Long-term follow-up of patients with persistent/recurrent,isolated haematuria: A Hungarian multicentre study

A retrospective multicentre study of 341 children with persistent/recurrent, isolated haematuria is described. The haematuria was isolated for at least 6 months at the beginning of observation. The duration of follow-up was 2–5 years in 201, 5–10 years in 119, 10–15 years in 19, and over 15 years in 2 cases. Of these patients 47.8% became symptom-free. In 18.4% the haematuria remained isolated; in 13.8% it was combined with proteinuria over 250 mg/day more than 2 years later. The occurrence of associated proteinuria increased progressively with time. It was 8.6% between the 3rd and 5th years, and 37.0% after the 5th year. Renal biopsy was performed because of the symptoms of glomerular disease in 47 cases at an average time of 12 months following the appearance of proteinuria. Proteinuria appeared after a 2–5, 5–10, 10–15 and more than 15 years follow-up period in 16, 23, 6, and 2 patients respectively; 14 of them had Alport's nephropathy. The percentage of more serious azotaemia was 1.7 (creatinine clearance: 10–50 ml/min per 1.73 m²) and 0.3 (creatinine clearance: < 10 ml/min per 1.73 m²). Mortality was 0.58%. Most of the patients who developed severe azotaemia had persistent microscopic haematuria at the beginning. The prevalence of hypertension was only 1.2%. The time of its appearance was above 5 years in 2 and below 5 years in 2 cases. All these patients had chronic glomerulonephritis. The haematuria was associated with hypercalciuria in 19.9%. In 14.3% of the overall group of patients urolithiasis developed 2–15 years after onset. All of these had hypercalciuria. Our findings suggest that symptoms of isolated haematuria may last for a longterm period and need systematic control. When proteinuria and/or hypertension is associated with haematuria a worse prognosis can be expected.Participating paediatric hospitals and university departments: Second Department of Paediatrics, I. Semmelweis Medical University of Budapest (M. Visy); Department of Paediatrics, University Medical School of Pécs (V. Jászai); Department of Paediatrics, A. Szent-Györgyi Medical University of Szeged (I. Haszon, S. Túri); County Children's Hospital, Miskolc (Á. Vissy); P. Heim Children's Hospital, Budapest (Z. Czirbesz); County Children's Hospital, Györ (Zs. Szelid); Buda-Children's Hospital, Budapest (I. Ferkis); I. Apáthy Hospital, Budapest (J. Kisbán); János Hospital, Budapest (I. Marosváry); Hospital of Hungarian State Railway, Budapest (J. Fehér); L. Madarász Hospital, Budapest (F. Kalmár); South Pest Hospital, Budapest (G. Halász); County Children's Hospital, Pécs (E. Kolman); County Children's Hospital, Gyula (P. Sipos); County Children's Hospital, Szolnok (I. Jaksics); County Children's Hospital, Debrecen (Á. Miskolczi); County Children's Hospital, Tatabánya (I. Kiss); County Children's Hospital, Eger (M. Frank, E. Ladányi); County Children's Hospital, Nyíregyháza (E. Bujdosó); County Children's Hospital, Szombathely (M. Andics); Kerepestarcsa Hospital, Budapest (M. Marcell); Komárom Hospital, Komárom (J. Kecskés)     

Transplantation in Hungary—Preface on the Occasion of Transplantation Proceedings Becoming the Official Journal of the Hungarian Transplantation Society

The first, long-term successful kidney transplantation happened 37 years ago in Hungary. At the same time an organized renal program was initiated followed by transplantations of other solid organs. The authors remember previous milestone operations and the preceding events. In 1982, Hungary was the first country in the Eastern block to introduce cyclosporine. After the Iron Curtain fell new circumstances and possibilities opened for the transplant community also. Young transplant surgeons were sent to Western countries returning with new experiences. In 1992 the heart transplantation program started in Budapest. The Universities of Debrecen and Pécs joined Budapest and Szeged with renal transplant programs. In 1994, a new Department was initiated at Semmelweis University with an immediate increase of 50%. The next year a liver transplantation program was launched. Pancreas transplants were performed in 1998 in Pécs, followed by Budapest. In 2003, a collaboration was initiated between Geneva and Budapest for islet transplantation and another with Vienna for lung transplantation. This article provides an overview of Hungarian transplant activities.     

Variation of venous admixture,SF6 shunt,PaO2, and the PaO2/FIO2 ratio with FIO2

Background. Measures of impairment of oxygenation can be affectedby the inspired oxygen fraction. Methods. We used a mathematical model of an inhomogenous lungto predict the effect of increasing inspired oxygen concentration(FI_O2) on: (1) venous admixture (Q^·va/Q^·t); (2)arterial oxygen partial pressure (Pa_O2); (3) the Pa_O2/FI_O2 indexof hypoxaemia; and (4) sulphur hexafluoride (SF₆) retention(often taken to be true right-to-left shunt). This model predictswhether or not atelectasis will occur. Results. For lungs with regions of low V^·/Q^·,increasing the inspired oxygen concentration can cause theseregions to collapse. In the absence of atelectasis, the modelpredicts that Q^·va/Q^·t will decrease and arterialoxygen partial pressure increase as FI_O2 is increased. However,when atelectasis occurs, Q^·va/Q^·t rises to a constantvalue, whilst Pa_O2 falls at first, but then begins to rise again,with increasing FI_O2. The SF₆ retention increased markedly insome cases at high FI_O2. Conclusions. Venous admixture will estimate true right-to-leftshunt at high FI_O2, even when oxygen consumption is raised.This model can explain the way that the P_a/FI ratio changeswith increasing inspired oxygen concentration. Br J Anaesth 2002; 88: 771–8     

Cerebral hypoperfusion in immediate postoperative period following coronary artery bypass grafting, heart valve, and abdominal aortic surgery

Perioperative levels of jugular bulb oxyhaemoglobin saturation(Sj_O2) and lactate concentration (Lj), and postoperative durationof Sj_O2<50% were compared between patients undergoing coronaryartery bypass grafting (CABG) (n=86), heart valve (n=14) andabdominal aortic (n=16) surgery. Radial artery and jugular bulbblood samples were aspirated after induction of anaesthesia,during re-warming on cardiopulmonary bypass (CPB) (36°C),on arrival in the intensive care unit (ICU) and, subsequently,at 1, 2 and 6 h after ICU admission. Most patients having heartsurgery were hypocapnic at 36°C on CPB. Following CABG andheart valve surgery, many patients were hypocapnic whereas afterabdominal aortic surgery, most were hypercapnic. During CPBand postoperatively, Sj_O2 and Lj were significantly correlatedto Pa_CO2 and the arterial concentration of lactate (La) respectively(P<0.05). After correction for arterial carbon dioxide tension(Pa_CO2) and La, there were no significant changes in Sj_O2 orLj on CPB. Postoperatively, having corrected for Pa_CO2, therewere significant effects on Sj_O2 over all groups as a resultof time from surgery (P<0.001) and its interaction with operationtype (P<0.001). Following correction for La, there were nopostoperative effects on Lj. No significant differences (P=0.2)in duration of Sj_O2<50% existed between patients undergoingCABG (1054 (82) min), abdominal aortic (893 (113) min) and heartvalve (1073 (91) min) surgery. The lack of significant reciprocaleffects on Lj combined with the frequency of hypocapnia andstrong influence of Pa_CO2on Sj_O2, suggest that Sj_O2<50% duringCPB and after cardiac surgery represents hypoperfusion as aconsequence of hypocapnia rather than cerebral ischaemia. Br J Anaesth 2001; 87: 229–36     

Patient well-being after general anaesthesia: a prospective, randomized, controlled multi-centre trial comparing intravenous and inhalation anaesthesia

Background. The aim of this study was to assess postoperativepatient well-being after total i.v. anaesthesia compared withinhalation anaesthesia by means of validated psychometric tests. Methods. With ethics committee approval, 305 patients undergoingminor elective gynaecologic or orthopaedic interventions wereassigned randomly to total i.v. anaesthesia using propofol orinhalation anaesthesia using sevoflurane. The primary outcomemeasurement was the actual mental state 90 min and 24 h afteranaesthesia assessed by a blinded observer using the AdjectiveMood Scale (AMS) and the State-Trait-Anxiety Inventory (STAI).Incidence of postoperative nausea and vomiting (PONV) and postoperativepain level were determined by Visual Analogue Scale (VAS) 90min and 24 h after anaesthesia (secondary outcome measurements).Patient satisfaction was evaluated using a VAS 24 h after anaesthesia. Results. The AMS and STAI scores were significantly better 90min after total i.v. anaesthesia compared with inhalation anaesthesia(P=0.02, P=0.05, respectively), but equal 24 h after both anaesthetictechniques (P=0.90, P=0.78, respectively); patient satisfactionwas comparable (P=0.26). Postoperative pain was comparable inboth groups 90 min and 24 h after anaesthesia (P=0.11, P=0.12,respectively). The incidence of postoperative nausea was reducedafter total i.v. compared with inhalation anaesthesia at 90min (7 vs 35%, P<0.001), and 24 h (33 vs 52%, P=0.001). Conclusion. Total i.v. anaesthesia improves early postoperativepatient well-being and reduces the incidence of PONV. Br J Anaesth 2003; 91: 631–7     

Small dose of exogenous surfactant combined with partial liquid ventilation in experimental acute lung injury: effects on gas exchange, haemodynamics, lung mechanics, and lung pathology

A combination of exogenous surfactant and partial liquid ventilation(PLV) with perfluorocarbons should enhance gas exchange, improverespiratory mechanics and reduce tissue damage of the lung inacute lung injury (ALI). We used a small dose of exogenous surfactantwith and without PLV in an experimental model of ALI and studiedthe effects on gas exchange, haemodynamics, lung mechanics,and lung pathology. ALI was induced by repeated lavages (Pa_O2/FI_O2less than 13 kPa) in 24 anaesthesized, tracheotomized and mechanicallyventilated (FI_O2 1.0) juvenile pigs. They were treated randomlywith either a single intratracheal dose of surfactant (50 mgkg^–1, Curosurf^®, Serono AG, München, Germany)(SURF-group, n=8), a single intratracheal dose of surfactant(50 mg kg^–1, Curosurf^®) followed by PLV with 30 mlkg^–1 of perfluorocarbon (PF 5080, 3M, Germany) (SURF-PLV-group,n=8) or no further intervention (controls, n=8). Pulmonary gasexchange, respiratory mechanics, and haemodynamics were measuredhourly for a 6 h period. In the SURF-group, the intrapulmonaryright-to-left shunt (Q^·S/Q^·T) decreased significantlyfrom mean 51 (SEM 5)% after lavage to 12 (2)%, and Pa_O2 increasedsignificantly from 8.1 (0.7) to 61.2 (4.7) kPa compared withcontrols and compared with the SURF-PLV-group (P<0.05). Inthe SURF-PLV-group, Q^·S/Q^·T decreased significantlyfrom 54 (3)% after induction of ALI to 26 (3)% and Pa_O2 increasedsignificantly from 7.2 (0.5) to 30.8 (5.0) kPa compared withcontrols (P<0.05). Static compliance of the respiratory system(C_RS), significantly improved in the SURF-PLV-group comparedwith controls (P<0.05). Upon histological examination, theSURF-group revealed the lowest total injury score compared withcontrols and the SURF-PLV-group (P<0.05). We conclude thatin this experimental model of ALI, treatment with a small doseof exogenous surfactant improves pulmonary gas exchange andreduces the lung injury more effectively than the combined treatmentof a small dose of exogenous surfactant and PLV. Br J Anaesth 2001; 87: 593–601     

Über die Bauchverletzungen in der Königl. Preußischen Armee,den Sächsischen und dem Württembergischen Armeekorps in den Jahren 1896–1906

Ohne Zusammenfassung Abgekürzt vorgetragen auf dem XVI. internat. med. Kongre? zu Budapest 1909.     

Complement activation is influenced by the membrane material, design of the dialyser, sterilizing method, and type of dialysate

The complement system becomes activated during blood-membranecontact in the dialyser. This study was designed to evaluateto what extent the dialyser design, the sterilization method,and the type of dialysate influence complement as measured byC3d. Twelve patients were dialysed three times on each of fourdifferent dialysers. Two hollow-fibre dialysers made of cuprophane(Hf-CuE ethylene-oxidesterilized, Hf-CuS steam-sterilized) werecompared with two plate dialysers made of cuprophane (P-Cu)or polycarbonate (P-Pc). Five patients were dialysed with acetateand seven with bicarbonate. Differences in C3d between at startof dialysis and after 180 mm were calculated. C3d was increasedmore by P-Cu than by the other dialysers (P<0.012, n=12).In the bicarbonate group, C3d was increased more by P-Cu thanby Hf-CuS or P-Pc (P<0.022, n=7) and more by Hf-CuE thanHf-CuS (P<0.013). In the acetate group, C3d was increasedmore by Hf-CuS and P-Cu than by P-Pc (P<0.006, n=5). In conclusion, complement activation during dialysis varieddue to membrane material, membrane design, sterilization method,and dialysate composition.     

Interactions between sodium balance, intrarenal dopamine synthesis, and sympathetic activity in HLA-identical kidney donors and recipients

Intrarenal dopamine (DA) synthesis, sympathetic activity andsodium homeostasis were studied in eight HLA-identical kidneyrecipient and donor pairs at 50, 150, and 300 mmol sodium intake.Trimethaphan was given intravenously (i.v.), to mimic acutedenervation, tyramine i.v. to induce noradrenaline (NE) release,and the DA precursor DOPA i.v. to study DOPA to DA conversion.Blood pressure was higher in the recipients (P<0.05) andwas not influenced by sodium intake. Cumulative sodium balanceswere not different between the groups. Sodium intake did notaffect DA excretion in either group. The recipients had higherDA (P<0.05) and DOPA (P<0.01) excretions and lower urinaryDA over DOPA ratio (U_DA/DOPA, P<0.01) and lower NE excretion(P<0.05) during the whole study. High sodium intake suppressedthe U_DA/DOPA in both groups (P<0.05). Trimetaphan decreasedrenal vascular resistance (RVR) and increased sodium excretiononly in the donors (P<0.05), while GFR increased in bothgroups. During HiSo tyramine increased RVR in the recipients(P<0.01) and U_DA/DOPA in the donors (P<0.05). DOPA infusionincreased DA excretion four to fivefold but did not change sodiumexcretion in either group. It is concluded that the recipientsmaintained sodium homeostasis well but seem to have an impairedfunctional innervation of the transplanted kidney. NE releaseseem to stimulate intrarenal DOPA to DA conversion. In bothgroups a direct relation between DA and sodium excretion waslacking.     

Atrial natriuretic peptide, sodium retention, and proteinuria in nephrotic syndrome

BACKGROUND.: Oedema formation in the nephrotic syndrome is primarily dueto tubular sodium retention. The pathogenetic role of alphaatrial natriuretic peptide (ANP), a hormonal promoter of natriuresisis unknown. METHODS.: In 31 patients (aged 35±11 years) with nephrotic syndromeand histopathological evidence of primary glomerulonephritis,we investigated plasma ANP concentration and its influence onrenal haemodynamics, natriuresis, and proteinuria (total protein,albumin, IgG excretion). Patients with a compensated treatedform of nephrotic syndrome due to primary glomerulonephritiswere included in the study. Serum creatinine levels were 1.4mg/dl. Diuretic medication was discontinued at least 24 h beforethe investigation was started. Patients were randomly assignedto ANP infusion (0.005 µg/kg*min; group II, n=15) or receivedplacebo (group III, n=16). Ten healthy subjects (group I) servedas normal controls. RESULTS.: In normal subjects (group I), ANP caused an increase in natriuresisfrom 14.5±4.2mmol/h to 26.4±11.1 mmol/h (P<0.01).In patients with nephrotic syndrome (group II), baseline sodiumexcretion of 10.5±6.0 mmol/h was increased to 19.6±14.8mmol/h with ANP infusion (P<0.01). No changes were seen inthe placebo group III. The absolute increase in ANP inducednatriuresis was not significantly different between group Iand II. However, plasma ANP levels were significantly higherin patients with nephrotic syndrome (166±87 pg/ml vs.74±21 pg/ml, P<0.05) and also reached higher levelsafter ANP infusion (P<0.01). Therefore, natriuresis was significantlyreduced when circulating ANP levels were taken into account(P<0.05). ANP administration resulted in an increase of totalprotein excretion in patients with the nephrotic syndrome (groupII, from 219±277 mg/h to 264±268 mg/h). Albuminelimination rose from 128±151 mg/h to 167±170mg/h (P<0.05) and IgG excretion from 4.91±6.67mg/hto 9.27±10.78mg/h (P<0.05). Healthy subjects alsoshowed a small but significant increase in albuminuria (48±38%,P<0.05). Low-dose ANP infusion did not, however, induce anysignificant alteration in GFR, ERPF and blood pressure. CONCLUSION.: ANP plasma concentrations in the steady state are elevated inpatients with the nephrotic syndrome. The natriuretic effectof ANP is reduced when referring to circulating ANP plasma levels.Elevated ANP levels enhance urinary protein excretion in thenephrotic syndrome. This is not due to modulation of GFR orFF, but is most probably attributable to increased glomerularpermeability.     

Postoperative nausea, vomiting, airway morbidity, and analgesic requirements are lower for the ProSeal laryngeal mask airway than the tracheal tube in females undergoing breast and gynaecological surgery

Background: We test the hypothesis that the frequency of postoperative nauseaand vomiting is similar for the ProSeal laryngeal mask airway(LMA) and the tracheal tube. Methods: Two hundred consecutive female patients (ASA I–II, 18–75yr) undergoing routine breast and gynaecological surgery weredivided into two equal-sized groups for airway management withthe ProSeal LMA or tracheal tube. Results: Ventilation was better and airway trauma less frequent for theProSeal LMA. For the ProSeal group, the time spent in the post-anaesthesiacare unit was shorter (69 vs 88 min, P < 0.0001); fewer dosesof tropisetron were required in the post-anaesthesia care unit(P 0.001) and ward (P = 0.004); morphine requirements werelower in the post-anaesthesia care unit (6.0 vs 8.1 mg, P =0.005) and ward (6.1 vs 8.9, P = 0.004); nausea was less frequentat all times (overall: 13% vs 53%, P < 0.0001); vomitingwas less frequent at 2 h (4% vs 18%, P = 0.003) and 24 h (5%vs 19%, P = 0.004); and sore throat was less frequent at alltimes (overall: 12% vs 38%, P < 0.0001). Conclusions: The ProSeal LMA reduced the absolute risk of postoperative nauseaand vomiting by 40% (53–13%). In patients without theneed for morphine, the ProSeal LMA reduced the absolute riskof postoperative nausea and vomiting by 23% (37–14%).We conclude that the frequency of postoperative nausea, vomiting,airway morbidity, and analgesic requirements is lower for theProSeal LMA than the tracheal tube in females undergoing breastand gynaecological surgery.     

Comparison of the effects of intrathecal ropivacaine, levobupivacaine, and bupivacaine for Caesarean section

Background. This study aimed to detect if intrathecal (i.t.)ropivacaine and levobupivacaine provided anaesthesia (satisfactoryanalgesia and muscular relaxation) and postoperative analgesiaof similar quality to bupivacaine in patients undergoing Caesareansection. Methods. Ninety parturients were enrolled. A combined spinal-epiduraltechnique was used. Patients were randomly assigned to receiveone of the following isobaric i.t. solutions: bupivacaine 8mg (n=30), levobupivacaine 8 mg (n=30), or ropivacaine 12 mg(n=30), all combined with sufentanil 2.5 µg. An i.t. solutionwas considered effective if an upper sensory level to pinprickof T4 or above was achieved and if intraoperative epidural supplementationwas not required. Sensory changes and motor changes were recorded. Results. Anaesthesia was effective in 97, 80, and 87% of patientsin the bupivacaine 8 mg, levobupivacaine 8 mg, and ropivacaine12 mg groups, respectively. Bupivacaine 8 mg was associatedwith a significantly superior success rate to that observedin the levobupivacaine group (P<0.05). It also provided alonger duration of analgesia and motor block (P<0.05 vs levobupivacaineand ropivacaine). Conclusions. The racemic mixture of bupivacaine combined withsufentanil remains an appropriate choice when performing Caesareansections under spinal anaesthesia. Br J Anaesth 2003; 91: 684–9     

Supplementary oxygen for emergency Caesarean section under regional anaesthesia,

Background: Controversy still exists if the administration of supplementaryoxygen to patients having emergency Caesarean section (CS) underregional anaesthesia is beneficial or potentially harmful. Therefore,in a prospective double-blinded study, we randomized patientshaving emergency CS under regional anaesthesia to receive eitherair or 60% oxygen until delivery and compared the effects onfetal oxygenation and lipid-peroxidation in the mother and baby. Methods: We recruited 131 women having emergency CS under regional anaesthesia.Either 21% (air group) or 60% oxygen (oxygen group) was administeredusing a Venturi-type facemask until delivery. We compared theoxygen exposure duration, umbilical arterial (UA) and venous(UV) blood gases and oxygen content, and plasma concentrationof 8-isoprostane. Subanalysis was performed according to whetheror not fetal compromise was considered present. Results: Data from 125 patients were analysed. For the oxygen group vsthe air group, there were greater values for UA PO₂ [mean 2.2(SD 0.5) vs 1.9 (0.6) kPa, P=0.01], UA O₂ content [6.6 (2.5)vs 4.9 (2.8) ml dl^–1, P=0.006], UV PO₂ [3.8 (0.8) vs 3.2(0.8) kPa, P<0.0001], and UV O₂ content [12.9 (3.5) vs 10.4(3.8) ml dl^–1, P=0.001]. There was no difference betweenthe groups in maternal, UA, or UV 8-isoprostane concentration.Apgar scores and UA pH were similar between the groups. Similarchanges were observed regardless of whether fetal compromisewas considered present (n=37) or not (n=88). Conclusions: Breathing 60% oxygen during emergency CS under regional anaesthesiaincreased fetal oxygenation with no associated increase in lipid-peroxidationin the mother or fetus.     

Adding ketamine to morphine for patient-controlled analgesia after thoracic surgery: influence on morphine consumption, respiratory function, and nocturnal desaturation

Background: I.V. patient-controlled analgesia (PCA) with morphine is oftenused for postoperative analgesia after thoracic surgery, butthe required doses may increase postoperative respiratory disorders.Adjunction of ketamine could reduce both doses and related respiratoryside-effects. Methods: The main objective of this prospective, randomized double-blindedstudy was to evaluate the influence of adding ketamine to PCAon morphine consumption and postoperative respiratory disorders.Consecutive patients undergoing lobectomy (n = 50) were randomlyassigned to receive, during the postoperative period, eitheri.v. morphine 1 mg ml^–1 or morphine with ketamine 1 mgml^–1 for each. Morphine consumption was evaluated by cumulativedoses every 12 h for the three postoperative days. Postoperativerespiratory disorders were assessed by spirometric evaluationand recording of nocturnal desaturation. Results: The adjunction of ketamine resulted in a significant reductionin cumulative morphine consumption as early as the 36th postoperativehour [43 (SD 18) vs 32 (14) mg, P = 0.03] with a similar visualanalogue scale. In the morphine group, the percentage of timewith desaturation < 90% was higher during the three nights[1.80 (0.21–6.37) vs 0.02 (0–0.13), P < 0.001;2.15 (0.35–8.65) vs 0.50 (0.01–1.30), P = 0.02;2.46 (0.57–5.51) vs 0.55 (0.21–1.00), P = 0.02].The decrease in forced expiratory volume in 1 s was less markedin the ketamine group at the first postoperative day [1.04 (0.68–1.22)litre vs 1.21 (1.10–0.70) litre, P = 0.039]. Conclusions: Adding small doses of ketamine to morphine in PCA devices decreasesthe morphine consumption and may improve respiratory disordersafter thoracic surgery.     

Narrative, Pain and Suffering. D. B. Carr, J. D. Loeser and D. B. Morris (editors). Published by IASP Press, Seattle, USA. Pp. 362; indexed; illustrated. ISBN 0-931092-57-4.

In the preface to Narrative, Pain and Suffering, the editorsexplain, ‘This book embodies the state-of-the art, multidisciplinaryperspective of a path-breaking (sic) international workdrop.’They go on to list the diverse disciplines from neurobiology     

Pharmacological preconditioning: comparison of desflurane,sevoflurane, isoflurane and halothane in rabbit myocardium

Background. Recent investigations showed that isoflurane caninduce pharmacological preconditioning. The present study aimedto compare the potency of four different halogenated anaestheticsto induce preconditioning. Methods. Anaesthetized open-chest rabbits underwent 30 min ofcoronary artery occlusion followed by 3 h of reperfusion. Beforethis, rabbits were randomized into one of five groups and underwenta treatment period consisting of either no intervention for45 min (control; n=10), or 30 min of 1 MAC halogenated anaestheticinhalation followed by 15 min of washout. End-tidal concentrationsof halogenated agents were 3.7% for sevoflurane (n=11), 1.4%for halothane (n=9), 2.0% for isoflurane (n=11), and 8.9% fordesflurane (n=11). Area at risk and infarct size were assessedby blue dye injection and tetrazolium chloride staining. Results. Mean (SD) infarct size was 54 (18)% of the risk areain untreated controls and 40 (18)% in the sevoflurane group(P>0.05, ns). In contrast, mean infarct size was significantlysmaller in the halothane, isoflurane, and desflurane groups:26 (18)%, 32 (18)% and 16 (17)%, respectively (P<0.05 vscontrol). Conclusions. Halothane, isoflurane and desflurane induced pharmacologicalpreconditioning, whereas sevoflurane had no significant effect.In this preparation, desflurane was the most effective agentat preconditioning the myocardium against ischaemia. Br J Anaesth 2002; 89: 486–91     

Differential effects of propofol, ketamine, and thiopental anaesthesia on the skeletal muscle microcirculation of normotensive and hypertensive rats in vivo

Background. This study utilized the dorsal microcirculatorychamber (DMC) model to determine differential effects of i.v.propofol, ketamine, and thiopental anaesthesia on the skeletalmuscle microcirculation (10–180 µm) of normotensive(Male Wistar Kyoto, WKY) and hypertensive (spontaneously hypertensiveHarlan, SHR) rats, importantly, comparing responses to a consciousbaseline. Methods. Three weeks following implantation of the DMC in WKY(n=8) and SHR (n=6) (130 g) 0.25 ml 100 g^–1 FITC–BSA(i.v.) was administered and the microcirculation viewed usingfluorescent in vivo microscopy for a 30 min baseline (t=0–30min). This was followed by either propofol, thiopental, ketamine,or saline (i.v. bolus induction over 5 min (t=30–35 min)),then maintenance step-up infusion for 60 min (t=45–105min), so that animals received all four agents 1 week apart(56 experiments). Results. Dilation of A3 arterioles (15–30 µm) andV3 venules (20–40 µm) with propofol was greaterin SHR (t=95 min, A3 36.7 (12)%, V3 15.5 (2.3)%) than WKY (t=95min, A3 19.4 (7.4)%, V3 8.0 (2.3)%) (P<0.05). Constrictionof A3 with ketamine was greater in SHR (t=95 min, A3 –29.1(6.4)%) than WKY (A3 –17.5 (8.8)%) (P<0.05). This wasaccompanied by hypotension with propofol in SHR (–32%decrease in systolic arterial pressure), but not WKY (–6%)and hypertension with ketamine in WKY (–15%) and SHR (–24%)(P<0.05). During thiopental anaesthesia there was dilationof A1 (80–180 µm), A3, and V3 in WKY (P<0.05).Conversely, in SHR dilation of venules (29.2 (8.7)%) was accompaniedby constriction of A1 and A3 (t=95 min, A1 –25.1 (5.9)%,A3 –45.2 (3.1)%) (P<0.05). Conclusion. Within the skeletal muscle microcirculation of hypertensiverats there is enhanced dilation with propofol and constrictionwith ketamine, associated with exaggerated changes in arterialpressure. Thus, dysfunctional control mechanisms at the levelof the microcirculation alter responses to anaesthesia duringhypertension.      

Patient's satisfaction with perioperative care: development, validation, and application of a questionnaire

Background: Measuring patient satisfaction after anaesthesia care is complex.The existing patient satisfaction questionnaires are limitedand omit aspects of patient satisfaction, such as professionalcompetence, information provision, service, and staff–patientrelationship. The aim of our study was to develop a valid andreliable self-reported multidimensional questionnaire assessingpatient satisfaction that included these issues. Methods: The development of the Leiden Perioperative care Patient Satisfactionquestionnaire (LPPSq) was as follows: expert consultation, constructionof the pilot questionnaire, pilot study, statistical analysisof the results of the pilot study (validity, reliability, andfactor analysis), compilation of the definitive questionnaire,main study, and repeated statistical analysis (validity, reliability,and factor analysis). The overall patient satisfaction is expressedby the mean satisfaction score. Results: Three hundred and eighty-two patients consented to participatein the study; 80.4% of the patients (n=307) completed the questionnaire.The LPPSq isolated three dimensions: information (Cronbach’s=0.82), fear and concern (Cronbach’s =0.69), and staff–patientrelationship (Cronbach’s =0.94). Patient satisfactionwith perioperative care was not directly dependent on the outcomesof anaesthesia but how patients were approached and the amountof information they received. Age (P=0.001), gender (P=0.001),work situation (P=0.003), and specialty (P=0.017) were the characteristicsmost influencing patient satisfaction. Conclusions: We developed the LPPSq questionnaire to measure patient satisfactionwith perioperative care, of which anaesthesia care is an importantelement. In this study, information provision and the relationshipbetween staff and patient were the major determinants of patientsatisfaction.     

Randomized, placebo-controlled trial of combination antiemetic prophylaxis for day-case gynaecological laparoscopic surgery

In a randomized, double-blind trial, we compared i.v. ondansetron4 mg (control), i.v. ondansetron 4 mg and cyclizine50 mg (combination) and i.v. saline 0.9% (placebo), givenafter induction of standardized anaesthesia, for the preventionof nausea and vomiting (PONV) after day-case gynaecologicallaparoscopic surgery. Compared with placebo, fewer patientsin the control group vomited (9/20 versus 11/59, P=0.02) orneeded rescue antiemetic (7/20 versus 9/59, P=0.06) before discharge.Compared with the control, fewer patients in the combinationgroup (n=60) vomited (11/59 versus 2/60, P=0.01) or needed rescueantiemetic (29/59 versus 2/60, P=0.03) before discharge. Theincidence of vomiting in the combination group was less than5% overall. Compared with the control, the combination grouphad a significantly lower incidence (P=0.001) and severity (P<0.001)of nausea after discharge and more patients with no PONV atany time during the study (15/59 versus 27/60, P=0.03). Unlikethe placebo and control groups, no patient receiving combinationprophylaxis was admitted overnight for PONV management. Br J Anaesth 2000; 85: 678–82 ^* Corresponding author