[Transillumination technique in difficult intubations in heart surgery]. / Die Transilluminationstechnik bei der schwierigen Intubation in der Herzanästhesie.

OBJECTIVE: The avoidance of myocardial depression still remains the goal of the management for cardiosurgical patients, also when unexpected difficulties in intubation face the anaesthetist. Therefore the difficult intubation should be managed by a short and easy procedure which provides safe results. To analyse the use of transillumination technique with a lightwand device (Trachlight(R), Laerdale, USA) in case of unexpected difficult intubation is the aim of our report. Methods All cardiosurgical patients (NYHA II - IV) were included from Jan 1998 - Dec 2001. After failure of the first intubation attempt by means of direct laryngoscopy (with non-adjustable vocal cord level) this intubation was qualified as an difficult intubation. In all these cases a lightwand device (Trachlight(R), Laerdale, USA) was applicated. Success, duration of the procedure, blood pressure, heart rate were recorded. Results 195 patients (out of total 7406) who could not be directly intubated by laryngoscopy (vocal cord level and arytenoid cartilage not visible), were classified as a difficult intubation. During the first year 1998 the light guided intubation (LGI) was successful as secondary procedure in 94 %, 3 cases, in which LGI failed the intubation was performed by fiberoptic method or McCoy blade. From 1999 to 2001 all difficult intubation could be managed by light guided intubation. In all cases of unexpected difficult intubation the procedure of the light guided intubation took as less than 3 min. The directly measured arterial blood pressure elevated by 14 % in comparison with the pressure prior to the passage through the larynx. Discussion and Conclusions 1998 after sufficient familiarisation of staff with the light wand device the transillumination technique was introduced as an alternative of using the McCoy blade or of using the fiberoptic method in the case of difficult intubation. Short neck or obesity, which occur as main reasons for intubation problems are surprisingly easy to control by light wand device. Therefore the light guided intubation could be an alternative procedure for unexpected difficult intubation in the setting of adult cardiac anesthesia.

Stability of parental nurturance as a salient predictor of self-esteem.

The relationship of parental nurturance to self-esteem for seven distinct adolescent and early-adulthood age groups (N = 784) was investigated. Analysis showed that even though mothers' and fathers' nurturance together were more strongly related to self-esteem during the junior high school years (R2 values greater than 50% were obtained in each of the junior high samples) than during the high school and college years (R2 values less than 40% were obtained in each of these samples), parental nurturance still remained a robust predictor of self-esteem during these latter years. These results were discussed within the context of (a) the stability at different ages of the bases upon which one's judgments of self-esteem are made, and (b) parental nurturance as a stabilizing influence during the transitional years of adolescence and early adulthood.

[Preoperative treatment with beta-receptor blockers and isoflurane anesthesia. Hemodynamic interactions in patients with coronary disease]. / Präoperative Therapie mit beta-Rezeptorenblockern und Isoflurananaesthesie. Hämodynamische Interaktionen bei Patienten mit koronarer Herzkrankheit.

Although many patients undergoing general anesthesia and surgery are pretreated with beta-adrenoceptor blocking drugs, hemodynamic interactions of beta-blockers and volatile anesthetics have so far only been studied in animals. We therefore designed a clinical study to evaluate the relationship between the extent of preoperative beta-adrenoceptor blockade and the hemodynamic effects of isoflurane anesthesia. Sixty-one patients with coronary artery disease (CAD) and normal global left ventricular function scheduled for elective myocardial revascularization were studied immediately prior to surgery. One group of patients (n = 39) had been treated with beta-adrenoceptor blocking agents for at least 3 weeks up to and including the day of surgery. The degree of clinical beta-adrenoceptor blockade was quantified using the isoproterenol sensitivity test. The dose of isoproterenol required to increase heart rate by 25 beats/min was defined as the chronotropic dose 25 (CD25), representing the degree of beta-adrenoceptor blockade. Hemodynamic data were collected before and during isoflurane anesthesia (0.5%-0.6% end-tidal) plus 50% nitrous oxide. Twenty-two patients without preoperative beta-blocker therapy served as a control group. Preanesthetic values of cardiac index (CI), heart rate (HR) and mean arterial pressure (MAP) were lower in patients pretreated with beta-blocking drugs, but statistically these differences were not significant when compared to data obtained in unblocked patients. Isoflurane anesthesia caused significant reductions of CI and arterial blood pressure. However, there were no significant differences in the absolute values or the percentage changes compared to baseline data obtained in awake patients between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Oxygen transport in newborn piglets with pulmonary hypertension.

Because of the neonate's susceptibility to pulmonary hypertension (PHN) and his inefficiency in invoking the compensatory mechanisms often used by adults to maintain stable levels of O2 consumption (VO2) in the face of changes in O2 delivery (DO2) and metabolic demand, we have attempted to define the O2 handling capabilities of the newborn piglet affected with various types of pulmonary vasoconstriction. Hemodynamically similar levels of PHN were generated in 18 newborn piglets (six through group B beta-hemolytic Streptococci infusion; six through hypoxia; six through hypercarbia) and O2 transport was studied. At 60 min VO2 was similar in all groups, although DO2 was different (10.7 +/- 6.7, 7.2 +/- 1.6, and 21.7 +/- 8.9 ml/kg.min, in the septic, hypoxic, and hypercarbic groups, respectively). Extraction efficiency varied in an inverse fashion (43 +/- 12%, 72 +/- 12%, and 27 +/- 16%, in the septic, hypoxic, and hypercarbic groups, respectively). Supply dependency and a critical DO2 were observed in the septic and hypoxic PHN groups (18.4 and 12.2 ml/kg.min, respectively). Both of these were elevated as compared to healthy adult levels. Hypercarbic pulmonary hypertension was supply independent at the levels studied; however, DO2 remained elevated in these animals and may never have reached the critical DO2 level.

Altered hemodynamic response to dobutamine in relation to the degree of preoperative beta-adrenoceptor blockade.

The relationship between the extent of preoperative beta-adrenoceptor blockade and the hemodynamic properties of dobutamine was investigated in patients scheduled for elective myocardial revascularization during isoflurane-nitrous oxide anesthesia. Twenty patients had been treated with beta-adrenoceptor blocking drugs for at least 4 weeks before the study; 11 unblocked patients served as control group. The extent of clinical beta-adrenoceptor blockade was quantified using the isoproterenol sensitivity test. The dose of isoproterenol required to increase heart rate by 25 beats/min was defined as the CD25 (chronotropic dose 25), representing the degree of beta-adrenoceptor blockade. Geometric mean CD25/70 kg was 3.8 micrograms in the control group, and 24.5 micrograms in the patients receiving beta-adrenoceptor blocking drugs. The authors found a significant inverse relationship between CD25 values and changes in cardiac index in response to three dobutamine infusion rates (1.0, 2.0, and 4.0 micrograms.kg-1.min-1), the correlation coefficients being -0.78, -0.79, and -0.82, respectively. Compared to unblocked patients, almost no change, or even a decrease, of the cardiac index was observed at higher degrees of clinical beta-adrenoceptor blockade. Moreover, there was a significant linear correlation (r = 0.66 - 0.75) between CD25 values and the effects of dobutamine on systemic vascular resistance index (SVRI), i.e., SVRI decreased in control patients, but increased in patients with high degrees of preoperative beta-adrenoceptor blockade. This unmasked vasocontrictive response to dobutamine was observed despite the fact that the majority of our patients had received cardioselective adrenergic blocking drugs.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypoxic vs septic pulmonary hypertension. Selective role of thromboxane mediation.

Pulmonary hypertension was generated in 11 newborn piglets, via either infusion of group B beta-hemolytic streptococci (n = 5) or induction of isocapnic hypoxia (n = 6), to study the contributions of thromboxane metabolite thromboxane B2 levels to different types of pulmonary hypertension. After 30 minutes of stable pulmonary hypertension, mean (+/- SD) pulmonary artery pressure increased similarly from 16 +/- 4 to 33 +/- 5 mm Hg (hypoxic), and from 14 +/- 2 to 34 +/- 6 mm Hg (septic). All other measured hemodynamic variables were similar. Despite these hemodynamic similarities, there were significant differences in thromboxane B2 levels. After 60 minutes of pulmonary hypertension, thromboxane B2 levels were 760 +/- 253 pg/mL (hypoxic), and 3103 +/- 1083 pg/mL (septic). These data demonstrate that, while thromboxane appears to be crucial in mediating septic pulmonary hypertension in the piglet, it is not associated with hypoxic pulmonary hypertension, implying that different types of pulmonary hypertension are probably mediated by different biochemical agents.

Selective inhibition of thromboxane synthetase reduces group-B-beta-hemolytic-streptococci-induced pulmonary hypertension in piglets.

13 newborn piglets with group-B-beta-hemolytic-streptococci (GBS)-induced pulmonary hypertension were assigned to receive either placebo (group 1) or Dazmegrel, a thromboxane synthetase inhibitor (group 2). All piglets with pulmonary hypertension had increased thromboxane B2 (TxB2) and 6-keto PGF1 alpha levels. With continued GBS infusion, the placebo group demonstrated a continued elevation of pulmonary artery pressure (PAP) and of TxB2. The Dazmegrel piglets, however, despite continued GBS infusion, demonstrated a selective decrease in PAP associated with a significant decrease in TxB2 levels and stability of systemic pressure and cardiac output. These data demonstrate that thromboxane synthetase inhibition is effective therapeutically in selectively reducing PAP.

Neither nitroglycerin nor nitroprusside selectively reduces sepsis-induced pulmonary hypertension in piglets.

No therapeutic agent consistently decreases pulmonary arterial pressure (PAP) more than aortic pressure in neonates with persistent pulmonary hypertension of the newborn. We have investigated whether nitroglycerin (NG) or nitroprusside (NP) selectively decreases PAP in an animal model of sepsis-induced pulmonary hypertension. Piglets were anesthetized, intubated, and ventilated. Pulmonary hypertension was induced by an iv infusion of group B Streptococci. Piglets were then divided into three groups with group B Streptococci infusion ongoing. Neither PAP nor the pulmonary vascular resistance index was decreased significantly by either NP or NG. NP decreased significantly both mean aortic pressure and the systemic vascular resistance index. Cardiac index decreased significantly during both NG and placebo infusion. These data suggest that neither NP nor NG is likely to be beneficial in sepsis-induced pulmonary hypertension in newborns.

Oxygen delivery, oxygen consumption, and metabolic acidosis during group B streptococcal sepsis in piglets.

The development of metabolic acidosis during neonatal sepsis with group B streptococci (GBS) has been attributed to progressive tissue ischemia resulting from reduced oxygen delivery (QO2). Using an animal model of GBS disease, we attempted to test this hypothesis by comparing the development of metabolic acidosis in two groups of piglets with comparably diminished systemic QO2, one septic and one not. Eighteen anaesthetized piglets were instrumented to observe aortic pressure, cardiac output, arterial and mixed venous blood gases, oxygen content, and hemoglobin concentration. QO2, oxygen consumption, and oxygen extraction ratio were calculated. Six piglets (group 1) received continuous infusion of live GBS organisms; six piglets (group 2) received continuous infusion of phenylephrine (PE), beginning with 10-micrograms/kg/min and increasing as required to match the PE-induced reduction in QO2 to the fall observed in the group 1 (GBS) piglets at each 30-min interval. Group 3 piglets (n = 6) received 0.9% saline and served as controls. No differences in either cardiac output or QO2 were noted comparing GBS and PE piglets at any time interval from 0-180 minutes. At 120, 150, and 180 minutes, both QO2 and cardiac output were lower in GBS and PE piglets compared to controls. Despite equivalent reductions in cardiac output and QO2, only GBS piglets developed significant metabolic acidosis, while pH and base deficit for PE piglets did not differ from controls. Oxygen consumption did not differ significantly among the three experimental groups at any observation time. Oxygen extraction ratio did not differ comparing PE and GBS piglets at any observation time.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure of prophylactic indomethacin to improve the outcome of the very low birth weight infant.

Prophylactic closure of the patent ductus arteriosus (PDA) has been recommended as a means of decreasing early respiratory distress, and thereby chronic respiratory sequelae in the very low birth weight (VLBW) neonate. This study was undertaken to evaluate some possible mechanisms for the observed failure of early indomethacin therapy to achieve such improvement. 24 VLBW infants with echocardiographic evidence of PDA were randomized to receive either indomethacin or placebo at 48 h of life; and then they were studied for clinical, metabolic and laboratory signs of ductal constriction and/or reopening. Early indomethacin conferred no improvement in respiratory sequelae. However, this was not secondary to a short-term therapeutic failure. Prophylactic indomethacin, even in the VLBW infant, was successful in decreasing dilator prostaglandin production, and probably in closing the PDA and in decreasing the number of recurrences. The implications are that even with effective ductal constriction, overall morbidity is not affected.

Reduced cytocidal efficacy for adriamycin in cultured human carcinoma cells depleted of polyamines by difluoromethylornithine treatment.

We have studied the effect of pretreatment with difluoromethylornithine (DFMO), an ornithine decarboxylase inhibitor, on the cytocidal responses of four human adenocarcinoma cell lines to Adriamycin (ADR). The cell lines utilized included HuTu-80 (duodenum), HT-29 (colon), ME-180 (cervix), and A-427 (lung). A 48-h DFMO pretreatment reduced putrescine and spermidine content to less than 10 and less than 1% of control levels and decreased spermine to between 70 and 30% of controls. Plating efficiency assays were used to generate ADR dose-response survival curves for DFMO-treated and control cultures. The DFMO pretreatment significantly protected human adenocarcinoma cells from the lethal effects of ADR. Addition of exogenous putrescine to the DFMO-treated cultures 24 h before treatment with ADR restored their cytocidal response to ADR to near control levels. Putrescine had no effect on cell survival in cultures that were not pretreated with DFMO. These observations suggest that DFMO-induced protection from ADR may be a specific consequence of DFMO-induced inhibition of polyamine biosynthesis. Alternatively, since ADR efficacy varies directly with cellular growth rates and DFMO inhibits proliferation, the protection may have resulted from DFMO-induced growth inhibition. Comparison of ADR uptake in DFMO-pretreated and control cells showed that the protection did not result from decreased intracellular accumulation of ADR.

Altered cell cycle phase distributions in cultured human carcinoma cells partially depleted of polyamines by treatment with difluoromethylornithine.

We have studied the effects of partial polyamine depletion, induced by treatment with alpha-difluoromethylornithine (DFMO) on cell cycle phase distributions in five cultured human carcinoma cell lines. We used flow cytometry of cells stained with chromomycin-A3 and computer analysis to measure phase distributions of treated and control cultures. All five lines respond to 1-5 mM DFMO treatment with a total absence of measurable putrescine, a loss of greater than 90% of spermidine, and a 30-40% decline in spermine by 48 h after DFMO addition. The proliferation of all five lines is inhibited as well. Nonetheless, only four of the cell lines (HuTu-80, HT-29, MCF-7, and A-427) show a marked increase in the G1-phase fraction and decrease in the S-phase fraction as a consequence of DFMO treatment. Small, but significant, decreases in the G2-M populations of these cell lines also occurred after DFMO treatment. Exogenous putrescine (5-50 microM) reversed both the polyamine depletion and the perturbed phase distributions of DFMO-treated cultures but was without effect on phase distributions of cultures not treated with DFMO. The fifth cell line (ME-180) showed no effect of polyamine depletion on cell cycle phase distributions in DFMO-treated cultures and also no effect of exogenous putrescine on phase fractions of either control or DFMO-treated cells. These observations indicate that some human tumor cell lines are dependent upon adequate intracellular polyamine content for maintenance of cell cycle traverse. They also imply that human tumor cell lines are heterogeneous with regard to their cell cycle response to DFMO-induced polyamine deficiency.

Effects of DFMO-induced polyamine depletion on human tumor cell sensitivity to antineoplastic DNA-crosslinking drugs.

We investigated the effect of pretreatment with difluoromethylornithine (DFMO), an ornithine decarboxylase inhibitor, on the cytocidal responses of four human adenocarcinoma cell lines to two alkylating and crosslinking agents: chlorambucil and N,N',N"-triethylenethiophosphoramide (thiotepa). The cell lines studied included HuTu-80 (duodenum), HT-29 (colon), ME-180 (cervix), and A-427 (lung). A 48- to 72-h pretreatment with DFMO reduced intracellular putrescine and spermidine contents to less than 10% and less than 1% of control levels. This treatment also caused a 30%-70% decline in spermine content. Survival of control and DFMO-pretreated cells after treatment with chlorambucil or thiotepa was measured by a plating efficiency assay. For three of the four lines studied, the DFMO-induced partial polyamine depletion significantly protected cells from the lethal effects of chlorambucil. In ME-180 cultures alone, DFMO pretreatment did not alter the cytocidal efficacy of chlorambucil. Addition of exogenous putrescine to cultures of HuTu-80, HT-29, or A-427 24 h after DFMO addition but 24 h before treatment with chlorambucil reversed the polyamine depletion and its protective effects on chlorambucil-induced cell kill. In contrast to the above observations, DFMO and partial polyamine depletion had no effect on cell survival after thiotepa treatment for any of the cell lines investigated.

Report of a case and further delineation of the SHORT syndrome.

We describe a boy with the manifestations of the SHORT syndrome: lipoatrophy, delayed speech development, minor facial anomalies, clinodactyly, and short stature. In addition, this boy had deafness, which was not previously reported in the SHORT syndrome.

Chemosensitization of cultured human carcinoma cells to 1,3-bis(2-chloroethyl)-1-nitrosourea by difluoromethylornithine-induced polyamine depletion.

We have investigated the effect of pretreatment with the ornithine decarboxylase inhibitor alpha-difluoromethylornithine (DFMO) on the cytocidal efficacy of 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) in a series of five cultured human adenocarcinoma cell lines. Plating efficiency assays were used to generate BCNU dose-response survival curves for DFMO-treated and control cells. The cell lines varied in their sensitivity to BCNU, with A-427 (lung) and HuTu-80 (duodenum) cells being most sensitive, HT-29 (colon) and ME-180 (cervix) most resistant, and MCF-7 (breast) showing intermediate sensitivity. For all five cell lines, a 48-h pretreatment with 5 mM DFMO reduced intracellular putrescine and spermidine content to less than 10% of control levels and decreased spermine content to between 60 and 70% of controls. This pretreatment resulted in a shift of the BCNU survival curves for each of the five cell lines downward and to the left, indicating that the cells were sensitized to the lethal effects of BCNU. Dose enhancement ratios for DFMO-induced chemosensitization ranged from 1.2 (HuTu-80 cells at the 1% survival level) to 1.9 (HT-29 cells at the 10% survival level). The cell lines most resistant to BCNU appeared to give the greatest degree of potentiation by DFMO pretreatment. For four of the five cell lines, addition of 50 to 100 microM exogenous putrescine to DFMO-pretreated cultures 12 to 24 h before BCNU addition reversed the chemosensitization. ME-180 cells were the sole exception. Exogenous putrescine did not increase the surviving fraction after BCNU of any cells not pretreated with DFMO. These results suggest that DFMO-induced chemosensitization to BCNU in the four cell lines other than ME-180 is a specific consequence of the inhibition of ornithine decarboxylase by DFMO and the resulting depletion of intracellular polyamine content.

[Dantrolene in the treatment of life-threatening psychiatric disease pictures. A contribution to the therapy of the malignant neuroleptic syndrome and acute febrile catatonia]. / Dantrolen in der Behandlung lebensbedrohlicher psychiatrischer Krankheitsbilder. Ein Beitrag zur Therapie des malignen neuroleptischen Syndroms und der akuten febrilen Katatonie.

The malignant neuroleptic syndrome and acute febrile catatonia are life-threatening psychiatric disorders which frequently are treated in intensive care units outside psychiatric departments. Their manifestations are very similar to those of anaesthesia-specific malignant hyperthermia. The three syndromes have in common signs of increased muscle metabolism. Dantrolene, a specific drug in the treatment of malignant hyperthermia, has been used successfully several times recently in the treatment of the malignant neuroleptic syndrome. One such case is reported. In a 23-year-old man with signs of acute febrile catatonia parenteral dantrolene and electroconvulsive shocks succeeded in counteracting the symptoms of the abnormally raised muscle metabolism.