Effects of exogenous secretin on pancreatic and biliary ductal and sphincteric pressures in man demonstrated by endoscopic manometry and correlation with plasma secretin levels

An endoscopic manometric technique was used to investigate the effects of exogenous secretin on pancreatic duct, common bile duct, pancreatic duct sphincter, and bile duct sphincter pressures in 20 healthy volunteers. Synthetic secretin was infused intravenously at rates of 8.05, 16.1, 32.2, 64.4, 129, 258, and 516 ng/kg/hr, and plasma secretin concentrations were measured by a radioimmunoassay. Secretin produced a significant fall in peak and trough pancreatic duct sphincter pressures from basal values of 48.2±7.9 mm Hg (mean±sd) and 16.9±7.7 mm Hg, respectively, to 34.4±6.8 mm Hg and 11.2 ±5.8 mm Hg (P<0.005), respectively, at a mean plasma secretin concentration of 16 pg/ml (during an infusion rate of 32.2 ng/kg/hr). Higher infusion rates had no additional effect. Pancreatic duct pressure became significantly elevated above basal (11.5±4.0 mm Hg) at the two highest secretin rates. Secretin had no effect on common bile duct or bile duct sphincter pressures. Plasma secretin concentrations were within the postprandial range during the lowest four secretin infusion rates. We conclude that secretin produces selective physiological relaxation of the pancreatic duct sphincter.This work was supported by grants from the Katherine Gavriluk and Sara Jordan Funds, New England Baptist Hospital, Boston, Massachusetts; NIH Research Grant AM 25962. Dr. Carr-Locke is also in receipt of grants from the Wellcome Research Travel Fund, London, England, the Leicester Area Health Authority, Leicester, England, and the P&C Hickinbotham Trust, Leicester, England.     

Postoperative hyperglycemia is associated with mediastinitis following pediatric cardiac surgery

Introduction: Mediastinitis is an infrequent, but significant complication of median sternotomy. Perioperative hyperglycemia is associated with increased morbidity, including infection in pediatric and adult cardiac surgical patients. We hypothesized that perioperative blood glucose levels would be higher in patients who later developed mediastinitis. Methods: We examined the medical records of all infants and children diagnosed with poststernotomy mediastinitis (n = 24) from July 2001 to December 2005. Data recorded included postoperative blood glucose levels, age, diagnosis, operation, surgical complexity score, duration of operation and cardiopulmonary bypass, delayed sternal closure, perioperative use of steroids and total parenteral nutrition, and duration of postoperative inotropic and ventilatory support. Records of patients without mediastinitis matched for age, complexity score, and month of operation (control group, n = 32) were also reviewed. Data were analyzed with t‐tests and chi‐square tests. Variables with P < 0.21 on univariate tests were entered into a multivariate logistic regression model. Results: Initially, postoperative blood glucose levels were elevated, but similar in both mediastinitis and control groups. The number of subjects having peak blood glucose levels >7.2 mm (>130 mg·dl^?1) during the first 24 h was greater in the mediastinitis group (P = 0.07). The significant multivariate predictor of mediastinitis was 24 h peak blood glucose >7.2 mm (>130 mg·dl^?1) (P = 0.039). Conclusion: Our data support the hypothesis that postoperative hyperglycemia is a risk factor for the development of mediastinitis in infants and children following cardiac surgery.     

Gastric distension and ventilation during laparoscopic cholecystectomy: LMA-classic vs. tracheal intubation

PURPOSE: The standard laryngeal mask airway LMA-Classic was designed as an alternative to the endotracheal tube (ETT) or the face mask for use with either spontaneous or positive pressure ventilation. Positive pressure ventilation may exploit leaks around the LMA cuff, leading to gastric distension and/or inadequate ventilation. We compared gastric distension and ventilation parameters with LMA vs ETT during laparoscopic cholecystectomy. METHODS: One hundred and one, ASA I-II adults scheduled for elective laparoscopic cholecystectomy were randomly assigned to LMA-Classic or ETT. Patients with BMI >30 kg x m(-2), hiatus hernia or gastroesophageal reflux were excluded. Following induction of anesthesia, an in-and-out orogastric tube was passed to decompress the stomach before insertion of the LMA (women size #4, men size #5) or ETT (women 7 mm, men 8 mm). Anesthesia was maintained with isoflurane in nitrous oxide and oxygen (FIO2 0.3-0.5), rocuronium and fentanyl. The surgeon, blinded to the type of airway, scored gastric distention 0-10 at insertion of the laparoscope and immediately before removal at the end of the surgical procedure. RESULTS: Incidence and degree of change in gastric distension were similar in both groups. Ventilation parameters during insufflation (mean +/- SD) for LMA and ETT were: S(P)O2 98 +/- I vs 98 +/- I, P(ET)CO2 38 +/- 4 vs 36 +/- 4 mm Hg and airway pressure 21 +/- 4 vs 23 +/- 3 cm water. CONCLUSION: Positive pressure ventilation with a correctly placed LMA-Classic of appropriate size permits adequate pulmonary ventilation. Gastric distension occurs with equal frequency with either airway device.     

Enprostil,a prostaglandin E2 analogue,in the treatment of gastric ulcer — a multicentre comparison with pirenzepine

In a double-blind, multicentre study 77 patients with benign gastric ulcer were randomly allocated to treatment with either enprostil 35 μg bd or pirenzepine 50 mg bd. After four weeks of treatment 13/26 (50 per cent) of evaluable enprostil-treated patients and 9/30 (30 per cent) of evaluable pirenzepine-treated patients were healed. Corresponding healing figures after eight weeks were 20/25 (80 per cent) and 25/31 (81 percent). Both drugs rapidly reduced the severity of ulcer pain and the need for antacid use. No statistically significant differences were detected between the treatments with respect to healing rate or symptom control. Adverse events were reported by eight patients taking enprostil and by 17 patients taking pirenzepine. Two patients withdrew from each treatment group because of adverse events. None of these was serious. In conclusion, enprostil and pirenzepine were equally effective in healing gastric ulcers and no statistically significant differences in safety and efficacy were detected. There was a tendency for earlier healing and fewer side effects in the enprostil-treated patients.     

Pyloric stenosis in full term babies. A postal survey of the management by paediatric anaesthetists

We report the results of a postal survey of the management of full term babies with pyloric stenosis by specialist paediatric anaesthetists. The conclusions from the survey are that the most likely anaesthetic techniques used are: rehydration and at least partial correction of electrolyte and acid-base abnormalities before surgery; aspiration of stomach contents before induction of anaesthesia; a rapid sequence induction; extubation of the trachea with the baby awake and on its side; and infiltration of the wound at the end of surgery with local anaesthetic.     

PSEUDOEPHEDRINE TOXICITY IN RENAL FAILURE

SUMMARY A case of pseudoephedrine toxicity is reported in a man with chronic renal failure. The effects of renal impairment on the metabolism of pseudoephedrine are discussed and the implications of the widespread availability of the drug in proprietary cold remedies are highlighted.