The effect of two different doses of remifentanil on postoperative pain and opioid consumption after cardiac surgery--a randomized controlled trial.

BACKGROUND: Remifentanil, an ultra-short-acting opioid, provides intensive analgesia without prolonged respiratory depression and is widely used in cardiac surgery. Diminished dosing may also offer stable hemodynamics, even during sternotomy and sternal retraction. However, increased postoperative pain and induced opioid tolerance after remifentanil dosing during abdominal surgery was reported. We tested whether remifentanil 0.3 µg/kg/min infusion increased postoperative opioid consumption and pain compared to 0.1 µg/kg/min dosing. METHODS: Ninety coronary artery bypass grafting or heart valve surgery patients were randomized to remifentanil 0.1 µg/kg/min or 0.3 µg/kg/min infusions during surgery. All patients received oxycodone bolus 0.15 µg/kg postoperatively, and patient-controlled analgesia (PCA) with oxycodone thereafter. Postoperative pain was estimated thrice daily by visual analogue scale, and 48-h opioid consumption was recorded from the PCA-device. RESULTS: Total remifentanil dosing was 64 µg/kg in the higher and 22 µg/kg in the lower dosing group during the 3-h cardiac operations. Mean postoperative opioid consumption was 107 (SD 36) mg in the lower and 104 (SD 33) mg in the higher dose remifentanil groups. Postoperative pain did not differ between groups, at rest or during deep breathing, at any time (P = 0.110 and 0.941, respectively). CONCLUSIONS: Remifentanil 0.3 µg/kg/min infusion did not increase postoperative pain or opioid consumption after cardiac surgery compared to the 0.1 µg/kg/min infusion. Remifentanil infusion 0.1-0.3 µg/kg/min during cardiac surgery was safe, with no exaggerated postoperative pain or opioid consumption.

Preoperative and perioperative use of levosimendan in cardiac surgery: European expert opinion.

In cardiac surgery, postoperative low cardiac output has been shown to correlate with increased rates of organ failure and mortality. Catecholamines have been the standard therapy for many years, although they carry substantial risk for adverse cardiac and systemic effects, and have been reported to be associated with increased mortality. On the other hand, the calcium sensitiser and potassium channel opener levosimendan has been shown to improve cardiac function with no imbalance in oxygen consumption, and to have protective effects in other organs. Numerous clinical trials have indicated favourable cardiac and non-cardiac effects of preoperative and perioperative administration of levosimendan. A panel of 27 experts from 18 countries has now reviewed the literature on the use of levosimendan in on-pump and off-pump coronary artery bypass grafting and in heart valve surgery. This panel discussed the published evidence in these various settings, and agreed to vote on a set of questions related to the cardioprotective effects of levosimendan when administered preoperatively, with the purpose of reaching a consensus on which patients could benefit from the preoperative use of levosimendan and in which kind of procedures, and at which doses and timing should levosimendan be administered. Here, we present a systematic review of the literature to report on the completed and ongoing studies on levosimendan, including the newly commenced LEVO-CTS phase III study (NCT02025621), and on the consensus reached on the recommendations proposed for the use of preoperative levosimendan.

Nanopapers for organic solvent nanofiltration.

Would it not be nice to have an organic solvent nanofiltration membrane made from renewable resources that can be manufactured as simply as producing paper? Here the production of nanofiltration membranes made from nanocellulose by applying a papermaking process is demonstrated. Manufacture of the nanopapers was enabled by inducing flocculation of nanofibrils upon addition of trivalent ions.

Gastric mucosal end-tidal PCO2 difference as a continuous indicator of splanchnic perfusion.

Gastric mucosal and arterial blood PCO2 must be known to assess mucosal perfusion by means of gastric tonometry. As end-tidal PCO2 (PE'CO2) is a function of arterial PCO2, the gradient between PE'CO2 and gastric mucosal PCO2 may reflect mucosal perfusion. We studied the agreement between two methods to monitor gut perfusion. We measured the difference between gastric mucosal PCO2 (air tonometry) and PE'CO2 (= DPCO2gas) and the difference between gastric mucosal PCO2 (saline tonometry) and arterial blood PCO2 (= DPCO2sal) in 20 patients with or without lung injury. DPCO2gas was greater than DPCO2sal but changes in DPCO2gas reflected changes in DPCO2sal. The bias between DPCO2gas and DPCO2sal was 0.85 kPa and precision 1.25 kPa. The disagreement between DPCO2gas and DPCO2sal increased with increasing dead space. We propose that the disagreement between the two methods studied may not be clinically important and that DPCO2gas may be a method for continuous estimation of splanchnic perfusion.

Laparoscopic or open cholecystectomy: a prospective randomised trial to compare postoperative pain, pulmonary function, and stress response.

OBJECTIVE: Open cholecystectomy (OC) has been superseded by laparoscopic cholecystectomy (LC) for the treatment of cholelithiasis, although this fashion has not been validated by prospective studies. Our aim was to compare the two techniques. DESIGN: Prospective, randomised, open study. SETTING: University hospital, Finland. PATIENTS: 49 patients who required cholecystectomy for cholelithiasis confirmed by ultrasound. INTERVENTIONS: 49 patients were randomly allocated to LC (n = 27) or OC (n = 22): 25 and 22, respectively, eventually had the operation. LC was done using a four-trocar technique, and OC through a transverse right subcostal incision, as short as possible. MAIN OUTCOME MEASURES: Length of hospital stay and the duration of the sick leave were the primary outcome measures. Secondary outcome measures were: postoperative pain evaluated by visual analogue scale (VAS) and the need for opioids; pulmonary function measured by forced vital capacity (FVC), forced expiratory volume in one second (FEV1), peak flow velocity (PEFV), and arterial oxygen tension (PaO2), and endocrine stress measured by plasma catecholamines, cortisol and glucose concentrations. RESULTS: The median (range) hospital stay was significantly shorter after LC than OC, being 2.0 (1-15) compared with 4.5 (2-19) days p < 0.01. The duration of sick leave was also significantly shorter after LC than OC, being 14 (7-17) compared with 29 (4-34), p < 0.01. Patients had significantly less postoperative pain after LC than OC as reflected by the need for opioids. Pulmonary function and arterial oxygen tension deteriorated significantly less after LC than OC. The stress response was equal. There were three documented complications, one pneumonia after LC and two wound infections after OC. CONCLUSIONS: LC gives significantly better results in terms of less postoperative pain, better pulmonary function, better arterial oxygenation, and shorter hospital stay and duration of sick leave.

Phospholipase A2 activity is copurified together with herpes simplex virus-specified Fc receptor proteins.

We purified Fc-binding proteins from herpes simplex virus (HSV)-infected Vero cells by using an inverse immunoaffinity column chromatography. Polyacrylamide gel electrophoresis analysis revealed a single, virus-specific 65-kd polypeptide both in HSV type 1- and HSV type 2-infected cell-derived preparations. A Ca2+-dependent phospholipase A2 activity was demonstrated to be associated with the viral Fc-binding proteins.