The effect of pre-operative gastric ultrasound examination on the choice of general anaesthetic induction technique for non-elective paediatric surgery. A prospective cohort study.

Ultrasound examination of the gastric antrum is a non-invasive tool that allows reliable estimation of gastric contents. We performed this prospective cohort study in non-elective paediatric surgery to assess whether gastric ultrasound may help to determine the best anaesthetic induction technique, whether rapid sequence or routine. The primary outcome was the reduction of inappropriate induction technique. A pre-operative clinical assessment was performed by the attending anaesthetist who made a provisional plan for induction. Gastric ultrasound was performed in the semirecumbent and right lateral decubitus positions for a qualitative assessment of gastric contents, using a 0-2 grading scale. A final induction plan was made based on this assessment. Immediately after tracheal intubation, gastric contents were suctioned through a multi-orifice nasogastric tube; these were defined as above risk threshold for regurgitation and aspiration if there was clear fluid > 0.8 ml.kg-1 , and/or the presence of thick fluid and/or solid particles. Gastric ultrasound was feasible in 130 out of 143 (90%) of children, and led to a change in the planned induction technique in 67 patients: 30 from routine to rapid sequence, and 37 from rapid sequence to routine. An appropriate induction technique was therefore performed in 85% of children, vs. 49% planned after pre-operative clinical assessment alone (p < 0.00001). Our results suggest that gastric ultrasound is a useful guide to the general anaesthetic induction technique with respect to the risk of pulmonary aspiration, in comparison with pre-operative clinical assessment alone.

Solution structure and excitation energy transfer in phycobiliproteins of Acaryochloris marina investigated by small angle scattering.

The structure of phycobiliproteins of the cyanobacterium Acaryochloris marina was investigated in buffer solution at physiological temperatures, i.e. under the same conditions applied in spectroscopic experiments, using small angle neutron scattering. The scattering data of intact phycobiliproteins in buffer solution containing phosphate can be well described using a cylindrical shape with a length of about 225Å and a diameter of approximately 100Å. This finding is qualitatively consistent with earlier electron microscopy studies reporting a rod-like shape of the phycobiliproteins with a length of about 250 (M. Chen et al., FEBS Letters 583, 2009, 2535) or 300Å (J. Marquart et al., FEBS Letters 410, 1997, 428). In contrast, phycobiliproteins dissolved in buffer lacking phosphate revealed a splitting of the rods into cylindrical subunits with a height of 28Å only, but also a pronounced sample aggregation. Complementary small angle neutron and X-ray scattering experiments on phycocyanin suggest that the cylindrical subunits may represent either trimeric phycocyanin or trimeric allophycocyanin. Our findings are in agreement with the assumption that a phycobiliprotein rod with a total height of about 225Å can accommodate seven trimeric phycocyanin subunits and one trimeric allophycocyanin subunit, each of which having a height of about 28Å. The structural information obtained by small angle neutron and X-ray scattering can be used to interpret variations in the low-energy region of the 4.5K absorption spectra of phycobiliproteins dissolved in buffer solutions containing and lacking phosphate, respectively.

Ultrasound assessment of the gastric contents for the guidance of the anaesthetic strategy in infants with hypertrophic pyloric stenosis: a prospective cohort study.

BACKGROUND: Evacuation of gastric content through a nasogastric tube, followed by rapid sequence induction, is usually recommended in infants undergoing pyloromyotomy. However, rapid sequence induction may be challenging, and is therefore controversial. Some anaesthetists regularly perform classical non-rapid induction technique, after blind aspiration of the gastric contents, although this aspiration may have been incomplete. This prospective observational study aimed to assess whether the ultrasound monitoring of the aspiration of the stomach contents, may be useful to appropriately guide the choice of the anaesthetic induction technique, in infants undergoing pyloromyotomy. METHODS: Infants undergoing pyloromyotomy were consecutively included. Ultrasound assessment of the antrum was performed before and after the aspiration of the gastric contents through a 10 French gastric tube. The stomach was defined as empty when no content was seen in both supine and right lateral positions. The correlation between antral area and the aspirated gastric volume was also tested. RESULTS: We analysed 34 infants. Ultrasound examination of the antrum failed in three infants. The stomach was empty in 30/34 infants (nine before aspiration, 21 after aspiration), allowing to perform a non-rapid induction technique in 88.2% of the infants. There was a significant correlation between antral area measured in right lateral decubitus and the aspirated gastric volume. CONCLUSIONS: Our results suggest that the qualitative ultrasound assessment of the antral content may be a simple and useful point-of-care tool, for the choice of the most appropriate anaesthetic technique for pyloromyotomy according to the estimated risk of pulmonary aspiration of gastric contents.

Crowding effect on helix-coil transition: beyond entropic stabilization.

We report circular dichroism measurements on the helix-coil transition of poly(L-glutamic acid) in solution with polyethylene glycol (PEG) as a crowding agent. The PEG solutions have been characterized by small angle neutron scattering and are well described by the picture of a network of mesh size ξ, usual for semi-dilute chains in good solvent. We show that the increase of PEG concentration stabilizes the helices and increases the transition temperature. But more unexpectedly, we also notice that the increase of concentration of crowding agent reduces the mean helix extent at the transition, or in other words reduces its cooperativity. This result cannot be taken into account for by an entropic stabilization mechanism. Comparing the mean length of helices at the transition and the mesh size of the PEG network, our results strongly suggest two regimes: helices shorter or longer than the mesh size.

The model Lysozyme-PSSNa system for electrostatic complexation: Similarities and differences with complex coacervation.

We review, based on structural information, the mechanisms involved when putting in contact two nano-objects of opposite electrical charge, in the case of one negatively charged polyion, and a compact charged one. The central case is mixtures of PSS, a strong flexible polyanion (the salt of a strong acid, and with high linear charge density), and Lysozyme, a globular protein with a global positive charge. A wide accurate and consistent set of information in different situations is available on the structure at local scales (5-1000Å), due to the possibility of matching, the reproducibility of the system, its well-defined electrostatics features, and the well-defined structures obtained. We have related these structures to the observations at macroscopic scale of the phase behavior, and to the expected mechanisms of coacervation. On the one hand, PSS/Lysozyme mixtures show accurately many of what is expected in PEL/protein complexation, and phase separation, as reviewed by de Kruif: under certain conditions some well-defined complexes are formed before any phase separation, they are close to neutral; even in excess of one species, complexes are only modestly charged (surface charges in PEL excess). Neutral cores are attracting each other, to form larger objects responsible for large turbidity. They should lead the system to phase separation; this is observed in the more dilute samples, while in more concentrated ones the lack of separation in turbid samples is explained by locking effects between fractal aggregates. On the other hand, although some of the features just listed are the same required for coacervation, this phase transition is not really obtained. The phase separation has all the macroscopic aspects of a fluid (undifferentiated liquid/gas phase) - solid transition, not of a fluid-fluid (liquid-liquid) one, which would correspond to real coacervation). The origin of this can be found in the interaction potential between primary complexes formed (globules), which agrees qualitatively with a potential shape of the type repulsive long range attractive very short range. Finally we have considered two other systems with accurate structural information, to see whether other situations can be found. For Pectin, the same situation as PSS can be found, as well as other states, without solid precipitation, but possibly with incomplete coacervation, corresponding to differences in the globular structure. It is understandable that these systems show smoother interaction potential between the complexes (globules) likely to produce liquid-liquid transition. Finally, we briefly recall new results on Hyaluronan/Lysozyme, which present clear signs of coacervation in two liquid phases, and at the same time the existence of non-globular complexes, of specific geometry (thin rods) before any phase separation. These mixtures fulfill many of the requirements for complex coacervation, while other theories should also be checked like the one of Shklovskii et al.

Temperature- and hydration-dependent internal dynamics of stripped human erythrocyte vesicles studied by incoherent neutron scattering.

BACKGROUND: We focus on temperature- and hydration-dependence of internal molecular motions in stripped human red blood cell (RBC) vesicles, widely used as a model system for more complex biomembranes. METHODS: We singled out picosecond local motions of the non-exchangeable hydrogen atoms of RBC vesicles by performing elastic and quasielastic incoherent neutron scattering measurements in dry and heavy water (D2O)-hydrated RBC powders. RESULTS: In dry stripped RBCs, hydrogen motions remained harmonic all along the measured temperature range (100-310K) and mean-square displacements (MSDs) exhibited no temperature transition up to 310K. In contrast, MSDs of hydrated stripped RBCs (h ≈ 0.38g D2O/g dry powder) exhibited a pronounced transition near 260K, with the sharp rise of anharmonic diffusive motions of hydrogen atoms. This transition at ~260K was correlated with both the onset of nonvibrational (harmonic and nonharmonic) motions and the melting of crystallized hydration water. GENERAL SIGNIFICANCE: In conclusion, we have shown that MSDs in human RBC vesicles are temperature-and hydration-dependent. These results provide insight into biomembrane internal dynamics at picosecond timescale and nanometer length scale. Such motions have been shown to act as the "lubricant" of larger conformational changes on a slower, millisecond timescale that are necessary for important biological processes.

[Ultrasound-guided supraclavicular subclavian vein catheterization: a novel approach in children]. / Abord de la veine sous-clavière par voie sus-claviculaire sous échographie: une nouvelle approche en pédiatrie.

The subclavian vein (SCV) is often the preferred site for long-term central venous catheterization in children. It has many advantages over the internal jugular vein. But with the classical landmark technique for SCV catheterization the ultrasound-guidance technique is usually not suitable, because of the clavicle (a bright hyperechoic structure with an acoustic shadow beneath it). Because the SCV can easily be visualized via a supraclavicular approach, we developed a useful ultrasound-guided approach for SCV catheterization in infants and children.

Aquaporin-2 downregulation in kidney medulla of aging rats is posttranscriptional and is abolished by water deprivation.

Aging kidney is associated in humans and rodents with polyuria and reduced urine concentrating ability. In senescent female WAG/Rij rats, this defect is independent of arginine-vasopressin (AVP)/V(2) receptor/cAMP pathway. It has been attributed to underexpression and mistargeting of aquaporin-2 (AQP2) water channel in the inner medullary collecting duct (IMCD). We showed previously that dDAVP administration could partially correct this defect. Since AQP2 can also be regulated by AVP-independent pathways in water deprivation (WD), we investigated AQP2 and phosphorylated AQP2 (p-AQP2) regulation in thirsted adult (10 mo old) and senescent (30 mo old) female WAG/Rij rats. Following 2-day WD, urine flow rate decreased and urine osmolality increased in both groups. However, in agreement with significantly lower cortico-papillary osmotic gradient with aging, urine osmolality remained lower in senescent animals. WD induced sixfold increase of plasma AVP in all animals which, interestingly, did not result in higher papillary cAMP level. Following WD, AQP2 and p-AQP2 expression increased hugely in 10- and 30-mo-old rats and their mistargeting in old animals was corrected. Moreover, the age-related difference in AQP2 regulation was abolished after WD. To further investigate the mechanism of AQP2 underexpression with aging, AQP2 mRNA was quantified by real-time RT-PCR. In the outer medulla, preservation of AQP2 protein expression was achieved through increased AQP2 mRNA level in senescent rats. In the IMCD, no change in AQP2 mRNA was detected with aging but AQP2 protein expression was markedly lower in 30-mo-old animals. In conclusion, there is a posttranscriptional downregulation of AQP2 with aging, which is abolished by WD.

Efficacy and plasma levels of ropivacaine for children: controlled regional analgesia following lower limb surgery.

BACKGROUND: Continuous regional analgesia (CRA) is considered a safe and efficacious technique for postoperative pain relief in children after lower limb surgery. We recently evaluated the feasibility of patient-controlled regional analgesia (PCRA) in a similar acute pain situation and we concluded that PCRA might be advantageous over CRA in terms of lower costs, risk of systemic toxicity while producing similarly adequate analgesia. We therefore prospectively compared both techniques in the paediatric population. METHODS: In total, 30 children undergoing lower limb orthopaedic surgery were randomized to receive PCRA or CRA with ropivacaine 0.2%. Visual analogue scale scores, rescue analgesia, overall satisfaction, motor blockade and plasma ropivacaine concentrations were recorded for 48 h. RESULTS: Adequate analgesia was achieved with both techniques. No significant difference was noted for rescue analgesia, overall satisfaction and motor blockade. In contrast, children in the PCRA group received significantly less local anaesthetics than those in the CRA group. In addition, total plasma concentrations of ropivacaine were significantly reduced in the PCRA group as compared with the CRA group during the 48 h postoperative period. CONCLUSIONS: Both techniques are efficacious and satisfactory. However, PCRA with ropivacaine 0.2% can provide adequate postoperative analgesia for paediatric orthopaedic procedures with smaller doses of ropivacaine than CRA.

Inhibition of nitric oxide synthase reverses changes in peritoneal permeability in a rat model of acute peritonitis.

BACKGROUND: Acute peritonitis is the most frequent complication of peritoneal dialysis (PD), and nitric oxide (NO) is thought to play a role in the structural and permeability changes observed in this condition. We have used a combination of expression, enzymatic and pharmacological studies to substantiate the potential role(s) played by NO during peritonitis. METHODS: The peritoneal equilibration test was performed in control rats and rats with acute peritonitis (originating from skin flora), using standard dialysate supplemented or not with the NO synthase (NOS) inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME). In parallel, peritoneal NOS enzymatic activities were measured and expression studies for NOS isoforms and S-nitrosocysteine reactivity performed in the peritoneum. RESULTS: In comparison with controls, rats with acute peritonitis were characterized by inflammatory changes, increased S-nitrosocysteine immunoreactivity, and increased NOS activities in the peritoneum, due to the up-regulation of endothelial and inducible NOS. In parallel, rats with acute peritonitis showed increased permeability for small solutes; decreased sodium sieving; loss of ultrafiltration (UF); and increased protein loss in the dialysate. Addition of L-NAME to the dialysate did not induce permeability changes in control rats, but significantly improved UF and reversed permeability modifications in rats with peritonitis. The effect of L-NAME was reflected by a mild but consistent increase in blood pressure during PD exchange. CONCLUSIONS: Our results demonstrate that local generation of NO, secondary to up-regulation of NOS isoforms, plays an important role in the regulation of peritoneal permeability during acute peritonitis in rats. By itself, NOS inhibition improves UF and reverses permeability changes, which might offer new therapeutic perspectives in acute peritonitis.

Food restriction prevents age-related polyuria by vasopressin-dependent recruitment of aquaporin-2.

The mechanisms underlying the prevention of age-related polyuria by chronic food restriction were investigated in female WAG/Rij rats. The decreased osmolality of renal papilla observed in senescent rats was not corrected by food restriction. A reduced urea content in the inner medulla of senescent rats, fed ad libitum or food-restricted, was suggested by the marked decrease in expression of UT-A1 and UT-B1 urea transporters. Aquaporin-2 (AQP2) downregulation in the inner medulla of senescent rats was partially prevented by food restriction. Both AQP2 and the phosphorylated form of AQP2 (p-AQP2), the presence of which was diffuse within the cytoplasm of collecting duct principal cells in normally fed senescent rats, were preferentially targeted at the apical region of the cells in food-restricted senescent animals. Plasma vasopressin (AVP) was similar in 10- and 30-mo-old rats fed ad libitum, but was doubled in food-restricted 30-mo-old rats. This study indicates that 1) kidney aging is associated with a marked decrease in AQP2, UT-A1, and UT-B1 expression in the inner medulla and a reduced papillary osmolality; and 2) the prevention of age-related polyuria by chronic food restriction occurs through an improved recruitment of AQP2 and p-AQP2 to the apical membrane in inner medulla principal cells, permitted by increased plasma AVP concentration.

Regulation of NO synthase isoforms in the peritoneum: implications for ultrafiltration failure in peritoneal dialysis.

BACKGROUND: Ultrafiltration (UF) failure often complicates peritoneal dialysis (PD). At least two molecules might be involved in UF failure: aquaporin-1 (AQP1), a water channel thought to be the ultra small pore of the peritoneal membrane (PM), and nitric oxide (NO), which might regulate effective peritoneal surface area and microvascular permeability. METHODS: The contributions of AQP1 and NO in UF failure were evaluated by combining different experimental approaches. Specific antibodies were used to investigate the expression (immunoblotting) and localization (immunostaining) of AQP1 and NO synthase (NOS) isoforms in the peritoneum, in correlation with: (i) morphometric analyses; (ii) the l-citrulline assay, which specifically measures NOS enzymatic activities; and (iii) permeability parameters across the PM. RESULTS: AQP1 is located in the endothelium lining peritoneal capillaries, and its expression is remarkably stable in samples ranging from normal to highly inflamed peritoneum and even when transcellular water permeability is absent (loss of sodium sieving). A significant NOS activity, mediated by specific NOS isoforms, can be assayed in the peritoneum. The NOS activity significantly increases in conditions such as peritonitis and long-term PD, and this increase is mirrored by up-regulation of NOS isoforms, as well as angiogenesis and increased endothelial area. CONCLUSIONS: These data suggest that the NO-mediated increase in effective peritoneal surface area, followed by a dissipation of the osmotic gradient, is a major mechanism accounting for the loss of UF in PD. Other biological consequences of increased NO levels in the peritoneum might include initiation of angiogenesis or modification of functionally important proteins such as AQP1.

A specific method for measurement of nitric oxide synthase enzymatic activity in peritoneal biopsies.

UNLABELLED: A specific method for measurement of nitric oxide synthase enzymatic activity in peritoneal biopsies. BACKGROUND: Nitric oxide (NO) is synthesized by NO synthase (NOS) isoforms that are expressed in the peritoneum. Thus far, NOS activity in the peritoneum has been assessed by nonspecific methods. We describe the application of a specific method for determination of NOS activity in rat and human peritoneal biopsies. METHODS: The L-citrulline assay is based on the stoechiometric production of NO and L-[3H]-citrulline from L-[3H]-arginine by NOS. The assay is technically difficult when applied on small samples with relatively low levels of NOS activity, which required specific procedures for extraction and samples processing. Reaction parameters ensuring assay linearity in the peritoneum were defined. Peritoneum lysates were also used for immunoblot analysis to identify the NOS isoforms involved. RESULTS: A significant NOS activity is detected in the normal peritoneum because of both Ca2+-dependent and Ca2+-independent NOS. The specificity of NOS activity has been demonstrated by various controls, including the NOS inhibitor L-NMMA. Competition experiments with L-valine and amino acid analyses have reasonably excluded the interference of endogenous arginase and L-arginine, which both might underestimate NOS activity. The procedure is sensitive; it detects a high range of NOS activities as well as the appropriate NOS isoforms in various tissues and conditions, as shown by correlations with immunoblot studies. CONCLUSIONS: We have adapted and characterized the L-citrulline assay to measure specific NOS activities within the peritoneum. The peritoneum lysate assayed for NOS activity can also be used for characterizing NOS isoform expression by immunoblot analysis.

Regulation of aquaporin-1 and nitric oxide synthase isoforms in a rat model of acute peritonitis.

The loss of ultrafiltration (UF) that accompanies acute peritonitis is a common problem in peritoneal dialysis (PD). It has been suggested that changes in nitric oxide (NO)-mediated vascular tone and permeability might be involved in the loss of UF, whereas channel-mediated water permeability should not be affected. This study used a model of acute peritonitis in rats to characterize changes in PD parameters, in correlation with: (1) expression studies of water channel aquaporin-1 and NO synthase (NOS) isoforms and (2) enzymatic assays for NOS in the peritoneum. Compared with controls, rats with peritonitis had a higher removal of plasma urea, a faster glucose absorption, and a loss of UF. Additional changes, including high protein loss, elevated leukocyte counts in dialysate, positive bacterial cultures, edema, and mononuclear infiltrates, were similar to those observed in PD patients with acute peritonitis. Acute peritonitis in rats induced a major increase in total NOS activity, which was inversely correlated with free-water permeability. The increased NOS activity was mediated by both inducible (Ca2+-independent) and endothelial (Ca2+-dependent) NOS isoforms and was reflected by increased peritoneal staining for nitrotyrosine. In contrast, aquaporin-1 expression was unchanged in rats with peritonitis. These findings cast light on the pathophysiology of permeability changes and loss of UF that characterize acute peritonitis. In particular, these data suggest that a local production of NO, mediated by different NOS isoforms, might play a key role in these changes.

Expression of aquaporin-1 in a long-term peritoneal dialysis patient with impaired transcellular water transport.

Aquaporin-1 (AQP1) has been claimed to be the molecular counterpart of the transcellular pathway for free-water movement across the peritoneum during peritoneal dialysis. We report the case of a 67-year-old man, on peritoneal dialysis for 11 years, in whom ultrafiltration failure due to an abolition of the transcellular water transfer (documented by a loss of sodium sieving) was associated with an apparently normal expression of AQP1. We suggest that an alteration of AQP1 structure, rather than of its expression, accounts for this observation.

[Acute gastric distension necessitating gastrostomy after anesthetic induction for surgical correction of type III esophageal atresia]. / Distension gastrique aiguë nécessitant une gastrostomie après induction anesthésique pour correction chirurgicale d'une atrésie de l'oesophage de type III.

IPPV during anaesthesia for management of oesophageal atresia with tracheo-oesophageal fistula (TOF) can cause gastric insufflation. We report such a complication in a one-day-old newborn, who developed, 15 min after induction, a distension of the abdomen, hypoxia and bracdycardia. An emergency gastrostomy was performed. His status improved rapidly and surgery could be completed. TOF was located at the carina and had a large calibre. To avoid gastric distension in such cases, the tip of the tube is located just proximal to the carina, but distal to the fistula to prevent intubation of the latter. Difficulties are due to position of the fistula (carina, main bronchi) or its large bore. Gastric distension carries a risk of regurgitation and inhalation of gastric contents, elevation of hemidiaphragm and lung compression, decreased tidal volume, decreased venous return, cardiovascular collapse and cardiac arrest. When insufflation peak pressures are low, gastrostomy is benefitful, as in our case, as the tidal volume loss through the stomach is acceptable. In case of high insufflation pressures because of co-existing lung disease, gastrostomy is better avoided, as most if not all the tidal volume may be lost through the stomach.

[A rare cause of hyponatremia during introductory treatment of acute lymphoblastic leukemia in an infant: inappropriate secretion of atrial natriuretic factor?]. / Une cause rare d'hyponatrémie lors du traitement d'induction d'une leucémie aiguë lymphoblastique chez un nourrisson: la sécrétion inappropriée de facteur atrial natriurétique?

BACKGROUND: --Hyponatremia is frequently seen during the treatment of acute lymphoblastic leukemia: its causes are numerous. This work aims to present a case in whom hyponatremia was possibly due to an increased secretion of atrial natriuretic factor. CASE REPORT: --A 3 week-old baby was admitted because of malignant hemopathy. A diagnosis of acute lymphoblastic leukemia was rapidly made and the patient was firstly given alkaline diuresis, urate-oxidase and corticosteroids. Vincristine and daunorubicin were associated one week later. Insertion of a central intravenous line in the right subclavicular artery failed so that this catheter was finally inserted into the left jugular vein. Natremia was 126 mmol/l at that time and dramatically decreased within 24 hours to 109 mmol/l without net changes in water and electrolytic input. At that time, sodium urinary excretion was 6 mmol/kg/day (diuresis: 420 mlF/day). There was no hemodynamic changes, nor digestive or cardiac manifestations. Ultrasonography showed that the left superior cava vein drained into the right cardiac atrium. The catheter was withdrawn and the patient was given sodium supplementation permitting complete and definitive cure of hyponatremia within 2 days. CONCLUSIONS: --All usual causes of hyponatremia having been ruled out in this patient, we postulate that hyponatremia was due to direct stimulation of atrial natriuretic peptide through an increase in atrial pressure secondary to the catheter insertion near the cardiac atrium.