Assessment of myocardium at risk with computerized vectorcardiography and technetium-99m-sestamibi-single photon emission computed tomography during coronary angioplasty

OBJECTIVE: To compare the myocardium at risk (MAR) as estimated by computerized vectorcardiography (cVCG) with MAR determined by Tc-99m-sestamibi-SPECT using coronary angioplasty as the model for transient transmural ischemia in humans. METHODS AND RESULTS: In 37 patients with stable angina pectoris, cVCG was recorded continuously during coronary angioplasty. The scintigraphic defect was quantified using an automated software program (CEqual). The ST vector magnitude (ST-VM) and the ST change vector magnitude (STC-VM) correlated well with MAR estimated by scintigraphy, ST-VM (r = 0.71, p < 0.001) and STC-VM (r = 0.84, p < 0.001). All patients with STC-VM <50 microV during occlusion had defects of less than 10% of the left ventricle. CONCLUSION: 1) ST-VM and STC-VM give a reasonable useful estimate of MAR size during transient coronary occlusion. 2) STC-VM <50 microV is a reliable limit to identify patients with MAR size less than 10%. 3) ST-VM does not add information to STC-VM with respect to detection of ischemia. 4) The existence of collateral vessels has great impact on both ST-vector changes and scintigraphic imaging of myocardial ischemia.     

Assessment of Myocardium at Risk with Computerized Vectorcardiography and Technetium-99m-Sestamibi-Single Photon Emission Computed Tomography during Coronary Angioplasty

Objective - To compare the myocardium at risk (MAR) as estimated by computerized vectorcardiography (cVCG) with MAR determined by Tc-99m-sestamibi-SPECT using coronary angioplasty as the model for transient transmural ischemia in humans. Methods and results - In 37 patients with stable angina pectoris, cVCG was recorded continuously during coronary angioplasty. The scintigraphic defect was quantified using an automated software program (CEqual). The ST vector magnitude (ST-VM) and the ST change vector magnitude (STC-VM) correlated well with MAR estimated by scintigraphy, ST-VM ( r = 0.71, p < 0.001) and STC-VM ( r = 0.84, p < 0.001). All patients with STC-VM <50 &#119 V during occlusion had defects of less than 10% of the left ventricle. Conclusion - 1) ST-VM and STC-VM give a reasonable useful estimate of MAR size during transient coronary occlusion. 2) STC-VM <50 &#119 V is a reliable limit to identify patients with MAR size less than 10%. 3) ST-VM does not add information to STC-VM with respect to detection of ischemia. 4) The existence of collateral vessels has great impact on both ST-vector changes and scintigraphic imaging of myocardial ischemia.     

Dexmedetomidine blunts acute hyperdynamic responses to electroconvulsive therapy without altering seizure duration

Background: This study was designed to evaluate the effect of dexmedetomidine on the acute hyperdynamic response, duration of seizure activity and recovery times in patients undergoing electroconvulsive therapy (ECT).
Methods: Fourteen patients underwent a total of 84 ECT sessions as a crossover design. Patients were randomly allocated to receive either dexmedetomidine (1 μg/kg IV over a period of 10 min) or saline (control). Anaesthesia was induced with propofol 1 mg/kg, and then succinylcholine 0.5 mg/kg IV was administered. Arterial blood pressure and heart rate (HR) were recorded during the study period.
Results: HR in the dexmedetomidine group was lower than that in the control group at 5 and 10 min after the start of study drug infusion, and at 1, 3 and 10 min after the seizure ended ( P <0.05). Peak HR was lower in the dexmedetomidine group compared with that in the control group ( P <0.05). The mean arterial pressure (MAP) values in the dexmedetomidine group were lower at 0, 1, 3 and 10 min after the seizure ended compared with the control group ( P <0.05). Both motor and electroencephalography (EEG) seizure duration in the control group (35.65 ± 14.89 and 49.07 ± 9.94 s, respectively) were similar to that in the dexmedetomidine group (33.30 ± 12.01 and 45.15 ± 17.79 s, respectively) ( P >0.05). Time to spontaneous breathing, eye opening and obeying commands were not different between the groups.
Conclusion: A dexmedetomidine dose of 1 μg/kg IV administered over 10 min before the induction of anaesthesia with propofol may be useful in preventing the acute hyperdynamic responses to ECT without altering the duration of seizure activity and recovery time.     

Anti-ischemic effects of inotropic agents in experimental right ventricular infarction

Background: Right ventricular (RV) function is an important determinant of survival after myocardial infarction. The efficacy of reperfusion therapy might be increased by the cardioprotective action of inotropic agents, which are used for symptomatic therapy in situations with compromised hemodynamics. Therefore, we used a porcine model of RV ischemia and reperfusion (IR) injury to study the influence of milrinone, levosimendan and dobutamine on the extent and degree of myocardial injury.
Methods: IR injury was induced by temporary ligation of the distal right coronary artery for 90 min, followed by 120 min of reperfusion. Treatment was initiated 30 min after coronary artery occlusion. A bolus of milrinone ( n =12; 50 μg/kg) and levosimendan ( n =10; 24 μg/kg) was applied in different groups, followed by continuous infusion of the drugs at 0.5 and 0.2 μg/kg/min, respectively. The effects on myocardial injury and inflammation were compared with a control ( n =12) and a dobutamine group ( n =10), where treatment was started with an infusion of 5 μg/kg/min.
Results: Milrinone and levosimendan reduced the resulting infarct size with respect to the area at risk (41.7±10.2%, 45.7±8.1%) when compared with the control group (58.3±6.1%). In contrast, dobutamine had no effect (55.8±7.7%). All drugs reduced the number of neutrophils infiltrating into the different myocardial regions and the circulating levels of interleukin-6. Increased levels of tumor necrosis factor α during reperfusion were only abated by milrinone and levosimendan.
Conclusions: Cardioprotective properties of milrinone and levosimendan were demonstrated for the first time in a clinically relevant model of RV infarction.     

Lidocaine abolishes the myocardial protective effect of sevoflurane post-conditioning

Background: Post-ischemic administration of volatile anesthetics activates ischemia–reperfusion injury salvage process and decreases myocardial damage. However, the mechanisms underlying anesthetic post-conditioning and effects of lidocaine on it remain unclear. Here we report the cardioprotection of sevoflurane-induced post-conditioning and the effects of lidocaine on it.
Methods: Isolated perfused rat hearts were exposed to 40 min of ischemia followed by 1 h of reperfusion. Volatile anesthetic post-conditioning was induced by 15 min of 3 vol% sevourane (1.5 minimum alveolar concentration) administered at the onset of reperfusion. In some experiments, lidocaine was coadministered with sevoflurane in different concentrations (2, 10 and 20 μg/ml). Infarct size was determined by dividing the total necrotic area of the left ventricle by the total left ventricular slice area (percent necrotic area).
Results: Sevoflurane-induced post-conditioning signicantly improved post-ischemia functional recovery and decreased infarct size (47.3±5.6% in unprotected hearts vs. 18.6±3.1% in anesthetic post-conditioning, P <0.05). Sevourane-mediated cardioprotection was abolished by 20 μg/ml lidocaine.
Conclusions: Sevourane-induced post-conditioning effectively protected myocardium against reperfusion damage and its cytoprotection was reversed by 20 μg/ml lidocaine.     

Mivazerol inhibits intrathecal release of glutamate evoked by halothane withdrawal in rats

Background : Mivazerol is a new and selective α₂-adrenergic receptor agonist devoid of hypotensive effects (1, 2). Previous studies have demonstrated that mivazerol prevents hemodynamic instability during emergence from halothane anesthesia in rats (3). The present study was to determine whether glutamate and aspartate are involved in this action of mivazerol, at the second to third thoracic segments (T2–T3) of the spinal cord.
Methods : In vivo microdialysis in combination with high-performance liquid chromatography (HPLC) was employed in the study. Blood pressure (BP) and heart rate (HR) were recorded along with intrathecal (i.t.) microdialysis perfusion.
Results : BP, HR and i.t. release of glutamate (GLU, pmol/μl) were stable in the rats under 1.1% halothane anesthesia. However, halothane withdrawal immediately increased BP, HR, and i.t. release of GLU, and remained elevated for at least 2 h after withdrawal of halothane. Thirty minutes prior to halothane withdrawal, intravenous (i.v.) infusion of mivazerol (15 μg · kg^–l · h^–) almost completely prevented the increases in HR (Δ18±7 vs Δ79±7 beats/min), and in the i.t. release of GLU (Δ10.3±3.7 vs Δ30.6±5.9; 112% vs 167%). Local i.t. microinjection of mivazerol (2.5 μg/kg) 2 min prior to withdrawal of halothane also blocked the HR responses, as well as on the i.t. release of GLU following halothane withdrawal.
Conclusion : The present study demonstrates that emergence from halothane anesthesia increases i.t. release of GLU, and that mivazerol has an inhibitory effect on the above, through its direct action on the spinal cord.     

Administration of milrinone before ischemia, in the presence of beta-blockade, to treat metabolic impairment and myocardial stunning in pigs

Background: We examined effects of phosphodiesterase type III inhibition on regional myocardial metabolism and global left ventricular function, during ischemia, in the presence of β-blockade.
Methods: Twenty-three pigs were randomized and studied to completion in four groups: C, did not receive drugs; M, received 50 μg/kg milrinone; E, received esmolol (150 μg/kg/min); E+M, received both. The left anterior descending artery (LADa) was then occluded for 15 min, followed by a 60-min reperfusion. Left ventricular (LV) function data obtained included LV pressures, cardiac output (CO), slope of end-systolic pressure–volume relationship (Emax), and dP/dT. Blood lactate concentrations were obtained from the aorta, LADa, and vein at baseline, end of occlusion, and during early (5 min) and late (1 h) reperfusion.
Results: During ischemia, occlusion produced significant depression in LV dP/dT, Emax and concomitant elevation of LVEDP that persisted over early reperfusion in groups not treated with milrinone. After ischemia, measurements of CO were higher, with lower LVEDP and SVR; LV dP/dT and the Emax were higher, with lower LVEDP in the E+M group vs. the E group. Ischemic region lactate extraction during ischemia was better with E group vs. C group. Esmolol without or with milrinone was associated with nonsignificant lactate ischemic production during early reperfusion from baseline values.
Conclusion: We demonstrated that the pre-emptive administration of milrinone before ischemia was associated with less ischemic hemodynamic effects, without worsening the ischemic metabolic process. The combination E+M diminished ischemic metabolic impairment, and preserved left ventricular function and baseline hemodynamics.     

Efficacy of a low-dose spinal morphine with bupivacaine for postoperative analgesia in children undergoing hypospadias repair

Background:  Children undergoing hypospadias repair need to be protected from highly unpleasant sensory and emotional experiences during and after surgery. We designed a double-blinded, randomized, and placebo-controlled study to compare the efficacy of a low-dose (2 μg·kg⁻¹) of intrathecal morphine with placebo for postoperative pain control of children undergoing repair of hypospadias surgery with spinal anesthesia.
Methods:  Fifty-four children were randomly assigned to one of two spinal anesthesia groups. Group M ( n  = 27) received hyperbaric bupivacaine plus 2 μg·kg⁻¹ of preservative-free morphine and group P ( n  = 27) received hyperbaric bupivacaine plus 0.9% NaCl (placebo) under inhalation anesthesia. General anesthetics were discontinued subsequent to the block. The primary outcome was the presence of pain-requiring analgesics during the first 12 h after the spinal block. Side effects were also recorded. The analgesic effects were evaluated by using the Children's Hospital of Eastern Ontario Pain Scale.
Results:  Forty-nine patients completed the trial. Fifteen patients (60%) in group P received supplementary analgesics within the first 12 h compared to only four patients (16.7%) in group M ( P  = 0.005). Mean duration of analgesia was 480 ± 209 and 720 ± 190 min in group P and group M respectively ( P  = 0.009). The groups were similar in postoperative side effects.
Conclusion:  Spinal anesthesia provided by hyperbaric bupivacaine is adequate for distal hypospadias repair in children, but adding 2 μg·kg⁻¹ intrathecal morphine provides better postoperative pain control when compared to placebo in these children.     

Comparison of spinal anesthesia with general anesthesia on morphine requirement after abdominal hysterectomy

Purpose: The aim of this study was to compare morphine consumption with patient-controlled analgesia (PCA) between spinal anesthesia (SA) (bupivacaine, morphine and fentanyl) and general anesthesia (GA) (sufentanil) after an abdominal hysterectomy.
Methods: Forty women were randomly assigned to receive SA with bupivacaine 15 mg, 0.15 mg of intrathecal morphine and 15 μg of fentanyl or GA with sufentanil, both combined with PCA. The primary outcome was morphine consumption with the PCA device. The secondary outcomes were post-operative pain at rest and under stress on a visual analog scale, nausea, pruritus and respiratory depression on a standardized scale. Outcome measures were recorded at 6, 12, 18, 24 and 48 h post-anesthesia. The duration of post-anesthesia care unit (PACU) and hospital stay were recorded.
Results: Patients in the SA group consumed at least two times less morphine at each time interval than the GA group: at 48 h, they used 19 ± 17 vs. 81 ± 31 mg ( P <0.0001). Post-operative pain at rest was lower in the SA group until the 18th hour and under stress until the 48th. There was more sedation in the GA group until the 18th hour. Little difference was observed in the incidence of pruritus. Nausea was more intense at the 6th hour in the GA group. There was no difference in the respiratory rate. The duration of PACU stay was shorter for the SA group (52 ± 9 vs. 73 ± 11 min, P <0.0001) as was the duration of hospital stay (2.2 ± 0.4 vs. 3.3 ± 0.7 days, P =0.01).
Conclusions: It is concluded that intrathecal morphine 0.15 mg with 15 μg of fentanyl decreases post-operative pain and morphine consumption by PCA without increasing adverse reactions for women undergoing an abdominal hysterectomy.     

Influence of acute normovolaemic haemodilution on bispectral index monitoring and propofol dose requirements

Background: Numerous medical and physiological conditions that might alter electroencephalography (EEG), such as hypoglycaemia, hypothermia or hypovolaemia, were shown to result in the bispectral Index (BIS) indicating an incorrect hypnotic state. Recently, acute normovolaemic haemodilution (ANH) was shown to be associated with significant impairment of cognitive functions that could alter EEG and consequently BIS monitoring, an EEG derived parameter.
Methods: In a randomised clinical study, we assessed the effect of ANH on BIS monitoring before induction and after propofol target controlled infusion (TCI) anaesthesia in 45 unmedicated patients randomly allocated to ANH with oxygen insufflation (oxygen group), ANH with air insufflation (air group), or control group.
Results: With ANH, mean BIS values briefly declined in the oxygen group (82±4) and air group (84±3) before returning to baseline values. The loss of consciousness time was significantly shorter, with fewer propofol TCI dose requirements, and BIS was significantly higher in the oxygen group (1.3±0.5 min, 2.41±0.15 μg/ml, 73±7) and air group (1.2±0.6 min, 2.44±0.17 μg/ml, 75±5), compared with the control group (1.7±0.4 min, 2.75±0.17 μg/ml, 61±5), respectively. Whereas, there was no significant difference in BIS values between the oxygen group (38±7), air group (36±5) and control group (40±6) at propofol TCI 4 μg/ml anaesthesia maintenance.
Conclusions: BIS values briefly declined with ANH before returning to baseline values before anaesthesia induction. Despite transient ANH enhancement of propofol effect during induction, there was no significant difference in BIS values with or without ANH during propofol maintenance of anaesthesia.     

The optimal bolus dose of alfentanil for tracheal intubation during sevoflurane induction without neuromuscular blockade in day-case anaesthesia

Background: The purpose of this study was to determine the optimal bolus dose of alfentanil required to provide successful intubating conditions following inhalation induction of anaesthesia using 5% sevoflurane and 60% nitrous oxide without neuromuscular blockade in adult day-case anaesthesia.
Methods: Twenty-four adults, aged 18–60 years, undergoing general anaesthesia for short ambulatory surgery were enroled into the study. After vital capacity induction, with sevoflurane 5% and 60% nitrous oxide in oxygen, pre-determined dose of alfentanil was injected over 30 s. The dose of alfentanil was determined by modified Dixon's up-and-down method (2 μg/kg as a step size). Ninety seconds after the end of bolus administration of alfentanil, the trachea was intubated. Systolic blood pressure, heart rate and SpO₂ were recorded at anaesthetic induction, before, 1 min and 3 min after intubation.
Results: The bolus dose of alfentanil for successful tracheal intubation was 10.7±2.1 μg/kg in 50% of patients during inhalation induction. From probit analysis, 50% effective dose (ED₅₀) and ED₉₅ values (95% confidence limits) of alfentanil were 10.7 μg/kg (8.0–12.9 μg/kg) and 14.9 μg/kg (12.9–31.1 μg/kg), respectively.
Conclusions: Using the modified Dixon's up-and-down method, the bolus dose of alfentanil for successful tracheal intubation was 10.7±2.1 μg/kg in 50% of adult patients during inhalation induction using 5% sevoflurane and 60% nitrous oxide in oxygen without neuromuscular blocking agent in day-case anaesthesia.     

Rotational thrombelastometry for the bedside monitoring of recombinant hirudin

Background: Recombinant hirudin is used as an alternative anticoagulant, particularly in patients with heparin-induced thrombocytopenia type II. However, bedside monitoring for hirudin is not available. The present study aims to evaluate rotational thrombelastometry regarding its suitability to detect the effects of recombinant hirudin on whole blood coagulation. Hirudin was added to whole blood samples from healthy donors ( n =5) and thrombelastometry variables resulting from activation of samples with tissue factor, ellagic acid, and ecarin were determined.
Methods: Hirudin (0.1–10 μg/ml) was added to citrated blood. Thereafter, rotational thrombelastometry was performed by initiating coagulation via recalcification and addition of tissue factor, ellagic acid, and ecarin, respectively, using the commercially available assays.
Results: In the absence of hirudin, clotting times (CT) induced by ellagic acid, tissue factor, and ecarin, respectively, were 141.7±18.0, 54.0±7.6, and 64.5±4.1 s. Increasing concentrations of hirudin led to dose-dependent prolongation of the clotting time with the three activators. All assays were capable to detect hirudin concentrations in the range of 0.5–5 μg/ml. At a final hirudin concentration of 1 μg/ml, clotting time increased to 268.0±25.1, 84.0±9.3, and 107.5±9.9 s, respectively, with the above-mentioned activators. The other thrombelastographic variables, including clot formation time, angle α, and maximum clot firmness, were not altered by hirudin at concentrations up to 5 μg/ml.
Conclusions: Our study demonstrates the suitability of rotational thrombelastometry to detect anticoagulant effects of recombinant hirudin.     

Remifentanil for percutaneous intravenous central catheter placement in preterm infant: a randomized controlled trial

Background:  There is limited evidence on the analgesic efficacy of opioids during percutaneous intravenous central catheter (PICC) insertion in preterm infants.
Aim:  To assess the analgesic and procedural efficacy of low-dose remifentanil infusion during PICC in preterm infants.
Methods:  Fifty-four neonates [mean gestational age (± sd ) 28 ± 2 weeks; birth weight 1126 ± 337 g] were randomly assigned to remifentanil infusion at 0.03 mcg·kg⁻¹·min⁻¹ (R) or placebo (C) in addition to 0.3 ml of 12% sucrose per os and non-nutritive sucking.
Results:  Validated pain scales [Neonatal Infants Pain Scale (NIPS) and Premature Infants Pain Profile (PIPP)] administered at the baseline T0, skin preparation T1, needle insertion T2, and recovery T3, revealed differences in mean NIPS scores (C 5.3 ± 1.3 vs R 4.2 ± 1.4 at T1 and C 5.0 ± 1.3 vs R 3.4 ± 1.3 at T2) and PIPP scores (C 9.3 ± 1.6 vs R 7.1 ± 1.5 at T1 and C 8.6 ± 1.7 vs R 6.1 ± 1.4 at T2); P  < 0.05. Cardiovascular and respiratory response, and body movements during PICC suggested better pain and distress control with remifentanil ( P  < 0.05), but the time to complete the maneuver and the number of attempts needed remained the same in the two groups.
Conclusions:  Low-dose remifentanil has a measurable, synergic analgesic effect in combination with 12% sucrose and non-nutritive sucking, but does not make PICC easier or quicker.     

Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block

Background: In this prospective randomized study, the authors compared the analgesic effect of a fascia iliaca compartment (FIC) block with that of intravenous (i.v.) alfentanil when administered to facilitate positioning for spinal anaesthesia in elderly patients undergoing surgery for a femoral neck fracture.
Methods: The 40 patients were randomly assigned to one of two groups, namely, the FIC group (fascia iliaca compartment block, n =20) and the IVA group (intravenous analgesia with alfentanil, n =20). Group IVA patients received a bolus dose of i.v. alfentanil 10 μg/kg, followed by a continuous infusion of alfentanil 0.25 μg/kg/min starting 2 min before the spinal block, and group FIC patients received a FIC block with 30 ml of ropivacaine 3.75 mg/ml (112.5 mg) 20 min before the spinal block. Visual analogue pain scale (VAS) scores, time to achieve spinal anaesthesia, quality of patient positioning, and patient acceptance were compared.
Results: VAS scores during positioning (mean and range) were lower in the FIC group than in the IVA group [2.0 (1–4) vs. 3.5 (2–6), P =0.001], and the mean (± SD) time to achieve spinal anaesthesia was shorter in the FIC group (6.9 ± 2.7 min vs. 10.8 ± 5.6 min; P =0.009). Patient acceptance (yes/no) was also better in the FIC group (19/1) than in the IVA group (12/8)( P =0.008).
Conclusions: An FIC block is more efficacious than i.v. alfentanil in terms of facilitating the lateral position for spinal anaesthesia in elderly patients undergoing surgery for femoral neck fractures.     

Delayed pharmacological pre-conditioning effect of mitochondrial ATP-sensitive potassium channel opener on neurologic injury in a rabbit model of spinal cord ischemia

Background: Diazoxide, pharmacological openers of mitochondrial ATP-sensitive potassium channels have been shown to induce early pre-conditioning in the spinal cord. Here, the authors investigated whether diazoxide also induce delayed pre-conditioning and thereby reduce neurologic complications using a rabbit model of spinal cord ischemia.
Methods: Infrarenal blood flow was interrupted for 20 min in 21 rabbits. Non-treated control animals received no pre-treatment. Diazoxide (5 mg/kg) were given 48 h before 20 min ischemia in the 48-h DZ group, whereas 15-min DZ group received diazoxide (5 mg/kg) 15 min before 20-min ischemia. Neurological functions were evaluated using Johnson scores for 3 days after reperfusion, after which, spinal cords were procured for hematoxylin and eosin staining for cell counting.
Results: Johnson scores revealed a marked improvement in both the diazoxide-treated groups vs. the non-treated control group at 3, 24, 48, and 72 h after reperfusion ( P <0.01). The histologic changes were proportional to the Johnson scores, with better preservation of motor neuron numbers in the animals of the 48-h DZ and 15-min DZ group relative to the non-treated controls (81±12, 90±10, 50±23 motor neurons, respectively, P <0.01). No difference was found between the 48-h DZ group and 15-min DZ group with respect to the Johnson scores or neuron numbers.
Conclusions: The study demonstrates that pre-treatment with diazoxide 48 h before ischemia, induce delayed pharmacological pre-conditioning, thereby significantly improving clinical neurologic scores and histologic findings in this animal model.     

Prognostic factors of renal cell carcinoma with extension into inferior vena cava

Objective:   To evaluate the prognosis of our series of patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC) treated with nephrectomy and thrombectomy.
Methods:   In 46 patients with unilateral RCC extending into IVC who underwent nephrectomy and thrombectomy (T3b in 38 patients, T3c in 6, T4 in 2, N+ in 15, M1 in 21), overall and cancer-specific survival rates were estimated, and the univariable and multivariable analysis were carried out to determine the prognostic factors among age, gender, performance status, fever, inflammatory laboratory parameters, nodal and distant metastasis, tumor thrombus level, pathological parameters and postoperative interferon-α administration.
Results:   The median age was 66.5 (range 35–79) years. The median follow-up was 18.0 (mean 36.7 ± 38.7) months. The overall and cancer-specific 5-year survival rates were 32.9% and 40.0%, respectively. The univariate analysis revealed that fever (hazard ratio: HR 4.03), C-reactive protein (HR 4.89), grade of tumor cell (HR 3.83), and lymph node metastasis (HR 5.99) were independent prognostic factors of cause-specific survival in all patients. The multivariate analysis demonstrated that lymph node metastasis (HR 4.13) was the only independent prognostic factor of cause-specific survival. The extension level or postoperative interferon-α administration did not influence the prognosis of patients with tumor thrombus involving IVC.
Conclusions:   Aggressive surgery should be considered first in RCC patients with any levels of tumor thrombus. However, patients with both IVC involvement and nodal metastasis showed significantly poor prognosis, and development of novel intensive multidisciplinary therapies will be needed.     

Pre-operative carbohydrate loading may be used in type 2 diabetes patients

Background: Post-operative insulin resistance and hyperglycaemia are associated with an impaired outcome after surgery. Pre-operative oral carbohydrate loading (CHO) reduces post-operative insulin resistance with a reduced risk of hyperglycaemia during post-operative nutrition. Insulin-resistant diabetic patients have not been given CHO because the effects on pre-operative glycaemia and gastric emptying are unknown.
Methods: Twenty-five patients (45–73 years) with type 2 diabetes [glycated haemoglobin (HbA1c) 6.2 ± 0.2%, mean ± SEM] and 10 healthy control subjects (45–72 years) were studied. A carbohydrate-rich drink (400 ml, 12.5%) was given with paracetamol 1.5 g for determination of gastric emptying.
Results: Peak glucose was higher in diabetic patients than in healthy subjects (13.4 ± 0.5 vs. 7.6 ± 0.5 mM; P <0.01) and occurred later after intake (60 vs. 30 min; P <0.01). Glucose concentrations were back to baseline at 180 vs. 120 min in diabetic patients and healthy subjects, respectively ( P <0.01). At 120 min, 10.9 ± 0.7% and 13.3 ± 1.2% of paracetamol remained in the stomach in diabetic patients and healthy, subjects respectively. Gastric half-emptying time (T50) occurred at 49.8 ± 2.2 min in diabetics and at 58.6 ± 3.7 min in healthy subjects ( P <0.05). Neither peak glucose, glucose at 180 min, gastric T50, nor retention at 120 min differed between insulin (HbA1c 6.8 ± 0.7%)- and non-insulin-treated (HbA1c 5.6 ± 0.4%) patients.
Conclusions: Type 2 diabetic patients showed no signs of delayed gastric emptying, suggesting that a carbohydrate-rich drink may be safely administrated 180 min before anaesthesia without risk of hyperglycaemia or aspiration pre-operatively.     

Correlation between plasma milrinone concentration and renal function in patients with cardiac disease

Background: The dose of milrinone should be reduced in patients with renal failure. However, there is little data examining the relationship between plasma concentration of milrinone (pCmil) and renal function in intravenous infusion.
Methods: We evaluated the pCmil relative to renal function during intravenous infusion. We enrolled 10 heart failure patients. Milrinone was continuously infused at a rate of 0.2 μg/kg/min. Blood samples were collected at 6, 12, 24, and 48 h after the beginning of infusion. Urine was sampled during the first 24 h to calculate creatinine clearance (CLcr) and renal clearance of milrinone (rCLmil).
Results: The pCmil exhibited stability over 6 h after the beginning of infusion. During the first 24 h, CLcr and rCLmil were 62.2±30.6 ml/min and 1.67±0.77 ml/kg/min (106.2±60.3 ml/min), respectively. The rCLmil was highly correlated with CLcr. Y =1.77 X −3.89 ( X , CLcr; Y , rCLmil; R ²=0.809, P <0.0001). Significant correlations were observed between CLcr and the plasma concentration during the continuous infusion. This correlation was expressed as the equation Y =51.1 × (BW/ X )+28.2 ( X ; CLcr, Y ; plasma concentration; BW, body weight; R ²=0.695, P <0.01).
Conclusion: The pCmil exhibited stability 6 h or later after the continuous infusion of milrinone 0.2 μg/kg/min. The pCmil can be estimated by the value of CLcr and BW.     

Intrathecal low-dose hyperbaric bupivacaine-clonidine combination in outpatient knee arthroscopy: a randomized controlled trial

Background: Spinal anesthesia for knee arthroscopy can be produced with a low dose of bupivacaine, but additional intrathecal drugs are often required to lower the risk of failed blocks. We investigated the effect of the addition of clonidine (0, 15 or 30 μg) to 5 mg hyperbaric bupivacaine on the duration of the motor block, analgesic quality and ability to void after the surgery in a randomized controlled trial.
Methods: Seventy-five patients received spinal anesthesia using either 5 mg hyperbaric bupivacaine (B5C0), 5 mg hyperbaric bupivacaine with 15 μg clonidine (B5C15) or 5 mg hyperbaric bupivacaine with 30 μg clonidine (B5C30). The primary outcome was the duration of the motor block. Secondary outcomes included the time until spontaneous voiding, and the need for additional analgesia or general anesthesia.
Results: The mean time to complete regression of motor block was 70 (±43) min in group B5C0. Adding 15 and 30 μg of clonidine increased the motor block duration by 25 [95% confidence interval (CI): 2–48] and 34 (95% CI: 11–57) min, respectively, but resulted in better analgesic quality. The mean time until spontaneous voiding was 177 min in the B5C0 group. This time increased with 18 (95% CI −13 to 49) and 44 (95% CI 15–74) min in group B5C15 and group B5C30, respectively.
Conclusion: The addition of 15 μg clonidine to 5 mg of intrathecal hyperbaric bupivacaine prolongs the duration of motor block and improves the quality of the block.     

Early Results and Feasibility of Incompetent Perforator Vein Ablation by Endovenous Laser Treatment

BACKGROUND Dissection of incompetent perforator veins even when using the subfascial endoscopic perforator surgery technique is associated with substantial side effects.
OBJECTIVE The objective was to evaluate the feasibility of endovenous laser ablation of incompetent perforator veins.
PATIENTS AND METHODS A 940-nm diode laser and a Nd:YAG laser with 1,320 nm were used with laser fibers of 600 μm diameter. Perforators were accessed by ultrasound-guided puncture using 16- and 18-gauge cannulas, respectively. Fiber tips were placed below the fascia with at least 1-cm distance from the deep vein system. After administration of perivascular local anesthesia, laser energy was delivered in a pulsed fashion using laser power in the range between 5 and 30 W.
RESULTS A total of 67 perforators were treated. Except one vein, all others were occluded at Day 1 after treatment. With 1,320 nm at 10 W, a median of 250 J (range, 103–443 J) was delivered resulting in significantly reduced posttreatment diameters to a mean of 69±23% ( p =.0005). With 940 nm at 30 W, a median of 290 J (range, 90–625 J) was administered, showing no significant posttreatment diameter reduction. Side effects were moderate.
CONCLUSION Ultrasound-guided endovenous ablation of incompetent perforators is safe and feasible.