Fentanyl is more effective than remifentanil at preventing increases in cerebral blood flow velocity during intubation in children

PURPOSE: Controlling the cerebral and systemic hemodynamic responses to laryngoscopy and tracheal intubation may play a role in determining clinical outcome in pediatric neurosurgical patients. This study compared the effects of remifentanil and fentanyl on cerebral blood flow velocity (CBFV) and hemodynamic profile during laryngoscopy and tracheal intubation in children under sevoflurane anesthesia. METHODS: Sixty healthy children aged two to six years undergoing dental surgery under general anesthesia were enrolled. Each child was randomly assigned to receive a remifentanil or fentanyl infusion, at a rate of 0.75, 1.0, or 1.5 microg x kg(-1) x min(-1) after induction of anesthesia with 2% sevoflurane. Middle cerebral artery blood flow velocity was measured by transcranial Doppler (TCD) sonography. Once a baseline set of hemodynamic variables and TCD measurements were recorded, the opioid infusion was started. Measurements were taken at two-minute intervals, starting four minutes prior to laryngoscopy until four minutes following naso-tracheal intubation. RESULTS: Remifentanil caused a more significant decrease in mean arterial pressure and CBFV prior to tracheal intubation than did fentanyl (P < 0.001). During laryngoscopy and for two minutes following tracheal intubation, CBFV increased in all remifentanil groups (P < 0.05), whereas it remained stable in all fentanyl groups. CONCLUSION: This study suggests that fentanyl was more effective than remifentanil at preventing increases in CBFV during and immediately following laryngoscopy and tracheal intubation in children undergoing sevoflurane anesthesia. Fentanyl also seemed to provide a more stable hemodynamic profile prior to laryngoscopy and tracheal intubation when compared to remifentanil.     

Results of the probe technique for transatrial repair of tetralogy of Fallot

OBJECTIVE: Total correction of classical tetralogy of Fallot (TOF) by transatrial approach has become a standard procedure in the goal to minimize structural damage to the pulmonary pump. The most critical point in transatrial repair of TOF is infundibular dissection. Right atrial approach provides better surgical exposure for parietal extension of the infundibular septum when compared to the right ventricular approach. However it is not always easy to determine the localization and amount of muscle bundles to be resected and this surgical maneuver requires experience. METHODS: Nineteen patients who had repair of isolated TOF using this technique from 1993 to 2001 were reviewed. The mean age of patients were 5 +/- 2 years. Transatrial-transpulmonary approach were performed for all patients. To make easier the infundibular muscle bundles resection and to determine the localization and amount of muscle bundle to be resected, we placed a Hegar dilator into the right ventricle through pulmonary arteriotomy. The muscle bundles between the dilator and the anterior leaflet annulus of the tricuspid valve were totally excised until the intraventricular part of the dilator and pulmonary annulus became completely visible. The area between the Hegar dilator and the margins of the ventricular septal defect (VSD) was left untouched. None of the patients had transannular patch. To improve exposure, tricuspid valve detachment was performed in 11 patients. All patients were followed-up in our clinic every 6 months using echocardiography. RESULTS: There were no early or late deaths, and no reoperation for residual VSD or residual right ventricle (RV) outflow obstruction. All patients were in NYHA Class I. RV on the echocardiography was spared late dilatation and had a good late functional status. Eighteen patients had no or mild pulmonary regurgitation. One patient who had undergone tricuspid anterior leaflet detachment showed mild tricuspid insufficiency. CONCLUSION: On the basis of hemodynamic outcomes, this procedure for elective repair of TOF in selected cases shows excellent early and mid-term results.     

Left ventricular systolic and diastolic function and carotid intima-media thickness in pediatric dialysis patients

Background  Cardiovascular complications are common in patients with end-stage renal disease (ESRD). We aimed to investigate left ventricular (LV) function and carotid intima-media thickness (cIMT) in children and adolescents with ESRD. Methods  This study included 38 ESRD patients (15 hemodialysis and 23 peritoneal dialysis) and 17 age- and sex-matched healthy subjects. Results  The ESRD patients had significantly lower mean mitral E/A ratio, and higher left ventricular mass index (LVMI) and cIMT than the control group. Compared with PD patients, HD patients had worse LV diastolic function. In stepwise linear regression analysis, LVMI (P = 0.043) and hemoglobin (P = 0.015) turned out to be independent variables for predicting diastolic dysfunction (reduced E/A ratio), and the only significant predictor of cIMT was indexed diastolic blood pressure (DBP) (P = 0.035). Conclusion  Cardiovascular structure and function abnormalities are also common in pediatric dialysis patients, as in adults. Furthermore our data indicated that hemodialysis was disadvantageous for preserving LV diastolic function as compared with peritoneal dialysis.     

Combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic decompression of a giant pituitary adenoma: case report

Objective  This is the first report of the simultaneous combined use of trans-sphenoidal and trans-ventricular-endoscopic route for decompression of a giant pituitary adenoma. Method  A 38 year old man presented to us with symptoms of raised intracranial pressure along with visual and hypothalamic disturbances. The CT scan revealed destruction of the sella by a large (5 × 3.5 × 2.5 cm) well defined enhancing mass in the sella and suprasellar region extending laterally up to the cavernous sinuses and both carotid arteries and superiorly into the lumen of the 3rd ventricle producing obstructive hydrocephalus. On T2WI of the non-contrast MRI scan the mass was iso-intense to grey matter suggesting the possibility of a firm nature of the adenoma. The tumour was first approached by the standard trans-sphenoidal route and as predicted from the pre-operative MRI, the tumour was found to be firm and not amenable to suction. After decompression of the intra-sellar part of the tumour, the intracranial pressure was raised in an attempt to make the remainder of the tumour descend into the sella but without success. The suprasellar part of the tumour was then simultaneously addressed via a trans-ventricular-endoscopic route but the firm tumour did not yield to endoscopic instruments viz. biopsy forceps, angiographic catheter and electrosurgical probes. It was then gently pushed down towards the sella and decompressed piecemeal by using trans-sphenoidal instruments. The sellar cavity was reconstructed using fat, fascia lata graft and a piece of septal bone. Results  Post-operatively, the patient showed a remarkable improvement of his symptoms of raised intracranial pressure, hypothalamic dysfunction and visual disturbances. Follow-up imaging at 2 months and 1 year, did not show any residual or recurrent tumour. Conclusions  This novel technique of the combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic approach is a viable option for patients with giant fibrous pituitary adenoma when the tumour is not yielding to the trans-sphenoidal route alone.     

Increased serum renalase in hemodialysis patients: is it related to left ventricular hypertrophy?

Introduction: Left ventricular hypertrophy (LVH) is one of the most common cardiac abnormalities in patients with end stage renal disease (ESRD). Hypertension, diabetes, increased body mass index, gender, age, anemia, and hyperparathyroidism have been described as risk factors for LVH in patients on dialysis. However, there may be other risk factors which have not been described yet. Recent studies show that renalase is associated with cardiovascular events. The aim of this study was to reveal the relation between renalase, LVH in patients under hemodialysis (HD) treatment.

Methods: The study included 50?HD patients and 35 healthy controls. Serum renalase levels and left ventricle mass index (LVMI) were measured in all participants and the relation between these variables was examined.

Findings: LVMI was positively correlated with dialysis vintage and C-reactive protein (CRP) (r?=?0.387, p?=?0.005 and r?=?0.597, p?r?=??0.324, p?=?0.022 and r?=??0.499, p?r?=?0.263, p?=?0.065). Serum renalase levels were significantly higher in HD patients (212?±?127?ng/mL) compared to controls (116?±?67?ng/mL) (p?r?=?0.677, p?r?=?0.625, p?Discussion: In our study, LVMI was correlated with dialysis vintage, residual diuresis, CRP, and hemoglobin. LVMI tends to correlate with renalase and this correlation may be significant in studies with more patient numbers. The main parameters affecting renalase levels are dialysis vintage and serum creatinine.     

Preoperative multimodal administration of morphine in arthroscopic surgery

Introduction The aim of the study was to demonstrate the possible effects of preoperative intra-articular, intravenous, or intrathecal administration of morphine on postoperative pain management.Materials and methods Sixty patients undergoing arthroscopic menisectomy were included. Spinal anesthesia was performed in the lateral decubitus position with 3 ml of 0.5% hyperbaric bupivacaine, and the patients were randomized into 4 groups. The IVM (intravenous, iv, morphine) group received 3 mg of iv morphine after completion of spinal anesthesia, the ITM (intrathecal morphine) group received 0.3 mg of morphine together with bupivacaine during spinal anesthesia, the IAM (intra-articular morphine) group received 3 mg intra-articular morphine diluted in 10 ml of saline after spinal anesthesia had been induced but 15 min before surgery, while the C (control) group did not receive any drugs in addition to spinal anesthesia. The sensory block level was determined 15 min after spinal anesthesia. Pain at rest (by visual analogue scale, VAS) and pain at 30° of flexion (by verbal rating scale, VRS) were evaluated during each of the first 2 h of the postoperative period and once every 4 h thereafter until 24 h. In each group; the number of patients in need of analgesics, the timing of the first analgesic intake (duration of analgesia), and the cumulative dose of analgesics were recorded.Results The mean duration of analgesia in the IAM group was significantly longer and the mean analgesic intake was significantly lower when compared with the other groups (p<0.05). The mean VAS value of the ITM group at the 4th postoperative hour was significantly lower than that of the other groups. Mean VAS values at 8 and 12 h and mean VRS values at 4 and 8 h were significantly lower in the ITM and IAM groups (p<0.05). The ITM group had the highest rates of nausea, vomiting, pruritus, and headache (p<0.05).Conclusion It was concluded that the preoperative administration of morphine, either intrathecally or intra-articularly, provides postoperative pain relief. Of these two, the intra-articular route seems to be superior in terms of fewer side-effects (nausea, vomiting, and pruritus), longer duration of analgesia, and reduction of total need for analgesics.     

Protective effect of resveratrol against renal oxidative stress in cholestasis

BACKGROUND/AIMS: This experimental study was designed to evaluate histological changes of the kidney and renal tissue levels of malondialdehyde (MDA), reduced glutathione (GSH), and nitric oxide (NO) and the effect of resveratrol on these metabolites after bile duct ligation in rats. METHODS: Secondary biliary cirrhosis was induced by bile duct ligation for 28 days. Swiss albino rats were divided into three groups. Group 1: Sham (n=7), Group 2: Bile duct ligation (n=7), Group 3: Bile duct ligation plus resveratrol (n=7). Bile duct ligation (BDL) plus resveratrol group received 10 mgr/kg dose of resveratrol intraperitoneally daily throughout 28 days. Kidney tissues were harvested to determine the tissue levels of MDA, GSH, and NO activity. Liver and kidney tissues were removed for light microscopic evaluation. RESULTS: Cholestasis was determined by biochemical and pathologic examination. In the resveratrol-treated rats, levels of MDA were significantly lower than those of the BDL group (p < 0.04). The levels of GSH in the resveratrol-treated rats were significantly higher than those in the BDL group (p < 0.01). The levels of NO in the resveratrol group were significantly lower than those in the BDL group (p < 0.01). CONCLUSION: The present study demonstrates that intraperitoneal administration of resveratrol in bile duct ligated rats maintains antioxidant defenses and reduces kidney oxidative damage. This effect of resveratrol may be useful in the preservation of renal oxidative stress in cholestasis.     

Are Discrete Coronary Artery Fistulae Different from Coronary Arteriovenous Malformations?

AIM: To delineate whether coronary arteriovenous malformations have different properties than classical discrete coronary artery fistulae. METHODS: Group 1 included 17 patients with discrete coronary fistula that represents a coronary artery fistula draining into any cardiac chamber. Group 2 included six patients with coronary arteriovenous malformations representing extensive coronary artery malformation. Cardiopulmonary bypass was used in 12 of the Group 1 patients and 5 in Group 2. RESULTS: There was no operative mortality in either group. Following a hemodynamically nonsignificant residual fistulous communication, which was detected by repeat coronary angiography in Group 2; we changed our surgical technique of suture ligation on beating heart. Then we preferred pulmonary arteriotomy and sutured the orifice of coronary arteriovenous malformations from within the chamber. CONCLUSIONS: Coronary arteriovenous malformations have different morphology and also complex progression properties when compared with discrete coronary artery fistulae. Surgical repair of coronary arteriovenous malformation should be done by suturing the multiple drainage holes inside the draining chamber. Suture ligation of coronary arteriovenous malformation is difficult due to the fragile vessel.     

Glycosaminoglycans in childhood urinary tract infections

It has been suggested that urinary glycosaminoglycans (GAGs) form a natural defense mechanism against urinary tract infections (UTIs). This study investigated whether urinary GAGs play a role in pediatric UTIs, and whether urinary GAG level can be used to differentiate upper UTI from lower UTI. Forty-one children with UTIs (33 girls and eight boys; mean age 5.4+/-3.7 years) and 46 age- and sex-matched healthy children (35 girls and 11 boys; mean age 6.6+/-3.9 years) were included in the study. Urinary GAG levels were measured at the onset of acute infection and after a 10-day course of antibiotic treatment. Group GAG findings were compared, and comparisons were also made with the patients divided according to sex and according to UTI type (upper versus lower). The mean urinary GAG level in the patient group at the onset of acute infection (pretreatment) was significantly higher than the mean level in the control group (132.2+/-104.8 mg/g vs 42.2+/-27.1 mg/g creatinine, respectively; P <0.01). In the patient group, the mean urinary GAG level after antimicrobial therapy was significantly lower than the pretreatment level (75.9+/-52.1 mg/g vs 132.2+/-104.8 mg/g creatinine, respectively; P <0.01). However, the mean post-treatment level was still higher than the mean level in the controls ( P <0.05). There was no significant difference in urinary GAG levels when patients were categorized as upper versus lower UTI ( P >0.05). The study results suggest that GAGs play an important role in the pathogenesis of UTIs in children, and that measurement of urinary GAGs may be a valuable noninvasive method for evaluating UTIs in this patient group. However, this assay cannot be used to differentiate upper UTI from lower UTI in children.     

End-to-side nerve coaptation: is an additional proximal coaptation useful when available?

The aim of this experimental study was to evaluate the effects of end-to-side coaptation of the proximal end of a severed nerve to the same intact nerve, in addition to traditional end-to-side coaptation of the distal end, with an aim to use the intact nerve as a nerve conduit in a rat model and to compare the functional and histologic results of this modality to those obtained after nerve grafting and traditional end-to-side nerve coaptation. In group A, a peroneal nerve defect measuring 1 cm was created in the left hind limb, and a nerve graft 1 cm long was used to bridge the defect. In group B, only the distal stump of the peroneal nerve was coapted to the intact tibial nerve. In group C, both ends of the peroneal nerve defect were coapted to the intact tibial nerve in an end-to-side fashion 1.5 cm apart from each other, and in group D, the peroneal nerve defect was left unrepaired. Group E was consisted of nonoperated peroneal nerves that were used to obtain normative data. Although significantly higher myelinated axon densities were observed in groups B and C compared with group A and group E, total number of the myelinated axons was significantly higher only in group C. Peroneal functional index assessments demonstrated that nerve recovery in the peroneal nerve was similar in groups A and C, and both were better than those observed in groups B and D. Collectively, these results suggest that end-to-side coaptation of both ends of a severed nerve to an intact nerve, in case of a nerve defect in this length, may serve as an alternative for nerve grafting.