Anaesthesia care and the adult cardiac catheterization patient.

The number and types of procedures being performed in the adult cardiac catheterization suite have increased dramatically, with an aggressive move towards percutaneous interventional cardiac procedures. Here we review many of these procedures, including the current trends in North America and Europe. Coronary angioplasty is now more commonly performed than coronary artery bypass grafting. The past 5 years have seen a proliferation of coronary stenting procedures. Restenosis of coronary arteries continues to be a major area of research and concern.

A new method for measuring nitrogen and gases in blood.

The authors developed a new apparatus for extracting nitrogen or other inert gases from blood by flushing (sparging) the specimen with another gas. To investigate the utility of the new methodology, the apparatus was used in conjunction with a mass spectrometer to measure the blood N2 content of healthy normobaric, non-smoking, adult volunteers; the mean was found to be 11.7 microliters/ml +/- 0.9 microliter. This compares closely with values cited in the literature. The within-subject variation for repeat samples taken several weeks apart was significantly (P < 0.003) less than the variation between different subjects, suggesting that there may be true differences in N2 content between different individuals. These data must be considered preliminary, a larger study is needed to investigate population differences in detail. The advantages of the new method are discussed.

Repetitive inhalation endotracheal anaesthesia for cobalt radiotherapy in a child.

PURPOSE: Provision of general anaesthesia in areas remote from the operating room creates many difficult challenges especially if required for repeated radiotherapy in the prone position. This case illustrates these problems and some innovative solutions. CLINICAL FEATURES: A nine-year-old girl with medulloblastoma became extremely distressed whenever cobalt radiotherapy was attempted. Sedation with midazolam and high dose propofol infusion failed to achieve satisfactory conditions and caused concerns regarding airway management. The patient received a total of 37 endotracheal anaesthetics in the prone position using isoflurane in oxygen. Activated charcoal was used to scavenge anaesthetic vapors and adequate gas supplies were assured by connecting an "H' size tank to the oxygen pipeline inlet of the anaesthesia machine. Measurement of isoflurane in exhaust gases using gas chromatography confirmed the effectiveness of scavenging. No serious complications occurred related to repeated anaesthesia. CONCLUSION: The methods and equipment described permitted safe delivery of repeated inhalation general anaesthesia for radiotherapy. The same methods could be applied to anaesthesia in other remote locations.

Pharmacokinetics of lidocaine in children with congenital heart disease.

The purpose of this study was to determine the pharmacokinetics of lidocaine in children with congenital heart disease (CHD). Fifteen children with left to right intracardiac shunting of blood (acyanotic group) and 15 children with right to left intracardiac shunting of blood (cyanotic group) were studied and compared with 15 children without CHD (control group). Lidocaine (1.5 mg.kg-1) was injected into a peripheral vein over 30 sec and serial samples of arterial blood were obtained up to 120 min after completion of the infusion. Total and free lidocaine were analyzed by enzyme immunoassay. The serum concentration of alpha 1-acid glycoprotein (alpha 1-AGP) at induction of anaesthesia was measured in the three groups by radial immunodiffusion. The percent free lidocaine (100 x [free lidocaine]/[total lidocaine]) was greater at 30 sec post-infusion in all three groups (35-37%) than it was at any other time but was not significantly different among the three groups (P less than 0.05). There was no significant difference in either the percent free or the total lidocaine concentration at any sample time or in any of the pharmacokinetic variables among the three groups. The serum concentration of alpha 1-AGP did not differ significantly among the three groups of patients. We conclude that the presence of intracardiac shunts does not alter the pharmacokinetic behaviour of intravenous lidocaine (1.5 mg.kg-1) in children. The percent free lidocaine is greatest immediately post-injection and this may mitigate against rapid bolus administration of intravenous lidocaine in children.

Alpha 1-acid glycoprotein and the binding of lidocaine in children with congenital heart disease.

The purpose of this study was to evaluate the effect of congenital heart disease (CHD) on the serum concentrations of alpha 1-acid glycoprotein (alpha 1-AGP) and the serum binding of lidocaine. Thirteen children with acyanotic CHD and 12 children with cyanotic CHD were studied and compared with 28 children without heart disease (control). The mean (+/- SD) serum concentration of alpha 1-AGP, as determined by radial immunodiffusion, did not differ significantly among the three groups. Five minutes after administration of 1.5 mg.kg-1 intravenous lidocaine, the free fraction of lidocaine correlated inversely and linearly with the serum concentration of alpha 1-AGP in children with acyanotic CHD (r2 = 0.74; P less than 0.001) cyanotic CHD (r2 = 0.57; P less than 0.005), and control (r2 = 0.63; P less than 0.001). The slopes and intercepts of the linear regressions did not differ significantly among the three groups. We conclude that the serum concentration of alpha 1-AGP in children with CHD does not differ quantitatively or qualitatively from that in children without CHD.

Effects of age on the serum concentration of alpha 1-acid glycoprotein and the binding of lidocaine in pediatric patients.

We determined the effect of age on the serum concentration of alpha 1-acid glycoprotein (alpha 1-AGP) in venous blood from 134 subjects who ranged in age from preterm neonates to 18-year-old adolescents. The mean (+/- SD) serum concentration of alpha 1-AGP, determined by radial immunodiffusion, increased significantly with age: the concentration found in neonates was less than that found in infants which, in turn, was less than that found in older children (p less than 0.001). In addition, we determined the effect of alpha 1-AGP on the free fraction of lidocaine in four groups of infants and children who received intravenous lidocaine (1.5 mg/kg). The percentage of free lidocaine correlated inversely and linearly with the serum alpha 1-AGP concentration (r2 = 0.617; p less than 0.001). The percentage of free lidocaine in the five neonates exceeded that in the older age groups. We conclude that the serum concentration of alpha 1-AGP increases while the free fraction of lidocaine decreases from early infancy to adolescence.

Delayed Treatment of Carbon Monoxide Poisoning by HbO(2).

This case report demonstrates the importance of hyperbaric treatment in managing cases of known or suspected carbon monoxide poisoning. Even when prolonged delays in initiating this treatment are unavoidable, it can be beneficial. Prolonged administration of normobaric oxygen is inadequate treatment.

The minimum alveolar concentration (MAC) of isoflurane in preterm neonates.

Studies in fetal lambs suggested that the minimum alveolar concentration (MAC) in preterm neonates may be less than that in full-term neonates and older infants. To determine the MAC of isoflurane in preterm neonates, 20 patients less than 32 weeks gestation at birth and 16 patients 32-37 weeks gestation at birth, all less than 1 month post-natal age, were studied. Following tracheal intubation, the neonates were anesthetized with a predetermined end-tidal concentration of isoflurane in oxygen and air. The move-no move responses to skin incision were recorded, and MAC was determined using the "up-and-down" technique. Heart rate and systolic arterial pressure were recorded awake, before skin incision, and after skin incision. MAC (mean +/- SD) of isoflurane in preterm neonates less than 32 weeks gestation was 1.28 +/- 0.17%, and MAC in neonates 32-37 weeks gestation was 1.41 +/- 0.18% (P less than 0.05). Although heart rate did not decrease significantly in either group during the study, systolic arterial pressure decreased between 20 and 30% below awake values both before and after skin incision in both age groups (P less than 0.01). We conclude that the MAC of isoflurane in preterm neonates less than 32 weeks gestation is significantly less than that in preterm neonates 32-37 weeks gestation, and that systolic arterial pressure decreases to a similar extent at approximately 1 MAC isoflurane in both age groups.