ketamine is an analgesic and sedative drug with dissociative attributes. When it is used without sedatives, nightmares have been described. The aim of this study was to assess the effects of postoperative analgosedation with propofol and S(+)-ketamine when compared to standard propofol analgosedation in terms of recovery, dreaming, hemodynamics, and patient satisfaction., Methods: Forty-eight patients were sedated with propofol (1-3 mg/kg/h) after coronary artery bypass grafting and allocated randomly on admission to the intensive care unit to receive either S(+)ketamine (2 mg mg/kg/h; group A) or 0.9% saline as a placebo (group B) in a double-blind fashion. If necessary, boli of 3.75 mg piritramide (an opioid) were given in both groups., Results: Patients receiving S(+)-ketamine had significantly higher satisfaction for pain management (Visual Analog Scale [VAS] = group A: median 10 [range 9-10]; group B: median 9 [range 6-10]) despite their lower piritramide consumption. Patients receiving S(+)ketamine showed significantly faster eye opening (82+/-51 vs 156+/-110 min) but dreamed significantly more often (at 2 h, 67% in group A vs 29% in group B; at 24 h, 43% in group A vs 10% in group B), whereas no significant differences were detected in the incidence of nightmares at 2 h, 14% in group A vs 10% in group B; at 24 h, 5% in group A vs 5% in group B., Conclusions: Patients receiving S(+)-ketamine showed higher satisfaction for pain management and dreamed more often, but they did not have more nightmares.

Background: Along with postoperative nausea and vomiting (PONV), postanesthetic shivering (PAS) is one of the leading causes of distress postoperatively. Previous studies report on a decrease in incidence of PAS due to ketamine administration; however, the S(+) isomer of ketamine has not been evaluated before. Additionally the administration of ketamine minimizes the use of opioids, one of the most important risk factor of PONV. The aim of the present study was to evaluate the efficacy of S(+)-ketamine in the prophylaxis of both PAS and PONV in patients undergoing cardiac surgery., Material/methods: After ethics committee approval and written informed consent from the patients, 54 patients scheduled for coronary artery bypass graft surgery (CABG) were studied for both postanesthetic shivering and PONV. The sedation on the ICU was maintained using continuous infusion of propofol (1-3 mg x kg(-1) x h(-1)) and if necessary boli of 3.75 mg piritramide. At arrival in the ICU patients supplementary received either S(+)-ketamine (2 mg x kg(-1) x h(-1); group A; n=27) or 0.9% saline as placebo (group B; n=27) in a double-blind fashion. The severity of PAS was assessed by using a five-point rating scale. Fifteen minutes after extubation and 24 hours postoperatively, patients were asked about occurrence of PONV., Results: In group A 4 (14.8%) patients suffered from PAS compared to 12 (44.4%) in the control group (p<0.05). The severity of shivering was significantly lower in group A than in group B (p<0.05). In group A, patients showed a significant lower incidence of PONV (3.7% vs. 33.3%) and vomiting (3.7% vs. 22.2%) compared to patients of group B (p<0.05)., Conclusions: S(+)-ketamine reduced both postanesthetic shivering and postoperative nausea and vomiting, when administered for postoperative analgosedation.

Background: Postoperative nausea and vomiting (PONV) is one of the most frequent complications after general anaesthesia. Single-dose antiemetic prophylaxis has limited efficacy in high-risk patients. Adding a simple potential antiemetic approach, such as increasing the inspired oxygen fraction, to the antiemetic portfolio would preserve pharmacological interventions for treatment of symptoms in the postoperative period. However, the antiemetic effect of a high inspired oxygen fraction is still discussed controversially. The aim of the study was to evaluate whether an inspired oxygen fraction of 0.8 decreases PONV in patients receiving the 5-HT3-antagonist dolasetron., Methods: In a randomized, placebo-controlled, double-blinded trial we studied 377 patients (ASA I-III) undergoing elective laparoscopic cholecystectomy. Induction of anaesthesia was standardized, including thiopental fentanyl and cis-atracurium. For all patients the individual risk for PONV was calculated using the Koivuranta score and all patients received 12.5 mg dolasetron i.v. before surgery. Patients were allocated randomly to one of three groups: Group A (n=125) received 80% oxygen in air, Group B (n=125) 40% oxygen in air and Group C (n=127) 40% oxygen in nitrous oxide. Postoperative nausea, postoperative vomiting (PV), or nausea, vomiting, or both (PONV) was assessed in the early (0-4 h) and overall postoperative period (0-24 h) by an anaesthesiologist unaware of patient allocation., Results: There was a significantly lower incidence of PONV and PV in Groups A (PONV: 11.2%; PV: 3.2%) and B (PONV: 10.4%; PV: 3.2%) compared with Group C (PONV: 26.7%; PV: 13.3%), but there were no significant differences between Groups A and B., Conclusions: An inspired oxygen fraction of 0.8 does not further decrease PONV or vomiting in dolasetron-treated patients undergoing laparoscopic cholecystectomy. The lower incidence of PONV in Groups A and B compared with Group C is most likely caused by the omission of nitrous oxide.

Organophosphate compounds are responsible for a large number of accidental and/or suicidal exposures and have been used also for warfare and terrorism. The mechanism of toxicity is by inhibition of cholinesterase. Oximes are the only enzyme reactivators clinically available but clinical experience with oximes is disappointing. There is a gap between laboratory data and clinical impression concerning the efficacy of oxime compounds. Oximes are responsible for thiocholinesteratic activity, a spurious signal caused by interaction between pralidoxime and the thiocholine substrate used for photometric enzyme activity determinations. In a prospective, controlled, non-randomized study performed in anaesthetized miniature pigs, we quantified the extent of pralidoxime-induced cholinesteratic pseudo-activity ex vivo (human blood) and in vivo (minipig) in order to be able to correct values obtained by photometric methods. Plasma cholinesteratic activity using two substrates (acetylthiocholine and butyrylthiocholine) was determined in vitro and in vivo in the presence of pralidoxime. Pralidoxime reacts with the substrate (acetyl- and butyrylthiocholine) used for enzyme activity determinations, producing a spurious signal implying cholinesterase activity (even in the absence of plasma and thus of any enzyme). Cholinesterase activities determined photometrically after pralidoxime therapy can be erroneously high. Although in theory this could mislead clinicians into assuming an efficacious therapy, this is unlikely to occur in vivo under normal pralidoxime dosing conditions. To avoid any ambiguity it is recommended that blood be drawn for enzyme activity determinations prior to reactivator use and no less than 1 h after its administration.

Postanaesthetic shivering is a frequent complication following general anaesthesia. The aim of this study was to compare the effectiveness of three doses of nefopam with clonidine and placebo in the prevention of postanaesthetic shivering. We studied 371 patients undergoing abdominal or orthopaedic surgery. Patients were allocated to one of five groups: Group A (n = 73) received 0.2 mg x kg(-1) nefopam, Group B (n = 75) 0.1 mg x kg(-1) nefopam, Group C (n = 76) 0.05 mg x kg(-1) nefopam, Group D (n = 73) 1.5 microg x kg(-1) clonidine, and Group E (n = 74) saline 0.9% as placebo. We found a significant reduction in the incidence of shivering in Group A compared to Group C and clonidine as well as to the placebo group. All active treatments reduced the incidence and the severity of shivering compared to placebo. At 5 min postoperatively clonidine-treated patients showed a significant decrease in MAP and a significantly lower Aldrete score compared to all other groups. No haemodynamic or sedative adverse events were observed in the nefopam-treated patients. The results of our study indicate that nefopam (0.2 mg x kg(-1)) is superior to clonidine (1.5 microg x kg(-1)) in the prophylaxis of postanaesthetic shivering and not accompanied by sedative or haemodynamic side-effects.

Background and Objective: This randomized, prospective study was performed to evaluate the efficacy of a subcutaneous local anaesthetic infiltration prior to venepuncture using different cannula sizes., Methods: Three-hundred-and-one patients were included in the study, 150 received mepivacaine 1% (0.25 mL) subcutaneously, 151 were cannulated without local analgesia. Patients were further allocated to one of five cannula size groups (standard wire gauge (G)): 20-, 18-, 17-, 16- and 14-G. They were asked to quantify the pain experienced using a four-point rating scale., Results: In the group without local anaesthetics, 28.8% complained about pain compared to 12% receiving local analgesia. The incidence of pain for 14-G (10%) and 16-G (12.9%) cannulae was significantly reduced in the local analgesia group (P < 0.01) compared to no local analgesia (77.4% and 45.1%). Other cannula sizes showed no difference in pain whether using local analgesia or not., Conclusions: Patients profit from a subcutaneous infiltration with mepivacaine 1% prior to intravenous cathetherization only when cannulae of size > or = 16-G are inserted.

Background: The aim of this study was to assess the practicality of the ProSeal laryngeal mask (PS-LMA) airway during laparoscopic surgery with capnoperitoneum compared to endotracheal intubation (ET)., Methods: Prospective, randomized study. 104 patients undergoing gynaecologic, laparoscopic surgery were allocated randomly to two groups: 1. ET-group (n = 50). 2. PS-LMA-group (n = 54). Total intravenous anaesthesia was performed by the same anaesthesiologist., Measurements: Mean arterial pressure, heart rate, at 4 and circuit pressure at 2 measurement points, and the incidences of coughing and sore throat. Insertion of the ET and the PS-LMA was scored by using a four-point scale. Ease of placing the gastric tube was judged by measuring the number of attempts at insertion and the insertion times. A p-value of < 0.05 was considered as significant., Results: There were no differences between PS-LMA and ET concerning circuit pressure at any measurement point. At the end of anaesthesia, mean arterial pressure (92 +/- 13 vs. 100 +/- 14 mmHg; p < 0.01) and heart rate (66 +/- 13 vs. 76 +/- 14 beats/min; p < 0.01) were lower in the PS-LMA-group compared to the ET-group. At the end of anaesthesia 25 patients of the ET-group coughed but nobody in the PS-LMA-group (p < 0.00001). There was no difference with regard to postoperative sore throat. The insertion of the PS-LMA was easier compared to ET (p < 0.05), but we found no significant difference concerning insertion times. Fewer attempts at insertion of the gastric tube were necessary in the PS-LMA-group than in the ET-group (p < 0.01), whereas insertion times did not differ., Conclusion: The PS-LMA is a convenient and practicable approach for anaesthesia in patients undergoing laparoscopic surgery.

Purpose: To evaluate the influence of dopamine and diltiazem on renal function and markers for acute renal failure, including urinary alpha-glutathion s-transferase (alpha-GST), alpha-1-microglobulin (alpha(1)-MG) and N-acetyl-ss-glucosaminidase (ss-NAG) after extracorporeal circulation., Methods: In a randomized, placebo-controlled, double-blind trial we evaluated the efficacy of dopamine (2.5 micro g x kg(-1) x min(-1)), diltiazem (2 micro g x kg(-1) x min(-1)) or placebo administered over 48 hr postoperatively to maintain renal tubular integrity in 60 elective cardiac surgery patients. alpha-GST, alpha(1)-MG, ss-NAG, and creatinine clearance were measured from urine collected during surgery (T0), the first four hours (T1), 24 hr (T2) and 48 hr (T3) postoperatively., Results: Cumulative urine output in the diltiazem group (9.0 +/- 2.8 L) increased significantly compared with placebo (7.0 +/- 1.6 L), but not compared with dopamine (7.8 +/- 1.8 L). Creatinine clearance showed no significant intergroup differences. In all groups alpha(1)-MG increased from T0 to T3, but we found no significant intergroup differences. alpha-GST increased significantly from T0 to T3 in the placebo (2.1 +/- 1.8 to 11.4 +/- 8.6 micro g x L(-1)) and in the dopamine groups (2.7 +/- 1.8 to 13.6 +/- 14.9 micro g x L(-1)), but not in the diltiazem group (1.8 +/- 1.4 to 3.2 +/- 3.2 micro g x L(-1)). Forty-eight hours postoperatively alpha-GST was significantly lower in the diltiazem group than in both other groups., Conclusions: Diltiazem stimulates urine output, reduces excretion of alpha-GST and ss-NAG and may be useful to maintain tubular integrity after cardiac surgery.

Background: Postoperative nausea and vomiting (PONV) are frequent complications after operations. The aim of this study was to assess the efficacy of combined dolasetron plus dexamethasone versus dolasetron alone with respect to the incidence and severity of emetic symptoms and patients satisfaction., Methods: In a prospective, randomised, double-blind study, 150 patients scheduled for hysterectomy or breast surgery were allocated to one of the following two groups: group A received 50 mg dolasetron orally and group B 50 mg dolasetron orally plus 8 mg dexamethasone intravenously. The follow-up was for 24 h after surgery., Results: In group A PONV was significantly more frequent (28%) compared to group B (12.0%). The incidence of vomiting was significantly lower in patients receiving dolasetron plus dexamethasone (0%) in comparison to patients receiving dolasetron (8.0%). Furthermore,patients satisfaction was significantly higher in group B compared to group A. About 6 or 7 patients need to be treated with additional dexamethasone instead of a placebo for one patient to benefit from this intervention (i.e. to stay free from PONV) who otherwise would have suffered from PONV., Conclusions: Combining oral dolasetron with intravenous dexamethasone further improves the antiemetic efficacy of dolasetron. With a number-needed-to-treat of about 6 the additional benefit might be considered clinically relevant.

In a randomised, double-blind study we compared the efficacy of continuous remifentanil infusion (0.25 microg x kg(-1) x min(-1) with 40 mg lidocaine and placebo in the prevention of injection pain due to intravenous propofol administration (1.5-2 mg x kg(-1)) in 155 patients scheduled for elective surgery. Pain severity was evaluated using a four-point scale. The incidence of injection pain was 62% in the placebo group and could be reduced significantly by using remifentanil (30%; p < 0.0015) or lidocaine (33%; p < 0.005). Analysis of the pain scores showed a significant difference between remifentanil and placebo (p < 0.00005) as well as between lidocaine and placebo (p < 0.0002). There was no significant difference between remifentanil and lidocaine. Remifentanil provided effective pain relief, comparable with lidocaine, and is an alternative as part of an intravenous anaesthesia regimen to using another concomitant drug.

Background: Emergency oral tracheal intubations in the pre-hospital setting can be more difficult because the rescuer's position with respect to a patient lying on the ground may not provide optimal conditions for intubation. Since optimal visualisation of the larynx often depends on the force generated during laryngoscopy, we measured the pressure required for intubation (P(i)) as well as the maximum pressure (P(max)) that can be generated with the laryngoscopy blade in seven intubator positions., Methods: Nineteen hospital personnel with intubation experience participated in this study. A modified #3 Macintosh laryngoscope blade was used to measure the pressure exerted on the tongue of a manikin placed on the ground during intubation. The following positions were studied: standard, sitting, prone, kneeling, left and right lateral decubitus and straddling., Results: Intubating in the straddling position required the lowest P(i), as a percent of P(max) (68+/-14%). This was significantly less than the prone, right lateral decubitus and sitting positions. (Tukey's W procedure, P<0.05), Conclusion: The straddling position affords the intubator significantly more reserve force than the prone, right lateral decubitus or sitting position. We suggest that the straddling position may be an advantageous position for pre-hospital intubations especially when visualisation of the glottis is difficult.

Intoxications with organophosphorus compounds such as paraoxon (POX) are frequent. Oximes are the only enzyme reactivators clinically available. In vitro and in vivo studies have shown that l-lactate reduces the inhibition of plasma acetylcholine-esteratic activity (AChEA) (in vitro and in vivo) and plasma butyrylcholine-esteratic activity (BChEA) (at least in vitro and possibly in vivo) by POX. However, a short infusion of 10 g of lactate was unable to elevate the plasma lactate level for >3 h. In this study we tested a substance related to l-lactate, i.e. pyruvic acid. The purpose of this animal experimental study (female minipigs with historical control group) was to determine in vivo whether intravenous (i.v.) pyruvic acid application under normoxic/normocapnic/normohydrogenaemic conditions is able to elevate blood lactate levels and whether it is able to protect AChEA and BChEA from POX inhibition. Animals were anaesthetized, intubated and mechanically ventilated. Each received 1 mg kg(-1) body wt. of POX in 50 ml of saline over 50 min and 10 g (ca. 0.5 g kg(-1) body wt.) of i.v. pyruvic acid in 50 ml of saline over 50 min. They were compared with a historical control group of six animals that received only 1 mg kg(-1) body wt. of POX in 50 ml of saline over 50 min. In central venous blood measurements of plasma AChEA and BChEA, the measurements were performed before (baseline), immediately after POX (50 min after start) and 110, 170, 230, 290, 530 and 1010 min after the start of infusion. A 10 g aliquot of i.v. pyruvic acid had a statistically significant protective effect in vivo on AChEA but not on BChE activity. Further study of the in vivo effects of pyruvic acid and l-lactate after paraoxon intoxication and a formal comparison with standard oxime therapy seems warranted. Also, a combination therapy with l-lactate and pyruvic acid in vivo should be investigated., (Copyright 2003 John Wiley & Sons, Ltd.)

Objective: A recent thrombelastography study indicated a compromised in vitro blood coagulation after 10:10 (equal parts of blood and infusion) and 10:4 (10 parts blood to four parts infusion) hemodilution with several plasma substitutes. Oncovertin N (Oncovertin) (a 10% dextran 40 solution) had the strongest anticoagulant effect of all solutions tested, and HAES-sterile 10% (HAES) (a 10% hydroxyethyl starch 200/0.5 solution) showed the strongest effect of five different hydroxyethyl starch preparations. The aim of this study was to determine how in vitro hemodilution with HAES and Oncovertin affects the activity of coagulation factors., Design: HAES and Oncovertin were tested to determine the intrinsic effect of colloid molecules, as opposed to hemodilution. Normal saline (NaCl) and nonlactated Ringer solution were used as noncolloidal controls., Setting: University research institute., Patients: Six healthy volunteers., Interventions: Twenty milliliters of blood was obtained from each subject., Measurements and Main Results: Prothrombin index, activated partial prothrombin time, soluble fibrin monomers, and the activity of coagulation factors I, II, V, VII, VIII, IX, X, XI, and XII were measured with the Behring Chromotimer according to the manufacturer's instructions. Two dilution ratios of citrated blood to infusion were used: 10:10 (equal parts of blood and infusion) and 10:4 (10 parts blood to four parts infusion). Baseline was undiluted. Hemodilution with NaCl at both 10:4 and 10:10 influenced the coagulation variables measured. The activities of factors I, VII, and soluble fibrin monomers were less influenced than expected by hemodilution alone. The activities of factors II, V, IX, and XI were significantly (p <.04) lower with both 10:4 and 10:10 dilution with NaCl. In the assays for factors IX, XI, and XII, clots formed immediately after adding the appropriate reagents in the presence of Ringer solution at 10:10 hemodilution, so that the activities of those factors could not be measured. For the other factors and for 10:4 dilution, the outcome after Ringer solution was similar to that of NaCl. The activities were less influenced after 10:4 hemodilution with both HAES and Oncovertin than after dilution with NaCl and Ringer solution, with no significant differences from baseline. At 10:10 hemodilution with both HAES and Oncovertin, several factor activities were significantly (p <.04) lower than baseline., Conclusions: Both NaCl and Ringer solution cause measurable effects on coagulation factors at 10:4 hemodilution that can be explained by hemodilution alone. The effects on clotting factors of 10:4 hemodilution with HAES and Oncovertin were not significant. Even at 10:10 hemodilution with HAES or Oncovertin, the reduction in factor activities, although significantly (p <.04) different from baseline, was less than what was expected by dilution alone.

Purpose: Postoperative nausea and vomiting (PONV) is one of the most frequent complications of general anesthesia. The aim of the study was to compare the antiemetic efficacy of dolasetron and metoclopramide after inhalational or i.v. anesthesia (IVA)., Methods: In a randomized, placebo-controlled, double-blinded trial we evaluated the efficacy of 12.5 mg dolasetron i.v. and 20 mg metoclopramide (MCP) i.v. in preventing PONV in 387 patients (ASA I-III) undergoing laparoscopic cholecystectomy. Patients were allocated randomly to one of three main groups: Group D (n = 129) received 12.5 mg dolasetron i.v., Group MCP (n = 129) 20 mg MCP i.v., and Group C (n = 129) saline as placebo i.v. Using a multifactorial study design, one third of each main group (n = 43) was further randomized to receive either general anesthesia with desflurane, isoflurane or IVA with propofol and remifentanil. PONV, postoperative piritramide and droperidol consumption were documented., Results: Independent from the anesthesia regimen chosen, dolasetron reduced PONV (19%) significantly compared to MCP (45%) and placebo (46%). Furthermore we could show a significant difference in the incidence of PONV between IVA (28%) and isoflurane (46%), but not in comparison to desflurane (36%). Patients receiving IVA had a higher postoperative piritramide consumption compared to the two other groups., Conclusions: The results of our study suggest that dolasetron was more effective than MCP and placebo in preventing PONV. This action is independent of the anesthetic technique used.

Background and Objective: Controlled hypotension may alter organ blood flow and tissue oxygenation. The aim of the study was to investigate whether induced hypotension using sodium nitroprusside alters pancreatic function assessed by pancreatitis-associated protein concentrations in the blood., Methods: Thirty patients undergoing elective radical prostatectomy were allocated randomly into two groups: (a) hypotension group: sodium nitroprusside was administered to lower mean arterial pressure to approximately 50 mmHg; (b) control group: no hypotension was used, mean arterial pressure was kept > 70 mmHg. Pancreatitis-associated protein and lipase were measured in arterial blood samples: after induction of anaesthesia (T1), at the end of surgery (T2), 2 h (T3) and 24 h (T4) postoperatively., Results: Pancreatitis-associated protein plasma concentrations increased significantly in patients in the hypotensive group (from 2.8 +/- 1.1 to 5.5 +/- 2.0 micrograms L-1 at T4) and pancreatitis-associated protein plasma concentrations were significantly higher in comparison with controls (5.5 +/- 2.0 versus 3.5 +/- 2.4 micrograms L-1) at T4. Lipase concentrations showed a similar course in both groups. None of the patients showed clinical signs of pancreatitis., Conclusions: Controlled hypotension during surgery was associated with a small but significant increase in pancreatitis-associated protein compared with controls. The absence of concomitant elevation in lipase concentrations and a lack of clinical evidence of pancreatitis damage suggest that hypotension induces mild pancreatic stress.

Objective: Intoxications with organophosphorous compounds such as paraoxon, an inhibitor of serine hydrolases, mainly butyrylcholinesterase and acetylcholinesterase, are frequent. Oximes are the only enzyme reactivators clinically available. In vitro studies have shown that L(+)-lactate reduces the inhibition of acetylcholinesteratic (AChEA) and butyrylcholinesteratic activity of plasma (BChEA) by paraoxon., Design: The purpose of this in vivo study was to determine whether intravenous L(+)-lactate application under normoxic/normocapnic/normohydrogenemic conditions is able to protect AChEA and BChEA from paraoxon inhibition., Setting: University research institute., Subjects: Eighteen female minipigs., Interventions: Animals were anesthetized, intubated, and mechanically ventilated. Every animal received 1 mg of paraoxon per kilogram of body weight in 50 mL of saline over 50 mins. In addition to receiving paraoxon, six pigs of 18 received 2.5 g (0.125 g kg-1 of body weight) of intravenous L(+)-lactate in 50 mL of saline over 50 mins, and six other pigs received 10 g of L(+)-lactate (0.5 g kg-1 of body weight), whereas the six remaining served as controls., Measurements and Main Results: In central venous blood, plasma acetylcholinesteratic and butyrylcholinesteratic activity were measured before paraoxon (baseline, 0 mins), immediately after paraoxon (50 mins after start), and 110, 170, 230, 290, 530, and 1010 mins after the start of infusion. Although 10 g of intravenous L(+)-lactate application had a statistically significant protective effect in vivo on AChEA, 2.5 g did not. No significant protective effect on BChEA was achieved with either 2.5 g or 10 g of L(+)-lactate., Conclusions: Ten grams of L(+)-lactate can increase AChEA when administered simultaneously with paraoxon. Further study of the in vivo effects of L(+)-lactate after paraoxon intoxication and a formal comparison with standard oxime therapy seem warranted. Also, methods for achieving a prolonged elevated lactate concentration in vivo should be investigated.

Background: Increasing inspired oxygen concentrations might provide a simple and effective intervention to increase oxygen tension in tissues during controlled hypotension. To test this hypothesis, the influence of hyperoxic ventilation (100% O2) on skeletal muscle oxygen partial pressure (Ptio2) in patients receiving sodium nitroprusside-induced controlled hypotension was studied., Methods: Forty-two patients undergoing radical prostatectomy were prospectively studied and randomly divided into three groups as follows: (1) Controlled hypotension induced by sodium nitroprusside (mean arterial blood pressure, 50 mmHg) and hyperoxic ventilation (CH-100%; n = 14); (2) controlled hypotension and ventilation with 50% O2 in nitrous oxide (CH-50%; n = 14); and (3) standard normotensive anesthesia with 50% O2 in nitrous oxide (control; n = 14). Ptio2 values were measured continuously in all patients using implantable polarographic microprobes. Arterial blood gases and lactate concentrations were analyzed in 30-min intervals., Results: Surgical blood loss and transfusion requirements were significantly reduced in both groups receiving hypotensive anesthesia. During surgery, arterial partial pressure of oxy-gen and arterial oxygen content were significantly higher in patients of the CH-100% group. Baseline values of Ptio2 were comparable between the groups (CH-50%: 25.0 +/- 0.7 mmHg; CH-100%: 25.2 +/- 0.2 mmHg; control: 24.5 +/- 0.2 mmHg). After a transient increase in Ptio2 in the CH-100% group during normotension, Ptio2 values returned to baseline and remained unchanged in the control group. Ptio2 decreased significantly during the hypotensive period in the CH-50% group. The lowest mean Ptio2 values were 15.0 +/- 4.1 mmHg in the CH-50% group, 24.2 +/- 4.9 mmHg in the CH-100% group, and 23.5 +/- 3.8 mmHg in the control group. There were no significant changes in lactate plasma concentrations in any group throughout the study period., Conclusions: Hyperoxic ventilation improved skeletal muscle tissue oxygenation during sodium nitroprusside-induced hypotension. This improved local tissue oxygenation seems to be most likely due to an increase in convective oxygen transport and the attenuation of hyperoxemia-induced arteriolar vasoconstriction by sodium nitroprusside.

Unlabelled: We designed this study to assess the efficacy of dolasetron compared with clonidine and placebo in prophylaxis of postanesthetic shivering. We included 90 patients undergoing elective abdominal or urologic surgery. The patients were randomly assigned to one three groups (each group n = 30) using a double-blinded study protocol: Group A received 12.5 mg dolasetron, Group B 3 microg/kg clonidine, and Group C saline 0.9% as placebo. The medication was given after the induction of anesthesia. Postanesthetic shivering was judged by using a five-point scale. In the Clonidine group, 86.6% showed no shivering, whereas in the Dolasetron and Placebo groups, only 63.3% and 66.6%, respectively, were symptom free. Only clonidine, but not dolasetron, significantly reduced the incidence and the severity of shivering. We conclude that clonidine is effective in preventing shivering when given before surgery, whereas dolasetron, at the dose used, is not effective., Implications: Shivering, an irregular muscular fasciculation lasting longer than 15 s, is a common complication secondary to general anesthesia. We compared dolasetron with clonidine (an established antishivering drug) in the prevention of postanesthetic shivering. Dolasetron 12.5 mg was not effective.

Purpose: To investigate the effect of 0.2 mg x kg(-1), 0.3 mg x kg(-1) and 0.4 mg x kg(-1) urapidil on the incidence and severity of postanesthetic shivering., Methods: One hundred and fifty patients (ASA I-III) scheduled for elective abdominal, urologic or orthopedic surgery under standardized general anesthesia were randomly allocated to one of five groups (each group n=30) using a double-blind protocol: group A received 0.2 mg x kg(-1) urapidil, group B: 0.3 mg x kg(-1) urapidil, group C: 0.4 mg x kg(-1) urapidil, group D: 3 microg x kg(-1) clonidine (positive control group), and group E: saline 0.9% as placebo (negative control group). Postanesthetic shivering was scored using a five-point scale., Results: Twelve patients of group A, 11 of group B, nine of group C, three of group D and 14 of group E showed signs of postanesthetic shivering. Postanesthetic shivering was significantly decreased in the clonidine group compared to the three urapidil groups and the placebo group. Significantly less patients treated with clonidine needed anti-shivering therapy. There were no significant differences between the urapidil and placebo groups. Therapeutic interventions for hemodynamic effects were not required in any group. Time to extubation, but not time to discharge, was prolonged in the clonidine group., Conclusion: Urapidil showed no beneficial effect on shivering in any of the doses evaluated, whereas prophylactic administration of clonidine was effective in preventing postanesthetic shivering.

This prospective randomised controlled study evaluated the effects of postoperative sedation with propofol and midazolam on pancreatic function. We studied 42 intensive care unit patients undergoing elective major surgery who were expected to be sedated postoperatively. Patients were randomly assigned to a propofol group (n = 21) or a midazolam group (n = 21). To assess pancreatic function, the following parameters were measured: pancreatitis-associated protein, amylase, lipase, cholesterol and triglyceride prior to start of sedation on the intensive care unit, 4 h after the sedation was started and at the first postoperative day. Patients in the propofol group received on average (SD) 1292 (430) mg propofol and were sedated for 9.03 (4.26) h. The midazolam group received 92 (36) mg midazolam and were sedated for 8.81 (4.68) h. Plasma cholesterol concentrations did not differ significantly between groups. Triglyceride plasma levels 4 h after the start of infusion were significantly higher in the propofol group (140 (54) mg.dl(-1)) than the midazolam-treated patients (81 (29) mg.dl(-1)), but were within normal limits. There were no significant differences between the two groups regarding amylase, lipase and pancreatitis-associated protein plasma concentrations at any time. No markers of pancreatic dysfunction were outside the normal range. We conclude that postoperative sedation with propofol induced a significant increase of serum triglyceride levels but that pancreatic function is unchanged with standard doses of propofol.

Background: In today's climate of financial restrictions, libraries and individual subscribers complain about the price increase of scientific journals. The development in prices of anesthesia/critical care journals was analysed over the past 6 years and compared to prices of some journals of other disciplines., Methods: Important journals in the categories Anesthesiology, Emergency Medicine & Critical Care, Surgery, Medicine (General), and Cardiac & Cardiovascular Systems listed in the 1999 Science Citation Index of Journal Citation Report were included and prices for the years 1995 to 2000 were analysed., Results: Increase in prices ranged from +13% to +199%. The mean increase in journal prices was lowest in the category Anesthesiology (+61%), higher in the category Critical Care (+73%), and highest in the category Medicine, General (+101%). Changes in the impact factor (IF) varied widely, ranging from a decrease (Lancet: -43%; J Neurosurg Anesth: -44%) to a tremendous increase (e.g. Reg Anesth +165%; Ann Emerg Med +149%). The journals' size (number of articles or pages) did not increase proportionally with the increase in prices., Conclusion: A disproportionate rise in journal prices was seen over the past 6 years. The large increase in cost may have multiple reasons. The rapidly increasing cost of research journals may affect research quality because economic pressure may result in reduction in availibility of information due to cancellation of subscriptions to journals.

Background and Objective: In a randomized, placebo-controlled, double-blind trial, we compared the efficacy of dolasetron and metoclopramide in preventing postoperative nausea and vomiting in women undergoing hysterectomy., Methods: Patients were allocated randomly to one of three groups: group A (n = 50) received 50 mg dolasetron orally, group B (n = 50) received 20 mg metoclopramide intravenously and placebo orally, group C (n = 50) received placebo orally. If patients complained of retching or vomiting, or if patients demanded an antiemetic, 1.25 mg droperidol was administrated intravenously. To quantify postoperative nausea and vomiting the following score was used: 0 = no nausea, 1 = nausea, 2 = retching, 3 = single vomiting, 4 = multiple vomiting. The Raatz test was used to analyse postoperative nausea and vomiting (PONV) scores., Results: Dolasetron reduced the postoperative nausea and vomiting score significantly (P < 0.02 vs. metoclopramide; P < 0.0001 vs. placebo). Metoclopramide also reduced the postoperative nausea and vomiting score (P < 0.02 vs. placebo). Fisher's exact test showed a significant reduction of vomiting in the dolasetron group compared with metoclopramide-treated patients (P < 0.007) and placebo-treated patients (P < 0.000006) and a significantly lower rate of nausea in comparison to the placebo group (P < 0.009). There were no significant differences between the metoclopramide and the placebo groups (in Fisher's exact test). The use of postoperative droperidol per patient was significantly lower in the dolasetron group (P < 0.04 vs. metoclopramide; P < 0.0001 vs. placebo) than in the metoclopramide (P < 0.02 vs. placebo) and in the placebo groups., Conclusions: Oral dolasetron is more effective than either metoclopramide given intravenously or placebo for preventing vomiting after hysterectomy. It also was significantly superior to either metoclopramide or placebo concerning the PONV score and the need for droperidol rescue.

Background and Objective: The per capita publication output of German medical research is low compared not only to the English-speaking nations but also to Austria and Switzerland. We assessed the publications from German universities in the leading English language general medical journals: New England Journal of Medicine (NEJM), Lancet, Journal of the American Medical Association (JAMA), and British Medical Journal (BMJ)., Methods: Medline (1988-5/2000) was searched for journal-articles with German origin published in the above journals and manually classified as to institution and speciality., Results: 372 publications from Germany were found. 216 had been published in Lancet, 87 in NEJM, 52 in BMJ, and 17 in JAMA. 58 were excluded (2 from British military hospitals in Germany, 2 from pharmaceutical companies, 2 from physician associations, 18 from non-university basic research institutions or government agencies, 3 from non-medical university departments, 30 from non-university hospitals, 1 from a transfusion service of the German Red Cross). The remaining 314 publications were from 34 universities. The most speciality was internal Medicine with 140 university publications, the most represented university was the Ludwig-Maximilians-University in Munich with 43 publications. 5 universities had no publications in the analysed journals., Conclusion: Large differences were found between the German universities with respect to publications in the leading English Language general medical journals.

Objective: To evaluate contributions of German university departments of anesthesiology to the German language literature., Methods: Using Medline (Silverplatter, volumes 1988-1997 of the 1999 edition) we searched for (journal-article IN SO) AND ((anesth* OR anasth* OR anaesth*) in AD) AND (LA-German). The publications found were manually evaluated for address. The "Jahrbuch der Anästhesiologie und Intensivmedizin" (1992-1995) was evaluated for the number of staff members (anaesthesiologists, residents and non-physician scientists)., Results: The total number of publications was about 200/year. Individual departments contributed very differently (range: 0.6 publications/year to 14.8 publications/year). The department with the highest per capita output had about 0.4 Medline-indexed papers per scientist and year, the department with the lowest per capita output had about 0.02 papers per scientist and year., Conclusion: There is a great difference with respect to total publication count. The differences in total publication count can only in part be explained by different size of the departments. Even the leading department had far less than 1 paper per scientist and year.

Background: The impact factor (IF) is published by the Institute for Scientific Information (ISI). There is a tendency to assess quality of scientific journals with the help of the IE An analysis of the changes in the IF over time in the different specialities may help to further enlighten the worth and problems of the IE METHODS: The IFs listed under the subheadings Anesthesiology and Emergency Medicine & Critical Care in the Science Citation Index - Journal Citation Report were descriptively analysed over the past 10 years. Additionally, IFs of some other important journals (subheadings Surgery, Cardiovascular, General Medicine) were analysed., Results: The IF of most of the journals showed a constant increase over the years (average in Anesthesiology: +65%; average in Emergency Medicine & Critical Care: +145%). IFs of the highest ranked journals of other specialities showed a similar increase over the years (average in surgical journals: +56%; average in cardiac journals: +59%; average in general journals: +40%). More Anesthesiology and Emergency Medicine & Critical Care journals originated from the USA show an IF >2.0 over the past 10 years than do European journals., Conclusion: Although the value of the IF is highly controversial, it is a frequently used tool to assess rating of a medical journal. Anesthesiology and Emergency Medicine & Critical Care journals showed a continuous increase in the IF over the past 10 years.

Purpose: To evaluate the effects of perioperative epidural analgesia on hemodynamics, splanchnic perfusion and regulators of circulation., Methods: Twenty patients undergoing aortic surgery were randomised into two groups: epidural analgesia group (EAG): epidural analgesia with bupivacaine (15 ml, 0.125%) was started before surgery. Eight and 16 hr postoperatively 10 ml bupivacaine 0.125% and 1 mg morphine were given. Control group (COG): patients received no epidural catheter. Monitoring included pulmonary artery catheter and gastric tonometer. Norepinephrine, epinephrine, renin, ADH, ANP and endothelin were measured: before epidural analgesia (T0), before aortic clamping (T1), 20 min after aortic clamping (T2), after declamping the first leg (T3), at end of surgery (T4), one hour (T5) and 24 hr postoperatively (T6)., Results: At T5 mean arterial blood pressure decreased in EAG compared with baseline (86 +/- 16 to 75 +/- 8 mmHg) and compared with COG (75 +/- 8 vs 84 +/- 11 mmHg). At T2 pulmonary capillary wedge pressure and cardiac index increased and at T6 decreased in both groups. Systemic vascular resistance decreased at T I and at T3-T5 in EAG compared with COG and at T1 and T3-T6 to baseline (1472 +/- 448 to 1027 +/- 184 dyn x sec x cm(-5) x m(-2)). In EAG and in COG, pHi decreased compared with baseline but without group differences. In both groups, epinephrine, norepinephrine, renin, and ADH levels increased from baseline. Endothelin and ANP levels showed no changes., Conclusions: Perioperatively administrated epidural bupivacaine has no beneficially effects on hemodynamics, pHi or release of regulators of circulation.

Objective: To investigate whether dopexamine hydrochloride beneficially influences splanchnic perfusion and regulators of the macrocirculation and microcirculation in patients undergoing surgery of the abdominal aorta., Design: Prospective, blinded, and randomized study., Setting: University-affiliated hospital., Participants: Twenty patients undergoing elective abdominal aortic surgery., Interventions: The patients were randomized to one of two groups. In the dopexamine group (DOP, n = 10), dopexamine, 1 microg/kg/min, was started before surgery and continued for 24 hours. In the control group (COG, n = 10), patients received saline solution as placebo. Extensive hemodynamic monitoring was carried out using a pulmonary artery catheter, and intramucosal pH was measured using a gastric tonometer. From arterial blood samples, important regulators of the circulation were measured before dopexamine was administered (T0), before aortic clamping (T1), 20 minutes after aortic clamping (T2), after declamping the first leg (T3), at the end of surgery (T4), 1 hour postoperatively (T5), and 24 hours postoperatively (T6)., Measurements and Main Results: Heart rate increased significantly in DOP (63+/-16 to 84+/-18 beats/min). At T5, mean pulmonary artery pressure was significantly lower in DOP (15+/-6 mmHg) than in COG (22+/-6 mmHg). During aortic clamping, pulmonary capillary wedge pressure increased significantly in both groups. Cardiac index increased significantly from baseline only in the dopexamine patients. No significant differences between the groups were seen with regard to oxygenation parameters and intramucosal pH. Renin plasma levels increased significantly only in COG (46+/-32 to 99+/-55 microU/mL). Endothelin and atrial natriuretic peptide plasma levels showed no significant differences between the two groups. Atrial natriuretic peptide increased significantly only in DOP (366+/-171 pg/mL; COG, 159+/-71 pg/mL). Antidiuretic hormone, norepinephrine, and epinephrine plasma levels increased significantly from baseline in both groups, without showing significant differences between the groups., Conclusions: In patients undergoing abdominal aortic surgery, prophylactic perioperative administration of dopexamine hydrochloride produced effects on hemodynamics but without improving oxygenation and intramucosal pH. From the measured regulators of the circulation, only renin was beneficially affected.

The currently recommended prehospital treatment for carbon monoxide (CO) poisoning is administration of 100% O(2). We have shown in dogs that normocapnic hyperpnea with O(2) further accelerates CO elimination. The purpose of this study was to examine the relation between minute ventilation (V E) and the rate of elimination of CO in humans. Seven healthy male volunteers were exposed to CO (400 to 1,000 ppm) in air until their carboxyhemoglobin (COHb) levels reached 10 to 12%. They then breathed either 100% O(2) at resting V E (4.3 to 9.0 L min) for 60 min or O(2) containing 4.5 to 4.8% CO(2) (to maintain normocapnia) at two to six times resting V E for 90 min. The half-time of the decrease in COHb fell from 78 +/- 24 min (mean +/- SD) during resting V E with 100% O(2) to 31 +/- 6 min (p < 0. 001) during normocapnic hyperpnea with O(2). The relation between V E and the half-time of COHb reduction approximated a rectangular hyperbola. Because both the method and circuit are simple, this approach may enhance the first-aid treatment of CO poisoning.