Haemodynamic consequences of etomidate administration in elective cardiac surgery: a randomized double-blinded study.

BACKGROUND: The consequences of inhibition of cortisol synthesis by a single dose of etomidate on subsequent vasopressor drug usage and the duration of relative adrenal insufficiency (RAI) after cardiac surgery are not known. METHODS: This was a prospective, randomized, double-blinded controlled trial of 100 patients undergoing elective cardiac surgery and receiving either etomidate or propofol at induction of anaesthesia. A short corticotropin test was performed 12, 24, and 48 h after anaesthesia induction. RAI was defined as a response <250 nmol litre(-1). RESULTS: The mean (sd) norepinephrine infusion rate during the first 48 postoperative hours was 0.11 (0.01) and 0.11 (0.01) µg kg(-1) min(-1) in the etomidate and propofol groups, respectively (P=0.89). Time to norepinephrine withdrawal was similar between the groups. The incidence of RAI was higher in the etomidate group at 12 h (100% vs 41%, P<0.001) and 24 h (85% vs 25%, P<0.001). CONCLUSIONS: A single bolus of etomidate blunts the hypothalamic-pituitary-adrenal axis response for more than 24 h in patients undergoing elective cardiac surgery, but this was not associated with an increase in vasopressor requirements.

Risk factors and context of men who physically abuse in Bogotá, Colombia.

OBJECTIVES: The aim of this study was to identify risk factors for physical abuse caused by male perpetrators, as well as to describe the context of abuse and the role of the female partner in these cases in Bogotá, Colombia. METHODS: Information from in-depth interviews of males reported to authorities for physical child abuse and their female partners (n = 45) was quantitatively and qualitatively analyzed and compared to to males and their female partners from the same neighborhood living with a child of the same gender and age (+/-3 years) as the abused child (n = 44). RESULTS: Situations of abuse occurred more often on a weekday, in the afternoon or early evening hours, with the mother present, exceptionally involved substance abuse, and tended to be repetitive. Male subjects' lower level of education, stepfather status, perceived stress, substance abuse and mental illness, lack of social support, history of childhood physical abuse, negative perceptions, attributions and unrealistic expectations of the child's behavior were associated with abuse. Cases' female partners were more likely to have a lower occupational level, a higher frequency of dependent personality, a history of childhood physical and sexual abuse and be herself physically and emotionally abused by her spouse. At least three scenarios for abuse emerged from the analyses: "explosive" men, "abusive disciplinarians," and "children out of parental control." CONCLUSIONS: Most of the findings are consistent with existing research despite the different social and cultural context. The different scenarios suggest the need to tailor preventive and rehabilitative interventions for abusers.

Clonidine for major vascular surgery in hypertensive patients: a double-blind, controlled, randomized study.

The utility of clonidine for hypertensive patients presenting for major vascular procedures remains debatable. Twenty-one hypertensive patients presenting for aortic surgery were given clonidine (n = 11) or placebo (n = 10) in a double-blind, randomized manner. Clonidine was administered 6 micrograms/kg per os 120 min before induction of anesthesia and 3 micrograms/kg intravenously (i.v.) over 60 min from aortic declamping to skin closure. Anesthesia was induced with alfentanil 20 micrograms/kg, midazolam, and atracurium and maintained with nitrous oxide 70%, an alfentanil infusion (0.25 microgram.kg-1. min-1), and isoflurane. Anesthetic requirements, circulatory variables, interventions, and isoproterenol dose-response curves (pre- and postoperatively) were determined. Plasma concentrations of clonidine, alfentanil, and vasoactive hormones were measured. When the clonidine group was compared with the placebo group, (a) isoflurane, alfentanil, and midazolam requirements were reduced by 38%, 42%, and 41%, respectively (P = 0.04, 0.03, 0.0002, respectively); (b) supplemental circulatory and anesthetic adjustments were reduced by 51% (P = 0.0006); (c) interventions with vasopressors were not significantly increased (placebo: two; clonidine: five); (d) systolic and mean arterial pressures and heart rate were reduced; (e) increases in norepinephrine, epinephrine, and plasma renin activity were suppressed, whereas vasopressin surge was attenuated; and (f) chronotropic response to isoproterenol was unaffected. Clonidine was effective in reducing anesthetic requirements and in improving circulatory stability in hypertensive patients presenting for major vascular procedures.

Efficacy of tracheal and bronchial stent placement on respiratory functional tests.

Stent placement is the only available treatment in patients presenting either a localized external compression or a malacia of the tracheobronchial tree. To assess the functional benefit of prosthesis insertion in these indications, we compared functional respiratory values before, immediately after (48 h), and at sometime after (mean, 10.1 months) operation in 24 patients presenting with a bronchial lesion (B group, n = 5) or a lesion of the intrathoracic part (ITT group, n = 9) or of the extrathoracic part of the trachea (ETT group, n = 10). Before treatment, airflow was severely impaired in most patients without significant differences among the groups. After prosthesis insertion, airflow parameters increased [change in forced expiratory volume in 1 s (delta FEV1 = 440 mL; delta peak expiratory flow (PEF) = 0.92 L.s-1; delta maximum expiratory flow 25/75 (delta MEF25/75) = 0.47 L.s-1; and delta forced inspiratory volume in 1 s (delta FIV1 = 310 mL)] and airway resistances (Raws) decreased (delta Raw = -0.43 kPa.s-1.s-1) without any significant variation in either forced vital capacity (FVC) or total lung capacity. Airflow improvement was more apparent in ITT and ETT groups than in the B group. Moreover, inspiratory flow increase and decrease of FEV1/PEF ratio were only observed in the ETT group. This airflow improvement was maintained for a long time after and was associated with a good clinical tolerance. This study supports the clinical and functional benefits of prosthesis placement both in benign and malignant airway compressions for palliative treatment.

[Rupture of the left subclavian artery associated with fracture of the 1st rib]. / Rupture de l'artère sous-clavière gauche associée à une fracture de la première côte.

Treatment in a case of partial rupture of the subclavicular artery, provoking subacute ischemia of the upper limb and associated with a fracture of the first rib, was by sternoclavicular disinsertion and resection-suture. The importance of systematic investigation of possible subclavicular lesions in patients with fractured first ribs is emphasized, both during the initial and follow-up examinations. The presence of a fracture of this type has little influence on the classical surgical attitude adapted, apart from the possible need for resection of the first rib.