Transversus abdominis plane block or subcutaneous wound infiltration after open radical prostatectomy: a randomized study.

BACKGROUND: Open radical retropubic prostatectomy (ORRP) is associated with moderate pain. We hypothesized that a transversus abdominis plane (TAP) block would reduce post-operative pain, morphine consumption and opioid-related side effects compared with wound infiltration and placebo in this population. METHODS: This was a randomized, double-blind and placebo-controlled study. The operations were performed with patients in general anaesthesia. Patients were allocated to receive either bilateral TAP block (n = 23), wound infiltration (n = 25) or placebo (n = 25). Treatment was 40 ml ropivacaine 0.75% and placebo was 40 ml saline 0.9%. Pre-operatively, all patients received oral gabapentin, ibuprofen and paracetamol, followed by oral paracetamol and ibuprofen at regular doses and intervals, and patient-controlled analgesia with IV morphine from 0 h to 24 h post-operatively. RESULTS: Visual analogue scale pain score during mobilization 4 h post-operatively (primary outcome) did not differ significantly between the TAP block and placebo group (TAP 28 ± 22 mm vs. placebo 33 ± 18 mm, P = 0.64). Pain scores (as area under the curve) during the first 24 h were not significantly different among any of the three groups, neither at rest nor during mobilization. Morphine consumption (0-24 h) did not differ significantly between groups {TAP block = 15 [8-23] mg, infiltration 15 [8-36] mg, placebo 15 [3-30] mg, [median (interquartile range)]}. Levels of nausea, sedation and number of vomits were not different among the groups. CONCLUSION: Neither TAP block nor wound infiltration with ropivacaine improved a basic multimodal analgesic regimen with paracetamol, ibuprofen and gabapentin after ORRP.

Orthostatic intolerance and the cardiovascular response to early postoperative mobilization.

BACKGROUND: A key element in enhanced postoperative recovery is early mobilization which, however, may be hindered by orthostatic intolerance, that is, an inability to sit or stand because of symptoms of cerebral hypoperfusion as intolerable dizziness, nausea and vomiting, feeling of heat, or blurred vision. We assessed orthostatic tolerance in relation to the postural cardiovascular responses before and shortly after open radical prostatectomy. METHODS: Orthostatic tolerance and the cardiovascular response to sitting and standing were evaluated on the day before surgery and 6 and 22 h after operation in 16 patients. Non-invasive systolic (SAP) and diastolic arterial pressure (DAP) (Finometer), heart rate, cardiac output (CO, Modelflow), total peripheral resistance (TPR), and central venous oxygen saturation (Scv(O2)) were monitored. RESULTS: Before surgery, no patients had symptoms of orthostatic intolerance. In contrast, 8 (50%) and 2 (12%) patients were orthostatic intolerant at 6 and approximately 22 h after surgery, respectively. Before surgery, SAP, DAP, and TPR increased (P<0.05), whereas CO did not change (P>0.05) and Scv(O2) decreased (P<0.05) upon mobilization. At 6 h after operation, SAP and DAP declined with mobilization (P<0.05) and the arterial pressure response differed from the preoperative response both upon sitting (P<0.05) and standing (P<0.05) due to both impaired TPR and CO. At approximately 22 h, the SAP and DAP responses to mobilization did not differ from the preoperative evaluation (P>0.05). CONCLUSIONS: The early postoperative postural cardiovascular response is impaired after radical prostatectomy with a risk of orthostatic intolerance, limiting early postoperative mobilization. The pathogenic mechanisms include both impaired TPR and CO responses.

Flow-related techniques for preoperative goal-directed fluid optimization.

BACKGROUND: Improved postoperative outcome has been demonstrated by perioperative maximization of cardiac stroke volume (SV) with fluid challenges, so-called goal-directed therapy. Oesophageal Doppler (OD) has been the most common technique for goal-directed therapy, but other flow-related techniques and parameters are available and they are potentially easier to apply in clinical practice. The objective of this investigation was therefore to use OD for preoperative SV maximization and compare the findings with a Modelflow determined SV, with an OD estimated corrected flow time (FTc), with central venous oxygenation ( Svo2 ) and with muscle and brain oxygenation assessed with near infrared spectroscopy (NIRS). METHODS: Twelve patients scheduled for radical prostatectomy were anaesthetized before optimization of SV estimated by OD. A fluid challenge of 200 ml colloid was provided and repeated if at least a 10% increment in OD SV was obtained. Values were compared with simultaneously measured values of Modelflow SV, FTc, Svo2 and muscle and cerebral oxygenation estimated by NIRS. RESULTS: Based upon OD assessment, optimization of SV was achieved after the administration of 400-800 ml (mean 483 ml) of colloid. The hypothetical volumes administered for optimization based upon Modelflow and Svo2 differed from OD in 10 and 11 patients, respectively. Changes in FTc and NIRS were inconsistent with OD guided optimization. CONCLUSION: Preoperative SV optimization guided by OD for goal-directed therapy is preferable compared with Modelflow SV, FTc, NIRS and Svo2 until outcome studies for the latter are available.

Residents lack knowledge and practical skills in handling the difficult airway.

BACKGROUND: Full-scale simulators have been developed in anaesthesia. We aimed at assessing Danish anaesthesia residents' knowledge and management of a standardized difficult airway situation in an advanced airway simulator. The reliability of the assessment was also determined. METHODS: Thirty-six residents answered a questionnaire testing their knowledge on difficult airway management and practice patterns. Secondly, all residents attempted management of a standardized 'cannot ventilate, cannot intubate' airway scenario. Three observers independently assessed a video recording of the performance. RESULTS: Only 17% of the residents passed the written test. Ninety-seven per cent stated that they had difficulties recalling the American Society of Anesthesiologists'(ASA) difficult airway algorithm and 53% did not know how to oxygenate through the cricothyroid membrane. Seventeen per cent had previously been involved in emergency situations with severe complications due to insufficient airway management. In the scenario 75% of the residents established ventilation using a laryngeal mask airway. After establishing ventilation, 26% would continue with surgery without a definitive airway, despite the risk of aspiration. Analysis of the interobserver agreement showed good (Kappa = 0.63) to excellent (Kappa = 0.78) consistency for objective parameters in the scoring scheme. Inter-observer reliability was satisfactory (R = 0.43) for trained Crisis Resource Management evaluators. CONCLUSIONS: Theoretical and practical education in difficult airway management needs to be improved among Danish anaesthesia residents. Simulator assessment should only be performed using well-defined objective parameters and trained assessors.

[Nitric oxide inhalation therapy in patients with acute respiratory distress syndrome. A retrospective analysis]. / Inhalationsbehandling med nitrogenoxid til patienter med akut respiratorisk distress-syndrom. En retrospektiv analyse.

Acute lung injury in the form of the acute respiratory distress syndrome (ARDS) continues to carry a high mortality. Recently, inhaled nitric oxide (NO) has been used in ARDS patients with severe hypoxaemia. We present a retrospective analysis concerning 33 ARDS patients treated with inhaled NO during a period of four years from 1994 to 1998. Patients were young, mean 43 years, had poor oxygenation (PaO2/FiO2 index 67 mmHG) and a lung injury score above 2.5. Eighty-two percent responded immediately to NO, 9% at a later challenge and 9% were non-responders. Mortality for the whole group was 67% and to be expected considering the severity of disease. For the group of patients with ARDS as a complication of pneumonia mortality was only 40%. In one patient therapy had to be stopped due to formation of NO2 even at very low concentrations of inhaled NO. We conclude that inhaled NO is effective in improving oxygenation in patients with ARDS. The study does not allow us to conclude anything about mortality, which was probably unchanged by this novel therapy.

[Mollaret's meningitis. A rare disease with a characteristic presentation]. / Mollarets meningitis. En sjaelden sygdom med et karakteristisk billede.

We report a case of a 72-year-old woman, who within a six-year period had four episodes of Mollaret's meningitis. Lumbar punctures during each episode revealed moderate leukocytosis with large mononuclear cells. Characteristic manifestations and differential diagnosis are briefly reviewed. There is no established therapy for Mollaret's meningitis. Extensive investigations failed to reveal a specific cause of this disease, although there is some evidence for infection caused by Herpes simplex-virus.

Renal threshold for glucose in non-insulin-dependent diabetic patients.

Measurement of glycosuria is still widely used for home monitoring of glycaemia control in non-insulin-dependent diabetes (NIDDM). This method has been criticized because the renal threshold for glucose (RTglu) varies between subjects. In order to evaluate the validity of RTglu by measuring corresponding measurements of blood and urine glucose in NIDDM patients, we studied the blood/urine glucose relationship in 24 NIDDM patients. RTglu estimated from 75 contemporary blood and urine glucose concentrations measured at home by each patient (h-RTglu) was compared with RTglu measured by a hyperglycaemic glucose clamp (c-RTglu). H-RTglu and c-RTglu, being 7.6 mmol/1 (range 5.5-12.4) and 10.3 mmol/1 (6.2-12.3) respectively (P < 0.005), were weakly correlated (R(S) = 0.35, P = 0.15). In conclusion, c-RTglu varies two-fold between NIDDM patients. RTglu detected by home monitored urine and blood glucose determinations underestimates the true RTglu, probably due to the splay phenomenon. However, the method for detection of RTglu used by us seems of clinical relevance, since it reflects the individual blood glucose level at which glucose is detectable in the urine.

[Alcohol consumption and organic damage. Views and attitudes of Danish patients and their relatives]. / Alkoholforbrug og organskader. Danske patienters og pårørendes viden og holdninger.

A total of 201 patients and their relatives in a hospital in Copenhagen participated in a structured interview investigation about their knowledge of the long-term effects of alcohol and their attitudes to restrictions. The majority approved of an upper limit for alcohol consumption within the recommended limits but a total of approximately 1/3 preferred a higher limit. Only 28% realised that there was a difference in how much alcohol women and men can tolerate. The majority, but far from all of the participants knew that alcohol could damage the liver and brain but few knew of damage to other organs. A total of 64% had a positive attitude to prohibition of alcohol consumption in places of employment in Denmark. It is suggested that information about alcohol should be concentrated in the form of simple clear messages.

Isolation and sequence analysis of a chalcone synthase cDNA of Matthiola incana R. Br. (Brassicaceae).

A cDNA clone (pcM12) of the chalcone synthase (CHS) of Matthiola incana R. Br. (Brassicaceae) was isolated from a cDNA library, sequenced and analysed. It comprises the complete coding sequence for the CHS and 5' and 3' untranslated regions. The deduced amino acid sequence shows that the Matthiola incana CHS consists of 394 amino acid residues. Comparison with CHS amino acid sequences of other plants indicates more than 82% homology.