Effect of remifentanil infusion on haemodynamics and stress response to pre-bypass phase of paediatric cardiac surgery

Fifty-two infants and children under 5 years old were randomized to receive one of four remifentanil infusion rates [0.25, 1.0, 2.5, or 5.0 mug.kg-1 min-1]. Blood samples were obtained at induction, pre-surgery, 5 min after opening the chest and immediately pre-bypass. Whole blood glucose was measured at all time points, while cortisol and neuropeptide Y [NPY] were measured in the first and last samples. Heart rate and arterial pressure were also recorded. There was a significant increase in whole blood glucose 5 min after opening the chest and pre-bypass in patients receiving remifentanil 0.25 mug.kg-1 min-1, but not in those receiving higher doses. Increased remifentanil dosage was associated with reduced plasma cortisol during surgery. Baseline NPY showed considerable variation and there was no association between pre-bypass NPY and remifentanil dose. There was a significantly higher heart rate at the pre-bypass stage of surgery in the remifentanil 0.25 mug.kg-1 min-1 group compared with higher doses. Four out of five neonates with complex cardiac conditions showed severe bradycardia associated with remifentanil. From these data, it was concluded that in infants and children under 5 years, remifentanil infusions of 1 mug.kg-1 min-1 and greater can suppress the glucose increase and tachycardia associated with the pre-bypass phase of cardiac surgery; while 0.25 mug.kg-1 min-1 did not. Remifentanil should be used with caution in neonates with complex congenital heart disease

Role of non invasive biomarkers in the assessment of liver condition in chronic hepatitis C Egyptian patients and if they correlate with the severity of liver affection

Hepatitis C virus [HCV] is considered the most common etiology of chronic liver disease in Egypt. Anti-HCV-positive patients are more likely to have elevated liver enzymes, liver cirrhosis, portal hypertension and spleen enlargement. Schistosomal liver disease in Egypt is commonly associated with HCV infection. Concurrent infection results in much more severe liver affection than that seen in either disease alone. Chronic hepatitis C is a slowly progressive inflammatory disease that can lead to cirrhosis with all its complications. Thus, repeated assessment of liver condition is always required. Assessment of liver damage has been primarily done by liver function tests as well as by histological evaluation. Meanwhile, assessment of liver affection is mainly done by liver biopsy with histological analysis which always remains the "reference standard" used by physicians to assess the presence as well as the degree of liver fibrosis in patients with chronic liver diseases and also to determine the appropriate management. However, many physicians are cautious to perform liver biopsy because of the relative risks associated with this procedure, particularly in patients with coagulation abnormalities. Among the possible alternatives, imaging is informative mainly for cirrhosis but not for lesser stages of fibrosis. In addition, it is nonquantitative and thus cannot track progression. Unfortunately, there are few reliable noninvasive methods for detecting liver fibrosis and its progression. Thus, a noninvasive test detecting hepatic fibrosis has become a priority in the context of hepatitis C evaluation and treatment. Therefore, identifying hepatic biomarkers that correlate with the severity of the liver pathology is an important issue in the follow up of such cases. Few serum markers such as hyaluronic acid, ferritin, and soluble interleukin-2 receptor [sIL-2R] have been reported to be useful in detecting fibrosis in liver disease. The aim of this study is to clarify the diagnostic value of serum hyaluronic acid, ferritin, and soluble interleukin-2 receptor levels as non-invasive biomarkers in the assessment of the liver condition in chronic hepatitis C Egyptian patients with and without concurrent Bilharzial affection and moreover, to evaluate whether their serum levels correlate with the histological severity of the related liver injury. One hundred and twenty Egyptian subjects were included in this study. They were divided into three main groups. Group A [n=30] included patients with chronic hepatitis C and with liver fibrosis as assessed by abdominal ultrasonography, Group B [n = 60] included patients with chronic hepatitis C and with liver cirrhosis and/or history of antibilharzial treatment and positive rectal snips for bilharzial ova, and Group C [n = 30] included apparently normal age and sex-matched subjects taken as a control group. Group B was further subdivided into two subgroups according to liver cirrhosis staging as performed by abdominal ultrasonography, where Subgroup B1 [n = 30] included patients with early cirrhotic changes while Subgroup B2 [n = 30] included patients with advanced cirrhotic changes. Patients were diagnosed as having hepatitis C by detecting HCV antibodies using a third generation enzyme immunoassay, ELISA. Biochemical blood tests were carried out to evaluate liver functions in the form of serum transaminases [AST and ALT], alkaline phosphatase [ALP], gamma glutamate [GGT], total bilirubin, as well as serum albumin. In addition, serum hyaluronic acid, ferritin, as well as sIL-2R levels were measured by EL1SA. Our study detected impaired liver functions in all patient groups compared to the controls. Liver functions were also detected to be more impaired in each of subgroup B1 early cirrhosis as well as in B2 advanced cirrhosis patients compared to group A fibrosis patients and this was statistically significant. Meanwhile, our study also demonstrated statistically significant difference on comparing both subgroups B1 and B2 together showing more impairment in subgroup. B2 advanced cirrhosis patients. The above findings denote that as the liver condition progresses from fibrosis to early then to advanced cirrhosis, the liver enzymes as well as the bilirubin concentrations increase progressively and the serum albumin concentrations decrease progressively, thus indicating more deterioration in liver functions and more liver injury. Not only this, but also our study detected more deterioration in liver functions occurring in the presence of bilharzial infection concurrent with hepatitis C infection than without it. This was shown clearly from comparing group B patients, whether subgroup B1 or B2, with history of bilharziasis to group A patients without, denoting that concurrent bilharzial infection adds more to the liver affection. As regarding the hepatic biomarkers, namely, serum hyaluronic acid, ferritin, and sIL-2R, our study detected statistically increased serum levels in each of the patient groups compared to the controls. A progressive increase in their serum levels was detected as the liver condition progressively deteriorates. Meanwhile, more serum level elevations occurred with the presence of bilharzial infection concurrent with hepatitis C infection than without it. In addition, our study reported that in advanced cirrhosis subgroup B2 patients; there was a significant positive correlation detected between each of serum hyaluronic acid, ferritin, and sIL-2R and each of ALT and GGT serum levels. A positive correlation was also detected between serum hyaluronic acid and ALP. Meanwhile, a significant negative correlation was detected between each of the above three biomarkers and serum albumin level. In conclusion, our study reported that in chronic hepatitis C Egyptian patients, as the liver affection progresses, the liver functions deteriorate progressively, thus indicating more liver injury. Not only this, but also more deterioration in liver functions was detected in the presence of concurrent bilharzial infection than without it. As regarding the serum biomarkers: serum hyaluronic acid, ferritin, and sIL-2R, a progressive increase in their serum levels was detected as the liver condition progressively deteriorates. In addition, more elevations occurred in the presence of concurrent bilharzial infection. Moreover, our study detected that in advanced cirrhosis, these biomarkers correlate significantly with the liver functions denoting not only their diagnostic value as non-invasive biomarkers in the assessment of the liver condition, but also that their levels correlate with the histological severity of the related liver injury, and thus can be used in the prognostic follow up to assess the degree of liver pathological progression especially when liver biopsy is contraindicated, thus, protecting the patient from its hazards especially in cases of hepatic coagulopathy which is well known to occur in this category of patients

Effect of a new hydroxyethy1 starch HES 130/0.4 [voluven] compared with HES 200/0.5 on coagulation in major orthopedic surgery

Hydroxyethyl starch [HES] solutions are effective plasma volume expanders. Impairment of coagulation occurs with large HES volumes infused perioperatively. Therefore, a lower substituted novel HES [Voluven, Fresenius Kabi, Bad Homburg, Germany] was developed to minimize hemostatic interactions and was compared with HAES-steril [Fresenius Kabi] [pentastarch] regarding safety and efficacy. A prospective randomized double-blinded study was performed on 100 major orthopedic surgery patients. Because of the 95% confidence interval [-330 ml, + 284 ml] for the treatment contrast Voluven-HAES- steril was entirely included in the predefined equivalence range [ +/- 500 ml], comparable efficacy was established. Voluven interfered significantly less than HAES-steril with coagulation factor VIII levels and partial thromboplastin time postoperatively. Total amounts of red blood cells transfusion were comparable between the Voluven and HAES-steril groups, but a significantly reduced need for homologous red blood cells was observed in the Voluven group. It was concluded that in large-blood-loss surgery, Voluven has a comparable efficacy with HAES-steril and may reduce coagulation impairment possibly leading to a similar number of allogenic blood transfusion

Nitric oxide as a marker for diagnosis and follow-up in children with systemic lupus erythematosus and juvenile rheumatoid arthritis

A cross sectional observational study of 56 children with juvenile rheumatoid arthritis [JRA] and systemic lupus erythematosus [SLE] was designed to study nitric oxide [NO] levels and their relation to the disease activity and its value as an indicator for the follow up of these two diseases. Twenty-five healthy age and sex matched children were recruited as controls. Full history taking, proper clinical examination and laboratory investigation of the subjects were done. Blood samples were collected and NO, nitrite and nitrate were measured biochemically. Serum NO, nitrite and nitrate were significantly higher in each of JRA and SLE cases compared with the control group. Patients with active disease showed higher NO levels compared with non-active disease, yet it did not reach significant levels. A positive significant correlation was observed between NO and erythrocyte sedimentation rate [ESR] for patients with active SLE and JRA, respectively. A negative significant correlation was found between NO and lymphocyte count in active SLE; while, a positive significant correlation between NO and steroid therapy duration of JRA with active disease was observed

Cardiorespiratory effects and systemic stress response of abdominal laparoscopic procedures in children: comparison with conventional laparotomy

In this study, 30 children aged 1.5-14 years were assigned to undergo laparoscopy or laparotomy with a standard anesthetic technique. Heart rate and mean arterial pressure were monitored at different time intervals. An intra-arterial cannula was inserted. From blood gases, arterial partial pressure of CO2[PaCO2], O2 saturation [SaO2] and pH were measured at five min. after induction [T0], 15 min. into surgery [T15], 30 min. into surgery [T30], at end of surgery prior to extubation [T end] and following extubation [T ext]. Blood prolactin, cortisol, glucose, insulin and interleukin-6 levels were determined at five min. after induction of anesthesia [T0], 30 min. into surgery [T30] and at the end of surgery [T end]. It was concluded that the surgical stress and trauma imposed by laparoscopy seems to be similar to that caused by laparotomy in children undergoing elective abdominal surgery