Blood glucose regulation during living-donor liver transplant surgery.

OBJECTIVES: The goal of this study was to compare the effects of 2 different regimens on blood glucose levels of living-donor liver transplant. MATERIALS AND METHODS: The study participants were randomly allocated to the dextrose in water plus insulin infusion group (group 1, n = 60) or the dextrose in water infusion group (group 2, n = 60) using a sealed envelope technique. Blood glucose levels were measured 3 times during each phase. When the blood glucose level of a patient exceeded the target level, extra insulin was administered via a different intravenous route. The following patient and procedural characteristics were recorded: age, sex, height, weight, body mass index, end-stage liver disease, Model for End-Stage Liver Disease score, total anesthesia time, total surgical time, and number of patients who received an extra bolus of insulin. The following laboratory data were measured pre- and postoperatively: hemoglobin, hematocrit, platelet count, prothrombin time, international normalized ratio, potassium, creatinine, total bilirubin, and albumin. RESULTS: No hypoglycemia was noted. The recipients exhibited statistically significant differences in blood glucose levels during the dissection and neohepatic phases. Blood glucose levels at every time point were significantly different compared with the first dissection time point in group 1. Excluding the first and second anhepatic time points, blood glucose levels were significantly different as compared with the first dissection time point in group 2 (P < .05). CONCLUSIONS: We concluded that dextrose with water infusion alone may be more effective and result in safer blood glucose levels as compared with dextrose with water plus insulin infusion for living-donor liver transplant recipients. Exogenous continuous insulin administration may induce hyperglycemic attacks, especially during the neohepatic phase of living-donor liver transplant surgery. Further prospective studies that include homogeneous patient subgroups and diabetic recipients are needed to support the use of dextrose plus water infusion without insulin.

Effects of sevoflurane or ketamine on the QTc interval during electroconvulsive therapy.

PURPOSE: To evaluate the effect of sevoflurane or ketamine on the corrected QT (QTc) interval and the interval from the peak to the end of the T wave (Tp-e) during electroconvulsive therapy (ECT) in patients with major depression. METHODS: This prospective, randomized, double-blinded study included 24 patients that were randomly allocated to receive sevoflurane (group S) or ketamine (group K) for ECT session. Group S patients received 8 % sevoflurane for anesthesia induction, which was maintained at 2-4 % until delivery of the electrical stimulus. Group K patients received a bolus of ketamine (1 mg/kg). The mean arterial pressure (MAP) and heart rate (HR) and the electrocardiogram (ECG) were recorded before (T1) and after induction of anesthesia (T2) and 0, 1, 3, and 10 min after the electrical stimuli ended (T3, T4, T5, and T6, respectively). RESULTS: In both groups, the QTc interval was significantly longer at T2, T4, T5, and T6 than at baseline. The QTc interval was longer at T4, T5, and T6 in group S compared to that in group K, the Tp-e interval was significantly longer at T4 in group K both baseline and group S. The HR in group S was increased at T4 compared with group K. MAP was significantly higher after induction of anesthesia in group K compared to those in group S at all time points. CONCLUSIONS: Although group S showed a prolonged QTc interval after ECT compared to group K, the Tp-e interval in both groups was not significantly affected clinically. Sevoflurane blunted MAP and peak HR.

Postoperative cognitive dysfunction in living liver transplant donors.

OBJECTIVES: Postoperative cognitive dysfunction is a serious complication that may be associated with increased mortality. Living-donor liver transplant includes major surgery for the donor. The purpose of this study was to evaluate preoperative and postoperative cognitive function of liver donors in living-donor liver transplant. MATERIALS AND METHODS: In 102 patients who had hepatectomy for liver transplant donation, preoperative and postoperative (1 week) neuropsychologic tests were performed including the Trail Making Test, the Stroop effect, score on the Beck Depression Inventory, and the mini-mental state examination. RESULTS: Liver transplant donors had significantly lower mean Trail Making A Test duration and greater mean Trail Making B Test error number after than before surgery. The mean Stroop effect reading durations (black and white reading; reading colored words) were significantly greater after than before surgery; the mean time difference between naming the colors of colored words minus reading colored words, and the error number, were smaller after than before surgery. The mean score on the Beck Depression Inventory and mini-mental state examination score were similar before and after surgery. CONCLUSIONS: Mild frontal lobe dysfunction may be present in liver donors at 1 week after surgery, and postoperative attention problems may be experienced by these patients.

Anesthesia management in a child with osteogenesis imperfecta and epidural hemorrhage.

Osteogenesis Imperfecta (OI) results from gene mutation that causes defective or insufficient collagen formation. It may cause various anesthetic complications due to the difficulty in airway management, existence of spinal deformity, respiratory disorders, cardiac anomalies, thrombocyte function disorder, risk of hyperthermia, bacillary invagination, bone deformities and metabolic disorders. The anesthesia management of OI patients should be exercised with caution given certain risks of respiratory disorders. These risks are due to thorax deformity, bone fractures during moving or changing position, mandibular and cervical fractures related with intubation, difficult intubation and malignant hyperthermia. The anesthetic technique using Total Intravenous Anesthesia (TIVA) and laryngeal mask airway is suitable for pediatric patient care with OI. However, these techniques have not yet been reported as useful in neurosurgery case reports. In this study, we present the use of TIVA and ProSeal Laringeal Mask in a child with OI and epidural hemorrhage. We came to the conclusion that LMA and TIVA can safely be used in the anesthetic management of OI patients with severe anesthetic problems.

Dexmedetomidine ameliorates TNBS-induced colitis by inducing immunomodulator effect.

BACKGROUND: Since sedatives are often administered to immune-compromised and critically ill patients, our understanding of immunomodulation by sedation will be critical. Dexmedetomidine, a selective α2-adrenergic receptor agonist, is often used for sedation and analgesia especially in intensive care units. There are conflicting and little data concerning both the effect and the mechanism of dexmedetomidine on immune response. In our study, we aimed to investigate the effect of dexmedetomidine on immune system at two different doses (5 µg.kg(-1) and 30 µg.kg(-1)) during inflammatory bowel disease by using an experimental model, which resembles both systemic and local inflammation. METHODS: The effect of dexmedetomidine on the course of inflammatory bowel disease was investigated by measuring macroscopic and microscopic parameters. We investigated pro-inflammatory Th1, Th2, and Th17 cytokine levels in serum samples to analyze systemic immune response. Following this, local immune response was investigated by measuring cytokine levels in the presence of dexmedetomidine in spleen cell culture. RESULTS: Dexmedetomidine administration led to amelioration of all disease associated pathological manifestations. According to our in vitro and in vivo results, dexmedetomidine shows anti-inflammatory effect by increasing IL-4 and IL-10 levels responsible from anti-inflammatory response via Th2 pathway. Moreover, we showed for the first time in the study that dexmedetomidine administration reduces IL-23, which is responsible from initiation of inflammatory response via Th17 pathway. CONCLUSIONS: Dexmedetomidine can have beneficial effect on preoperative or postoperative inflammatory bowel disease patients in intensive care units by down-regulating inflammatory immune response not only in systemic circulation but also in tissue-specific manner.

The effects of secondhand smoke on postoperative pain and fentanyl consumption.

BACKGROUND: Although the need for increased postoperative analgesia in smokers has been described, the effect of secondhand smoke on postoperative analgesia requirements has not been studied. We examined the effects of secondhand smoke on fentanyl consumption and postoperative pain. METHODS: In this study, 101 patients (American Society of Anesthesiology physical status I and II) who underwent abdominal hysterectomy were divided into 3 groups according to history of exposure to cigarette smoke as per medical records which was retrospectively confirmed by measurement of serum cotinine: smokers (n = 28), nonsmokers (n = 31), and secondhand smokers (n = 32). All patients received propofol-remifentanil total intravenous anesthesia and used fentanyl patient controlled analgesia for postoperative pain. The fentanyl consumption visual analogue scale-pain intensity (VAS-PI) score and side effects were recorded in the postanesthesia care unit (PACU) and at 2, 4, 6, and 24 h after surgery. RESULTS: Fentanyl consumption at all the evaluation time points was significantly higher in secondhand smokers than in nonsmokers (P < 0.05). However, fentanyl consumption in secondhand smokers was lower than that in smokers in the PACU and at 24 h (P < 0.05). VAS-PI scores during movement and at rest in the PACU and at 4, 6, and 24 h after surgery were higher in secondhand smokers than in nonsmokers (P < 0.05). There were no statistically significant differences between the groups with regard to side effects such as nausea, vomiting, and dizziness (P > 0.05). CONCLUSION: Secondhand smoking was associated with increased postoperative fentanyl consumption, and increased VAS-PI scores. These findings may be beneficial for managing postoperative pain in secondhand smokers.

Anaesthesia for Caesarean Delivery in a Pregnant with Acute Type B Aortic Dissection.

About 50% of aortic dissections in women younger than 40 years occur during pregnancy; mostly in the 3rd trimesters and postpartum period. Aortic dissection in pregnancy creates a serious mortality risk for both mother and the foetus. The ultimate goal is to ensure the safety of both the mother and the foetus. In such cases, the best method of anaesthesia for caesarean delivery is still controversial. The first aim of anaesthetic management is to reduce the effect of cardiovascular instability on the dissected aorta. Here, we report the anaesthetic management of a 36 year-old pregnant woman who developed acute type B aortic dissection in the 30(th) gestational weeks and scheduled for caesarean section. Since hemodynamic stability could not be achieved despite nitro-glycerine and esmolol infusions, together with invasive arterial monitoring, the decision for caesarean delivery was taken. A team of Cardiovascular Surgeons and an operating room were prepared because of the risks of aortic rupture and hemodynamic collapse during operation. Combined-spinal epidural anaesthesia was administered using 5 mg hyperbaric bupivacaine and 20 µg fentanyl given at the L3-4 spinal level in the side lying position. After achieving T4 sensory block level, the operation proceeded and a baby weighing 1432 grams was delivered in 4 min with a median subumbilical incision. Epidural patient controlled analgesia was applied to the patient during follow-up with medical treatment at postoperative period. In pregnant women with acute Type B aortic dissection, if adequate sensory block level cannot be achieved despite using a combination of low dose local anaesthetic (spinal use) and opioids, we are in the opinion that combined spinal-epidural anaesthesia, which allows the use of additional doses can be a decent choice.

Anesthesia management in a child with osteogenesis imperfecta and epidural hemorrhage.

Osteogenesis Imperfecta (OI) results from gene mutation that causes defective or insufficient collagen formation. It may cause various anesthetic complications due to the difficulty in airway management, existence of spinal deformity, respiratory disorders, cardiac anomalies, thrombocyte function disorder, risk of hyperthermia, bacillary invagination, bone deformities and metabolic disorders. The anesthesia management of OI patients should be exercised with caution given certain risks of respiratory disorders. These risks are due to thorax deformity, bone fractures during moving or changing position, mandibular and cervical fractures related with intubation, difficult intubation and malignant hyperthermia. The anesthetic technique using Total Intravenous Anesthesia (TIVA) and laryngeal mask airway is suitable for pediatric patient care with OI. However, these techniques have not yet been reported as useful in neurosurgery case reports. In this study, we present the use of TIVA and ProSeal Laringeal Mask in a child with OI and epidural hemorrhage. We came to the conclusion that LMA and TIVA can safely be used in the anesthetic management of OI patients with severe anesthetic problems.

Effects of propofol or etomidate on QT interval during electroconvulsive therapy.

BACKGROUND: Because patients with major depression have an altered autonomic nervous system activity, the risk of arrhythmias and sudden cardiac death may be increased. In addition, electroconvulsive therapy (ECT) may cause an acute rise in QT dispersion, which may predispose to arrhythmias. In this study, we investigated the effects of propofol or etomidate on the corrected QT (QTc) interval during ECT in patients with major depression. MATERIALS AND METHODS: Fourteen unpremedicated American Society of Anesthesiologists I patients, each scheduled for 6 ECT sessions for major depression, were included in a prospective, randomized crossover study. The patients randomly received either 1-mg/kg propofol (propofol group) or 0.2-mg/kg etomidate (etomidate group). The mean arterial pressure (MAP), heart rate (HR), and electrocardiogram were recorded before anesthetic induction, 0 and 1 minute after the seizure ended, and 3 and 10 minutes after the seizure ended (T3 and T4, respectively). RESULTS: In the propofol group, the QTc interval was shorter than the baseline at 0 minute after the seizure ended. The QTc interval increased from the baseline at T3 and T4 in the etomidate group. In the etomidate group, the QTc interval was longer at T3 and T4 than that in the propofol group (P < 0.05). In the etomidate group, the HR increased at T3 and T4, but the MAP increased at all measurement times from the baseline value. The HR and the MAP were lower at T3 and T4 in the propofol group than in the etomidate group (P < 0.05). CONCLUSIONS: Propofol did not induce prolongation of the QT interval and controlled the hemodynamic response better than etomidate during ECT. Therefore, propofol may be more suitable than etomidate for ECT treatments.

Propofol and erythropoietin antioxidant properties in rat brain injured tissue.

So far, several treatment modalities have been attempted to brain protection in cases such as brain trauma, stroke or brain hemorrhage. However, a treatment method that the effect begins immediately and definitely helpful has not been discovered yet. In this study, we aimed to compare the effects of propofol and erythropoietin (Epo) on brain injury caused by oxidative stress and antioxidant properties of these agents after closed head injury (CHI) in rats. For this study, female Wistar Albino rats were divided into five groups: non-traumatic control group, trauma performed group CHI, trauma with propofol (100 mg/kg) intraperitoneally (i.p.), trauma with Epo (5000 U/kg) i.p. and trauma with propofol and Epo performed study groups. Twenty-four hours after CHI, rats were sacrificed and the brains were removed. Superoxide dismutase (SOD), catalase (CAT), xanthine oxidase (XO), nitric oxide (NO), and malondialdehyde (MDA) levels were measured in brain tissue. MDA and NO levels were decreased significantly in Groups Epo, Propofol and Epo+Propofol than Group CHI (p<0.01). XO activity was significantly lower in Group Epo than Group CHI (p<0.05). Epo and propofol decreased oxidative stress by decreasing MDA and NO level in brain tissue after CHI. However, combination of Epo and propofol has no significant beneficial advantage than Epo or propofol alone.

Effects of polyenylphosphatidylcholine on cytokines, nitrite/nitrate levels, antioxidant activity and lipid peroxidation in rats with sepsis.

OBJECTIVES: To determine the effect of pretreatment with polyenylphosphatidylcholine (lecithin, PPC) on plasma levels of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-10, total nitrite/nitrate (NOx), and tissue levels of superoxide dismutase (SOD) and malondialdehyde (MDA) in septic rats. DESIGN: Prospective, randomized, controlled animal study. SETTING: University laboratory. SUBJECTS: Forty-five Spraque-Dawley rats were divided into three groups: group C, sham-operated; group S, sepsis; and group P, sepsis pretreated with PPC. INTERVENTIONS: Rats were made septic by cecal ligation and puncture (CLP). Group P rats were treated with PPC (100 mg/day orally) for 10 days before sepsis. Twenty-four hours later CLP, plasma concentrations of TNF-alpha, IL-6 and IL-10 and plasma levels of NOx were measured. SOD and MDA were determined in liver, lung and heart homogenates. MEASUREMENTS AND MAIN RESULTS: All rats in group P survived during the 24-h observation time after CLP, whereas survival rate in group S was 66.7% (10/15; P<0.05). PPC significantly reduced plasma levels of TNF-alpha (P=0.006), IL-6 (P=0.007), IL-10 (P=0.016), NOx (P<0.001), and tissue levels of MDA (P<0.001) in group P with respect to in group S. Tissue levels of SOD significantly increased in group P when compared with group S (P<0.001). CONCLUSIONS: These results show that PPC pretreatment exerts cumulative effects in decreasing the levels of cytokines, NOx, and tissue MDA concentrations, with a concomitant increase in survival in septic rats. Lecithin therapy may be a useful adjuvant therapy in controlling of the excessive production of the inflammatory cytokines in patients with severe sepsis. DESCRIPTOR: SIRS/sepsis, experimental studies.