Volume kinetics of Ringer's solution during induction of spinal and general anaesthesia

The kinetics of an i.v. infusion of 20 ml kg^–1 of Ringer’ssolution over 60 min was studied in patients undergoing spinal(n=10) and general (n=10) anaesthesia. The induction resultedin similar changes in volume kinetic parameters in both groups.When a one-volume model was employed (n=8), however, the infusionexpanded a smaller body fluid space in the four patients whohad received preoperative enteric lavage (3.3 vs 8.3 litres),which is consistent with hypovolaemia. When a two-volume modelwas statistically justified (n=12), the induction reduced therate of fluid equilibration between a fairly small central (V₁,mean 1.4 litres) and a peripheral body fluid space by about50% (P<0.01). The kinetic analysis suggested that a rapidfluid load of 350 ml given over 2 min just after the inductioncould possibly prevent arterial hypotension because of centralhypovolaemia. This was confirmed in five additional patients. Br J Anaesth 2001; 87: 406–14     

The microsurgical training programme in Gothenburg,Sweden: early experiences

Objective: Microsurgical techniques are increasingly used in routine surgical practice as well as in biomedical research. The training opportunities at standardised training courses are limited, and no microsurgical training facility or programme existed in Scandinavia before 2013.

Methods: A microsurgery laboratory was set up and two different courses were started, aiming separately at biomedical researchers and surgeons. The course for biomedical researchers teaches basic microsurgical skills such as vessel isolation, cannulation, and arterial microvascular suture under magnification. The more advanced course for surgeons focuses on various techniques of microvascular and nerve anastomosis. Both courses use a combination of theory and practice, with emphasis on the practical part, the course for surgeons also includes clinically relevant information.

Results: Twelve 5-day courses using both non-living models and exercises on laboratory animals have been conducted and attended by 49 researchers and 44 surgeons. The organisation and the programme of the training courses as well as ‘The 4E concept’ behind the course (educational curriculum, equipment, ergonomy, and evaluation) are further detailed.

Conclusions: We have successfully established the first training laboratory and series of microsurgical training courses in Scandinavia at two different levels. The experience from the first 12 courses shows the need for this type of structured training, and confirms that the microsurgical education curriculums needs to be adapted to participants’ prerequisites and expectations, and various difficulty levels should be considered.     

Kinetics and extravascular retention of acetated ringer's solution during isoflurane or propofol anesthesia for thyroid surgery

BACKGROUND: In sheep, isoflurane causes extravascular accumulation of infused crystalloid fluid. The current study evaluates whether isoflurane has a greater tendency than propofol to cause extravascular retention in surgical patients. METHODS: Thirty patients undergoing thyroid surgery lasting for 143 +/- 32 min (mean +/- SD) received an intravenous infusion of 25 ml/kg acetated Ringer's solution over 30 min. Anesthesia was randomized to consist of isoflurane or propofol supplemented by fentanyl. The distribution and elimination of the infused fluid was estimated using volume kinetics based on the fractional dilution of blood hemoglobin over 150 min. Extravascular retention of infused fluid was taken as the difference between the model-predicted elimination and the urinary excretion. The sodium and fluid balances were measured. RESULTS: The fractional plasma dilution increased gradually to approximately 30% during the infusion and thereafter remained at 15-20%. Urinary excretion averaged 11% of the infused volume. Mean arterial pressure was 10 mmHg lower in the isoflurane group (P < 0.001). The excess fluid volumes in the central and peripheral functional body fluid spaces were virtually identical in the groups. The sum of water losses by evaporation and extravascular fluid retention amounted to 2.0 +/- 2.5 ml/min for isoflurane and 2.2 +/- 2.1 ml/min for propofol. The sodium balance refuted that major fluid shifts occurred between the extracellular and intracellular spaces. CONCLUSIONS: The amount of evaporation and extravascular retention of fluid was small during thyroid surgery, irrespective of whether anesthesia was maintained by isoflurane or propofol.     

Beta 2-adrenergic responsiveness in vivo during abdominal surgery

We have studied adrenergic function in vivo during anaesthesia and surgery. Epinephrine 50 ng kg-1 min-1 was given by i.v. infusion over 30 min to 10 healthy adult volunteers and to 10 patients undergoing abdominal operations. The cAMP response to stimulation by epinephrine, which was obtained as the area under the curve (AUC) for plasma cAMP concentration divided by the AUC for plasma concentration of epinephrine, was more pronounced during surgery (mean ratio 3.5) than in the control situation (ratio 1.4; P < 0.02). This resulted in greater hypokalaemic and hyperglycaemic responses (ratios -0.67 and 4.5) than in the control group (ratios -0.33 and 1.6, respectively; P < 0.004). Mean arterial pressure decreased in the control group while it increased in the study group, and serum cortisol concentration was higher in those who underwent surgery (P < 0.02). These results are consistent with an increased adrenergic response during abdominal surgery.      

High-dose intravenous infusion of irrigating fluids containing glycine and mannitol in the pig

BACKGROUND: Large-scale absorption of electrolyte-free irrigating fluid during endoscopic surgery may result in a "transurethral resection syndrome." The severity of the syndrome can probably be modified by using mannitol 5% instead of the most widely used glycine 1.5%. METHODS: Seventeen pigs with a mean body weight of 22 (range 19-26) kg received an intravenous infusion of 100 mL kg(-1) h(-1) of either glycine 1.5% or mannitol 5% over 90 min. Central hemodynamics, whole-body and brain oxygen consumption, intracranial pressure, blood hemoglobin, and the sodium concentrations in serum and urine were monitored for 120 min. Selected measurements were made on 6 other pigs given mannitol 3% and in 2 controls not given any fluid. Morphological examinations of the hearts were conducted. RESULTS: Both glycine 1.5% and mannitol 5% transiently increased cardiac output, the aortic blood flow rate, and arterial pressures, but all of these parameters fell to below baseline after the infusions were ended. The intracranial pressure was lower (P < 0.05) and the oxygen consumption in the brain decreased (P < 0.001) during the infusion of mannitol 5%. Glycine 1.5% expanded the intracellular volume more than mannitol did (P < 0.002). Signs of myocardial damage were graded glycine 1.5% > mannitol 5% > mannitol 3%. CONCLUSIONS: Massive infusion of glycine 1.5% and mannitol 5% left the pigs in a hypokinetic hypotensive state. Glycine 1.5% increased the intracranial pressure and injured the myocardium more than mannitol 5%, which then seems to be a more appropriate irrigating fluid to use during endoscopic surgery.     

Moldy environments and toxic pneumonitis

Exposure to organic dusts might cause an acute reaction with influenza like symptoms (toxic pneumonitis). Although it is well known that endotoxin, which is often present in organic dusts, may cause this reaction, there is no information about fungal cell wall agents as causative agents. The capacity of different fungal cell wall agents to induce an acute inflammation was evaluated in animal inhalation experiments. Guinea pigs were exposed to an aerosol of endotoxin, molds, and different fungal cell wall agents (FCWA) in a continuous flow exposure chamber, and the number of free lung cells was determined 24 h thereafter. Endotoxin caused a dose-dependent increase in the number of neutrophils and macrophages. None of the other agents tested caused a neutrophil response. The results suggest that toxic pneumonitis in environments with organic dusts is caused by the presence of inhaled endotoxin. Although no effect from FCWA was found, it is well known that this inhalation under chronic conditions will cause lung disease, particularly granulomatous pneumonitis.