Hemodynamic effects of PEEP in a porcine model of HCl-induced mild acute lung injury.

BACKGROUND: Positive end-expiratory pressure (PEEP) and sustained inspiratory insufflations (SI) during acute lung injury (ALI) are suggested to improve oxygenation and respiratory mechanics. We aimed to investigate the hemodynamic effects of PEEP with and without alveolar recruiting maneuver in a mild ALI model induced by inhalation of hydrochloric acid. METHODS: Thirty-two pigs were randomly allocated into four groups (Control-PEEP, Control-SI, ALI-PEEP and ALI-SI). ALI was induced by intratracheal instillation of hydrochloric acid. PEEP values were progressively increased and decreased from 5, 10, 15 and 20 cmH2O in all groups. Three SIs maneuvers of 30 cmH2O for 20 s were applied to the assignable groups between each PEEP level. Transesophageal echocardiography (TEE), global hemodynamics, oxygenation indexes and gastric tonometry were measured 5 min after the maneuvers had been concluded and at each established value of PEEP (5, 10, 15 and 20 cmH2O). RESULTS: The cardiac index, ejection fraction and end-diastolic volume of right ventricle were significantly (P < 0.001) decreased with PEEP in both Control and ALI groups. Left ventricle echocardiography showed a significant decrease in end-diastolic volume at 20 cmH2O of PEEP (P < 0.001). SIs did not exert any significant hemodynamic effects either early (after 5 min) or late (after 3 h). CONCLUSIONS: In a mild ALI model induced by inhalation of hydrochloric acid, significant hemodynamic impairment characterized by cardiac function deterioration occurred during PEEP increment, but SI, probably due to low applied values (30 cmH2O), did not exert further negative hemodynamic effects. PEEP should be used cautiously in ALI caused by acid gastric content inhalation.

Hydroxyethyl starch is superior to lactated Ringer as a replacement fluid in a pig model of acute normovolaemic haemodilution.

BACKGROUND: Tissue tolerance to oxygen privation during acute normovolaemic haemodilution with different fluids remains unclear. We tested the hypothesis that hydroxyethyl starch (HES) is superior to lactated Ringer's solution in pigs for preserving tissue perfusion during acute normovolaemic haemodilution. METHODS: Twenty-four animals were randomized into control, lactated Ringer's solution and HES groups. All groups, except the control, underwent acute normovolaemic haemodilution. Haemodynamics, oxygen parameter indices, global anaerobic metabolic markers, echocardiographic parameters, gastric tonometry and serum osmolarity were monitored at baseline, immediately after (0 min) and 60 and 120 min after the end of haemodilution. Myocardial, liver, stomach and intestine samples were collected for further evaluation. RESULTS: Cardiac and oxygen parameter index responses to acute normovolaemic haemodilution were comparable. However, the increment in cardiac index, stroke volume index, and left ventricular stroke work index were more sustained in the starch group. In the lactated Ringer's group, gastric pH decreased significantly and was accompanied by a significant increase in lactate. Myocardial ultrastructure was better preserved in the starch group. The other tissue samples presented no change. CONCLUSIONS: In this model of ANH, the starch group had a superior haemodynamic response. Minor loss of myocardial cellular integrity and preserved gastric pHi reinforce these findings.

Glycemic control during pancreas transplantation: continous infusion versus bolus.

Pancreas transplantation is a method to restore endogenous insulin secretion in insulin-dependent diabetic patients. Because glycemia >150 mg/dL may harm pancreatic graft beta cells, early glucose control using insulin administration is recommended during transplantation. The aim of this study was to evaluate the benefits of strict glycemic control during pancreas transplantation by comparing two types of insulin and glucose administration: continuous infusion and bolus. Capillary glucose was measured every 30 minutes after anesthetic induction for pancreas transplantation alone or simultaneously with kidney transplantation. Intravenous regular insulin was administered for values >150 mg/dL or glucose for values <100 mg/dL. The following timepoints were evaluated: anesthetic induction, before pancreatic graft reperfusion, and the first 4 minutes after reperfusion. Pancreatic graft ischemia time was significantly lower in the bolus group (P <.02). Immediately after reperfusion, there was a small increase in glycemia with a decrease in subsequent measurements in both groups. No significant difference in glycemia was observed between the groups at any time. Induction values were greater than all other timepoints in both groups. Glycemic control is important; it was successfully obtained with both methods. The trend to decrease glucose after reperfusion suggest early graft function.

Anesthesia for pancreas transplantation alone or simultaneous with kidney.

Improvements in perioperative care, namely, organ preservation solutions, immunosuppression, and increased experience of surgical, anesthetic, and intensive care teams, have contributed to the success of pancreas transplantation. The objective of this study was to present data on anesthesia for pancreas transplantation alone (PTA) or simultaneous with kidney (SPKT), evaluating crystalloid, albumin and blood component infusions, graft ischemic times, and weights and ages of recipient. We evaluated patients undergoing SPKT (n=73), PTA (n=49), or SPKT with kidney living donor (n=8). Aggressive monitoring and therapy were used to avoid hypoperfusion, optimized with intravenous fluids, vasoative drugs, and correction of metabolic disturbances. Three SPKT patients were not extubated at the end of surgery. There were no other complications related to anesthesia in any patient. Although it is a high-risk surgery, PTA or SPKT is routine in our practice. Adequate perioperative care is important not only for the safety of the procedure but also for graft viability, contributing to a promising long-term treatment of insulin-dependent diabetic patients.

Renal effect of gentamicin in diabetic rats.

To evaluate the protective effect of diabetes mellitus (DM) on renal function of rats treated with gentamicin (GM), male Wistar-EPM rats (250-350 g) were treated with streptozotocin (SZ; 45 mg/kg) and starting 10 days after induction of diabetes, GM was given for ten consecutive days at a daily dose of 40 mg/kg. In the GM-treated group (G), a significant fall in inulin and sodium-p-amino-hippurate clearance was obtained (3.57 +/- 0.16 and 12.59 +/- 0.61 ml min-1 kg-1 vs 6.43 +/- 0.21 and 17.98 +/- 0.47 ml min-1 kg-1 in control rats (C), respectively) while in the animals previously injected with SZ (diabetic+gentamicin, DG group) these changes were not observed. The diabetic (D), G and DG groups showed a significant rise in urinary flow compared to C (0.165 +/- 0.009, 0.145 +/- 0.007 and 0.173 +/- 0.009 ml min-1 kg-1 vs 0.109 +/- 0.003 ml min-1 kg-1, respectively); however, only in G was the U/P inulin ratio significantly decreased when compared to C. The fractional excretion (FE) of sodium and potassium was significantly augmented in G when compared to C, D and DG. Thus, diabetes protected against gentamicin nephrotoxicity at both the glomerular and tubular level, although it did not promote a reduction in urinary flow.

Renal effect of gentamicin in diabetic rats

To evaluate the protective effect of diabetes mellitus (DM) on renal function of rats treated with gentamicin (GM), male Wistar-EPM rats (250-350 g) were treated with streptozotocin (SZ; 45 mg/kg) and starting 10 days after induction of diabetes, GM was given for ten consecutive days at a daily dose of 40 mg/kg. In the GM-treated group (G), a significant fall in inulin and sodium-p-aminohippurate clearance was obtained (3.57 + or - 0.16 and 12.59 + or - 0.61 ml min-1kg-1 vs 6.43 + or - 0.21 and 17.98 + or - 0.47 ml min-1 kg-1 in control rats (C), respectively) while in the animals previously injected with SZ (diabetic + gentamicin, DG group) these changes injected with SZ (diabetic + gentamicin, DG group) these changes were not observed. The diabetic (D), g and DG group showed a significant rise in urinary flow compared to C (0.165 + or - 0.009, 0.145 + or - 0.007 and 0.173 + or - 0.009 ml min-1kg-1 vs 0.109 + or - 0.003 ml min-1kg-1, respectively); however, only in G was the U/P inulin ration significantly decreased when compared to C. The fractional excretion (FE) of sodium and postassium was significantly augmented in G when compared to C, D and DG. Thus, diabetes protected against gentamicin nephrotoxicity at both the glomerular and tubular level, although it did not promote a reduction in urinary flow