Fast-track cardiac anesthesia: use of remifentanil combined with intrathecal morphine as an alternative to sufentanil during desflurane anesthesia.

UNLABELLED: The purpose of this cardiac fast-track study was to evaluate the use of remifentanil (R) combined with intrathecal (IT) morphine as an alternative to sufentanil (S) during desflurane anesthesia with respect to postoperative pain control. Prior to entering the operating room, patients in the R group (n = 20) received morphine, 8 microg/kg IT. Anesthesia was induced using a standardized anesthetic technique in all patients. In the R group, anesthesia was maintained with R, 0.1 microg. kg(-1). min(-1) in combination with desflurane 3-10%. In the S group (n = 20), patients received S 0.3 microg. kg(-1). h(-1) and desflurane 3-10%. There were no differences between the two groups with respect to time from arrival in the intensive care unit to tracheal extubation (5.1 +/- 4.3 h vs 5.8 +/- 6.7 h for R and S groups, respectively). After extubation, patients in the R group had significantly lower visual analog pain scores, reduced patient-controlled analgesic requirements, and greater satisfaction with their perioperative pain management, compared with patients in the S group. We conclude that R combined with IT morphine provided superior pain control after cardiac surgery compared with a S-based general anesthetic technique. IMPLICATIONS: As part of a cardiac fast-tracking program involving desflurane anesthesia, the use of intrathecal morphine in combination with a remifentanil infusion provided improved postoperative pain control, compared with IV sufentanil alone.

Fast-track cardiac anesthesia: a comparison of remifentanil plus intrathecal morphine with sufentanil in a desflurane-based anesthetic.

OBJECTIVE: To compare the effects of an intravenous remifentanil infusion plus intrathecal morphine with intravenous sufentanil infusion with respect to intraoperative hemodynamic variables, extubation times, and recovery profiles when administered as part of a desflurane-based fast-track anesthetic regimen for cardiac surgery. DESIGN: A prospective, randomized, nonblinded study. SETTING: University hospital. PARTICIPANTS: Forty patients undergoing elective primary coronary artery bypass graft, aortic valve replacement, or mitral valve replacement surgery. INTERVENTIONS: After a standardized anesthetic induction, anesthesia was maintained with a remifentanil infusion, 0.1 microg/kg/min, and desflurane, 3% to 10%, inspired (group I, n = 20) or a sufentanil infusion, 0.3 microg/kg/h, and desflurane, 3% to 10%, inspired (group II, n = 20). Patients receiving remifentanil were administered intrathecal morphine, 8 microg/ kg, for postoperative analgesia. MEASUREMENTS AND MAIN RESULTS: Both anesthetic regimens provided comparable intraoperative hemodynamic stability and similar recovery profiles, with extubation times of 5.1 +/- 4.3 hours (group I) and 5.8 +/- 6.7 hours (group II). CONCLUSIONS: Use of remifentanil in combination with intrathecal morphine did not facilitate earlier tracheal extubation or improve intraoperative hemodynamic stability compared with sufentanil alone for fast-track cardiac anesthesia.

Review of insecticide resistance in cat fleas (Siphonaptera: Pulicidae).

Insecticide resistance often is blamed for failures of insecticides to control cat fleas, Ctenocephalides felis (Bouché). Yet the genetics and adaptive advantage of resistance traits remain unexamined. Lethal doses of insecticides that kill 50% of the population fluctuate 7-fold within a cat flea strain. Many reports of flea resistance may be attributable to variable mortality from effects of solvents, substrates, humidities, temperatures, colonization, and ages of fleas. Resistance ratios (ratios of lethal doses of a resistant to a susceptible strain) are < 690-fold in fleas; lower than many other arthropods. This, plus strain variability, hinders resistance detection. Relationships between resistance levels, control failures, and health threats are unclear. Insensitive acetylcholinesterase, knockdown recovery, glutathione transferase conjugation, and mixed function oxidase/cytochrome P450 are demonstrated resistance mechanisms in cat fleas. Ecological genetics of resistance in cat fleas probably involves flea transfer among hosts, host movements, refugia, founder effects, and mortality from abiotic factors. Understanding cat flea resistance requires population monitoring before, during, and after insecticide treatments using conventional and rapid molecular bioassays. Sustained insecticide release devices such as flea collars and long-lived insecticide residues for premises possibly contribute to the development of resistance. New systemic and topical insecticides, especially when given prophylactically, may act similarly. Eliminating insecticides prevents insecticide resistance but necessitates application of biorational tactics incorporating mechanical, environmental, and cultural controls. Using high temperatures, low humidities, host grooming and such tactics as decreasing doses, increasing action thresholds, rotating insecticides, and leaving spatial and temporal refugia may suppress cat flea resistance.

Effects of ketorolac versus bupivacaine coadministration during patient-controlled hydromorphone epidural analgesia after thoracotomy procedures.

We studied the comparative effects of ketorolac versus bupivacaine supplementation of hydromorphone (HM) patient-controlled epidural analgesia (PCEA) on the HM requirement, postoperative pain, and pulmonary function in 62 consenting patients after thoracotomy procedures. Patients were randomly assigned to receive one of three different combinations of analgesic medications after the operation according to a double-blind, placebo-controlled study. The treatment groups consisted of: Group 1 (n = 23): PCEA HM 3-mL (0.15 mg) bolus doses + saline 1 mL intravenously (IV) q6h, Group 2 (n = 20): PCEA HM (0.15 mg) in 0.125% bupivacaine 3-mL bolus doses + saline 1 mL IV q6h, and Group 3 (n = 19): PCEA HM 3-mL (0.15 mg) bolus doses + ketorolac 1 mL (30 mg) IV q6h. Epidural HM and supplemental analgesic requirements, pain visual analog scale (VAS) scores, the incidence of nonincisional pain, and side effects were recorded at 24 and 48 h after surgery. Bedside pulmonary function tests were performed using a Puritan Bennett 100TM (Puritan-Bennett Corp., Wilmington, MA) spirometer before and 24 and 48 h after surgery. IV ketorolac supplementation of HM PCEA significantly reduced the incidence of nonincisional pain and the HM requirement over 48 h compared with the HM PCEA alone group (7% vs 26%; 3 +/- 1.6 mg vs 5.3 +/- 2.8 mg). Both ketorolac and bupivacaine supplementation of HM PCEA reduced the severity of pain on coughing and on movement compared with HM PCEA alone on postoperative day (POD) 1. Significant reductions in forced vital capacity, forced expiratory volume in 1 s, forced expiratory flow 25%-75% of the vital capacity, and peak expiratory flow rate (PEFR) were noted on PODs 1 and 2 in all three treatment groups. The decrease in PEFR on PODs 1 and 2 was significantly less with ketorolac compared with bupivacaine supplementation. We conclude that ketorolac supplementation of HM PCEA reduces the incidence of nonincisional pain and HM requirement compared with HM PCEA alone and may have a beneficial effect on pulmonary function compared with bupivacaine supplementation of HM PCEA in postthoracotomy patients.

Perioperative anaesthetic considerations for patients undergoing lung transplantation.

PURPOSE: Five thousand, two hundred and eight lung transplants were performed worldwide before April, 1996. This review will discuss lung transplantation from an historical perspective, its indications, donor and recipient selection criteria, donor lung preparation, surgical considerations, perioperative anaesthetic management, and associated morbidity and mortality. SOURCE: Recent literature on perioperative anaesthetic management of lung transplantation and experience from international centres including the Toronto Lung Transplant Group and the St. Louis Lung Transplant Group. PRINCIPAL FINDINGS: Lung transplantation comprises of a family of operations, including single lung transplant, bilateral single lung transplant, lobar transplant and block heart-lung transplant. Improved donor lung preservation techniques have increased the duration of cold ischaemic time. The advent of bilateral single lung transplant has decreased the requirement for cardiopulmonary bypass, and airway complications have been reduced by adoption of the telescoping bronchial anastomoses. Advances in perioperative monitoring (including transoesophageal echocardiography), pulmonary vasodilators (e.g., nitric oxide and prostaglandin E1), cardiopulmonary bypass and ventilatory management, and a better understanding of the pathophysiological processes during the procedure have improved perioperative anaesthetic management. Also, advances in broad spectrum antibiotics and immunosuppressant drugs have improved the outcome by better management of the complications of infection and rejection. CONCLUSION: Lung transplantation improves the quality of life with marginal improvement in life expectancy of the recipients. It is an expensive procedure requiring continued resources for long term management of these patients.

Ethinylestradiol treatment induces multiple canalicular membrane transport alterations in rat liver.

We investigated the effects of 17 alpha-ethinylestradiol treatment of rats on various transport functions in isolated basolateral and canalicular liver plasma membrane vesicles. Both membrane subfractions were purified to a similar degree from control and cholestatic livers. Although moderate membrane lipid alterations were predominantly observed in basolateral vesicles, no change in basolateral Na+/K(+)-ATPase activity was found. Furthermore, while Na(+)-dependent taurocholate uptake was decreased by approximately 40% in basolateral vesicles, the maximal velocity of ATP-dependent taurocholate transport was decreased by 63% in canalicular membranes. In contrast, only minimal changes or no changes at all were observed for electrogenic taurocholate transport in "cholestatic" canalicular membranes and total microsomes, respectively. However, canalicular vesicles from cholestatic livers also exhibited marked reductions in ATP-dependent transport of S-(2,4-dinitrophenyl)glutathione and in Na(+)-dependent uptake of adenosine, while in the same vesicles HCO3-/SO4- exchange and Na+/glycine cotransport activities were markedly stimulated. These data show that in addition to the previously demonstrated sinusoidal transport abnormalities ethinylestradiol-induced cholestasis is also associated with multiple canalicular membrane transport alterations in rat liver. Hence, functional transport alterations at both polar surface domains might ultimately be responsible for the inhibitory effects of estrogens on the organic anion excretory capacity and on bile formation in rat liver.