[Non-invasive brain stimulation in schizophrenia: hallucinations and negative symptoms]. / Non-invasieve hersenstimulatie bij schizofrenie, gericht op hallucinaties en negatieve symptomen.

BACKGROUND: New approaches are needed in the treatment of characteristic symptoms of schizophrenia such as hallucinations and negative symptoms. Non-invasive brain stimulation can make a useful contribution.
AIM: To discuss the published evidence regarding efficacy and safety of repetitive transcranial magnetic stimulation (rtms) and transcranial direct current stimulation (tdcs) when used in the treatment of auditory verbal hallucinations and negative symptoms.
METHOD: We review and discuss recent meta-analyses and we analyse relevant factors.
RESULTS: On average, when compared to sham-stimulation, rtms was found to have a significant effect on hallucinations and negative symptoms. Nevertheless, the results of some studies were variable and some studies did not report any improvement. There are indications that some factors such as age and distance between scalp and cortex may influence efficiency. There were only a few studies relating to the use of tdcs and none of these reported a clear effect.
CONCLUSION: There is reasonable evidence that rtms is an efficient treatment for hallucinations and negative symptoms, although some variable results have been reported. There is insufficient evidence for conclusions to be drawn about the efficacy of tdcs for the treatment of hallucinations and negative symptoms. However, both simulation methods are safe and largely without side-effects.

Efficacy of bilateral repetitive transcranial magnetic stimulation for negative symptoms of schizophrenia: results of a multicenter double-blind randomized controlled trial.

BACKGROUND: Few studies have investigated the efficacy of repetitive transcranial magnetic stimulation (rTMS) treatment for negative symptoms of schizophrenia, reporting inconsistent results. We aimed to investigate whether 10 Hz stimulation of the bilateral dorsolateral prefrontal cortex during 3 weeks enhances treatment effects. METHOD: A multicenter double-blind randomized controlled trial was performed in 32 patients with schizophrenia or schizo-affective disorder, and moderate to severe negative symptoms [Positive and Negative Syndrome Scale (PANSS) negative subscale ⩾15]. Patients were randomized to a 3-week course of active or sham rTMS. Primary outcome was severity of negative symptoms as measured with the Scale for the Assessment of Negative Symptoms (SANS) and the PANSS negative symptom score. Secondary outcome measures included cognition, insight, quality of life and mood. Subjects were followed up at 4 weeks and at 3 months. For analysis of the data a mixed-effects linear model was used. RESULTS: A significant improvement of the SANS in the active group compared with sham up to 3 months follow-up (p = 0.03) was found. The PANSS negative symptom scores did not show a significant change (p = 0.19). Of the cognitive tests, only one showed a significant improvement after rTMS as compared with sham. Finally, a significant change of insight was found with better scores in the treatment group. CONCLUSIONS: Bilateral 10 Hz prefrontal rTMS reduced negative symptoms, as measured with the SANS. More studies are needed to investigate optimal parameters for rTMS, the cognitive effects and the neural basis.

Sevoflurane-induced cardioprotection depends on PKC-alpha activation via production of reactive oxygen species.

BACKGROUND: We previously demonstrated the involvement of the Ca2+-independent protein kinase C-delta (PKC-delta) isoform in sevoflurane-induced cardioprotection against ischaemia and reperfusion (I/R) injury. Since sevoflurane is known to modulate myocardial Ca2+-handling directly, in this study we investigated the role of the Ca2+-dependent PKC-alpha isoform in sevoflurane-induced cardioprotective signalling in relation to reactive oxygen species (ROS), adenosine triphosphate-sensitive mitochondrial K+ (mitoK+(ATP)) channels, and PKC-delta. METHODS: Preconditioned (15 min 3.8 vol% sevoflurane) isolated rat right ventricular trabeculae were subjected to I/R, consisting of 40 min superfusion with hypoxic, glucose-free buffer, followed by normoxic glucose-containing buffer for 60 min. After reperfusion, contractile recovery was expressed as percentage of force development before I/R. The role of PKC-alpha, ROS, mitoK+(ATP) channels, and PKC-delta was established using the following pharmacological inhibitors: Go6976 (GO; 50 nM), n-(2-mercaptopropionyl)-glycine (MPG; 300 microM), 5-hydroxydecanoic acid sodium (5HD; 100 microM), and rottlerin (ROT; 1 microM). RESULTS: Preconditioning of trabeculae with sevoflurane improved contractile recovery after I/R [65 (3)% (I/R + SEVO) vs 47 (3)% (I/R); n = 8; P < 0.05]. This cardioprotective effect was attenuated in trabeculae treated with GO [42 (4)% (I/R + SEVO + GO); P > 0.05 vs (I/R)]. In sevoflurane-treated trabeculae, PKC-alpha translocated towards mitochondria, as shown by immunofluorescent co-localization analysis. GO and MPG, but not 5HD or ROT, abolished this translocation. CONCLUSIONS: Sevoflurane improves post-ischaemic contractile recovery via activation of PKC-alpha. ROS production, but not opening of mitoK+(ATP) channels, precedes PKC-alpha translocation towards mitochondria. This study shows the involvement of Ca2+-dependent PKC-alpha in addition to the well-established role of Ca2+-independent PKC isoforms in sevoflurane-induced cardioprotection.

[Measures for patients taking psychotropic drugs who undergo elective surgery]. / Maatregelen bij patiënten die psychofarmaca gebruiken en die een electieve operatie moeten ondergaan.

Psychotropic drugs can increase the risk of perioperative complications when given in combination with anaesthesia. Evidence-based guidelines that address this issue are lacking. Consensus-based recommendations were formed for the perioperative management of these patients based on the available literature and a systematic evaluation of perioperative risks by the medical specialists directly involved. Patients who use lithium, monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants or clozapine are at risk of experiencing adverse interactions. The anaesthesiology literature recommends discontinuing irreversible MAOIs and lithium in all cases, and tricyclic antidepressants in patients with systemic disorders. With the exception of lithium, the risks of psychiatric relapse or recurrence associated with discontinuation necessitate intensive integrated psychiatric treatment. Continuation of treatment under strict haemodynamic observation may also be an option in some cases. Patients taking selective serotonin reuptake inhibitors (SSRIs) should be observed carefully for psychological instability and physical abnormalities, and clinicians should be aware of medications that could increase the risk of haemorrhage when used in combination with SSRIs. In these cases, a psychiatrist should be consulted. The same is true for patients taking antipsychotic or other antidepressant medication who develop psychological instability or have a systemic disorder. Given the widespread use ofpsychotropic drugs and the seriousness of the associated risks, it is recommended that the decision whether to continue or discontinue psychotropic medication should become a standard component of preoperative assessment.

Compound A and carbon monoxide production from sevoflurane and seven different types of carbon dioxide absorbent in a patient model.

BACKGROUND: The degradation of sevoflurane can lead to the production of compound A (CA) and carbon monoxide (CO) and an increase in temperature of the absorbent. CA is known to be nephrotoxic in rats. These reactions depend on the strong base and water contents of the carbon dioxide absorbent used. The purpose of this study was to measure the maximum amounts of CA and CO produced, and the temperature increase, for seven different carbon dioxide absorbents for sevoflurane containing different contents of strong bases. METHODS: Seven absorbents [some free of strong bases (f)] were employed in hydrated (h) and completely desiccated (d) conditions in a patient model, using a circle anesthesia system connected to an artificial lung. Low-flow anesthesia with an oxygen-nitrous oxide mixture was maintained using 0.8% sevoflurane. For the quantification of CA and CO, a portable gas chromatograph was used. The temperature was measured inside the absorbent. RESULTS: In consecutive order of CA-producing potency, Amsorb(f)(d), Drägersorb(h), Medisorb(h), lithium hydroxide(f)(d), Drägersorb(d), Medisorb(d), Spherasorb(h) and Spherasorb(d) produced small amounts of CA. Loflosorb and Superia, which are free of strong bases, did not produce any CA or CO in hydrated or desiccated conditions. Only desiccated Drägersorb, Medisorb and Spherasorb demonstrated small amounts of CO accompanied by a significant temperature increase. CONCLUSION: In this patient model, we demonstrated that different types of absorbent produced small amounts of CA and CO or none at all. No relationship could be established between temperature and CA concentration.

The mechanism of sevoflurane-induced cardioprotection is independent of the applied ischaemic stimulus in rat trabeculae.

BACKGROUND: Sevoflurane protects the myocardium against ischaemic injury through protein kinase C (PKC) activation, mitochondrial K+ATP-channel (mitoK+ATP) opening and production of reactive oxygen species (ROS). However, it is unclear whether the type of ischaemia determines the involvement of these signalling molecules. We therefore investigated whether hypoxia (HYP) or metabolic inhibition (MI), which differentially inhibit the mitochondrial electron transport chain (ETC), are comparable concerning the relative contribution of PKC, mitoK+ATP and ROS in sevoflurane-induced cardioprotection. METHODS: Rat right ventricular trabeculae were isolated and isometric contractile force (Fdev) was measured. Trabeculae were subjected to HYP (hypoxic glucose-free buffer; 40 min) or MI (glucose-free buffer, 2 mM cyanide; 30 min), followed by 60 min recovery (60 min). Contractile recovery (Fdev,rec) was determined at the end of the recovery period and expressed as a percentage of Fdev before hypoxia or MI, respectively. Chelerythrine (CHEL; 6 microM), 5-hydroxydecanoic acid sodium (100 microM) and n-(2-mercaptopropionyl)-glycine (MGP; 300 microM) were used to inhibit PKC, mitoK+ATP and ROS, respectively. RESULTS: Fdev,rec after HYP was reduced to 47 (3)% (P<0.001 vs control; n=5) whereas MI reduced Fdev,rec to 28 (5)% (P<0.001 vs control; n=5). A 15 min period of preconditioning with sevoflurane (3.8%) equally increased contractile recovery after HYP [76 (9)%; P<0.05 vs HYP] and MI [67 (8)%; P<0.01 vs MI]. Chelerythrine, 5-hydroxydecanoate and n-(2-mercaptopropionyl)-glycine abolished the protective effect of sevoflurane in both ischaemic models. Trabeculae subjected to HYP or MI did not demonstrate any increased apoptotic or necrotic markers. CONCLUSIONS: PKC, mitoK+ATP and ROS are involved in sevoflurane-induced cardioprotection after HYP or MI, suggesting that the means of mitochondrial ETC inhibition does not determine the signal transduction pathway for cardioprotection by anaesthetics.

Postoperative condition after the use of remifentanil with a small dose of piritramide compared with a fentanyl-based protocol in patients undergoing craniotomy.

BACKGROUND AND OBJECTIVE: The use of remifentanil requires other analgesics for postoperative pain relief compared to fentanyl in patients undergoing craniotomy. This could possibly reduce the postoperative advantages of this short-acting opioid. METHODS: We compared remifentanil and fentanyl-based anaesthesia in a randomized observer and patient blinded trial on patients, undergoing an elective craniotomy. Twenty patients received anaesthesia using remifentanil with a small dose of piritramide (0.1 mg kg(-1)) after closure of the dura mater. Twenty patients underwent a fentanyl-based protocol. In both groups, anaesthesia was induced with thiopental and rocuronium, and maintained with 0.6-1 minimum alveolar concentration (MAC) isoflurane in a nitrous oxide/oxygen mixture 2:1 and rocuronium. Patients received 1 g of paracetamol rectally postoperatively. A visual analogue scale (VAS) for pain, the Glasgow Coma Score, a modified Aldrete Score, arterial carbon dioxide tension (PaCO2) and piritramide consumption were evaluated every half an hour postoperatively. RESULTS: No significant differences were found for pain, Aldrete or Glasgow Coma scores or for PaCO2 between the groups when controlled for age, although the pain and Glasgow Coma Scores were consistently higher and PaCO2 lower in the remifentanil group. Furthermore, 11 out of 20 patients in the remifentanil group requested extra piritramide as opposed to 7 out of 20 in the fentanyl group (P = 0.11). CONCLUSIONS: Despite the intraoperative use of piritramide in the remifentanil group, patients experienced more pain postoperatively. A significant influence of age on pain intensity was found. The use of remifentanil with a small dose of piritramide of 0.1 mg kg(-1) has no evident advantage over the use of fentanyl considering the postoperative conditions after craniotomy.

Carbon monoxide production from desflurane and six types of carbon dioxide absorbents in a patient model.

BACKGROUND: Desflurane is known to produce high concentrations of carbon monoxide (CO) in desiccated sodalime or Baralyme (Allied Healthcare Products, St. Louis, MO). Desiccated absorbents without strong bases like potassium hydroxide or sodium hydroxide are reported to produce less or no CO at all. The purpose of this study is to compare the concentration of CO in an anesthesia circuit for desflurane with six different types of completely desiccated CO(2) absorbents with less strong bases than sodalime. METHODS: A patient model was simulated using a circle anesthesia system connected to an artificial lung. Completely desiccated CO(2) absorbent (950 g) was used in this system. A low flow anesthesia (500 ml min(-1)) was maintained using desflurane. For immediate quantification of CO production a portable gas chromatograph was used. RESULTS: Peak concentrations of CO were very high in Medisorb (Datex-Ohmeda, Hoevelaken, The Netherlands) and Spherasorb (Intersurgical, Uden, The Netherlands) (13317 and 9045 p.p.m., respectively). It was lower with Loflosorb (Intersurgical, Uden, The Netherlands) and Superia (Datex-Ohmeda, Hoevelaken, The Netherlands) (524 and 31 p.p.m., respectively). Amsorb (Armstrong, Coleraine, N. Ireland) and lithium hydroxide produced no CO at all. CONCLUSION: Medisorb and Spherasorb are capable of producing large concentrations of CO when desiccated. Loflosorb and Superia produce far less CO under the same conditions. Amsorb and lithium hydroxide should be considered safe when desiccated.

Predictive value of symptom level measurements for complex regional pain syndrome type I.

The validity with respect to presence or absence of CRPS I according to Veldman's criteria was assessed for measured pain, temperature, volume differences and limitations in range of motion. Evaluated were 155 assessments of 66 outpatients, initially diagnosed with CRPS I, but many of them not so on follow up visits. Pain was measured with VAS and McGill, temperature by infrared thermometry, volume differences by water displacement volumeters and limitations in range of motion by universal goniometers. Sensitivity, specificity, positive and negative predictive value of the measurement instruments at different cut-off points was calculated. Combined symptom scores were evaluated in a similar fashion. High sensitivity was found for the VAS, McGill, and range of motion. The specificity was overall lower, but highest values were obtained for volume differences. The positive predictive value was good for all measurement instruments. Negative predictive value was lower, especially for measurement of temperature and volume asymmetries. If sensitivity and specificity are equally important, VAS>3 cm, McGill>6 words, temperature difference>or=0.4 degrees C, volume difference>6.5% and ROM limitation>15% provide the best results. Using these cut off values, the highest value of sensitivity and of sensitivity and specificity combined, was found for a combination of VAS, McGill and ROM. The highest value of specificity was found for different combinations of 3, 4 and 5 instruments, all containing the VAS. We conclude that the measured pain, temperature, volume and range of motion can be used as diagnostic indicators for establishing presence or absence of CRPS I.

[The practice guideline 'Neuraxis blockade and anticoagulation']. / Richtlijn 'Neuraxisblokkade en antistolling'.

In a patient with a coagulation disorder, the administration of a local anaesthetic by means of a needle or via the insertion of a catheter into the epidural space or spinal cavity may lead to bleeding and haematoma formation, with a danger of pressure on the spinal cord or nerve roots. Employing the method of the Dutch Institute for Healthcare (CBO) for the development of practice guidelines, a working group of anaesthesiologists, a haematologist and a hospital chemist have drawn up recommendations for neuraxis blockade in combination with anticoagulant therapy. In patients with a clinically acquired tendency toward increased bleeding, the management is highly dependent on the cause of the bleeding tendency. If the patient uses acetylsalicylic acid or clopidogrel, the medication must be withdrawn at least 10 days before neuraxis blockade is started. Therapy with glycoprotein-IIb/IIIa-receptor antagonists is an absolute contra-indication for neuraxis blockade. In patients who are using coumarin derivatives, neuraxis blockade results in an increased risk of a neuraxial haematoma. The coumarin derivative should then be withdrawn and replaced by a different form of anticoagulation. The use of low-molecular-weight heparin at the usual prophylactic dosage is not a contra-indication for neuraxis blockade and the risk of a neuraxial haematoma following neuraxis blockade is also not increased significantly by the subcutaneous administration of unfractionated heparin.

A retrospective analysis of the intubations performed during 5 years of helicopter emergency medical service in Amsterdam.

INTRODUCTION: Different skilled personnel perform prehospital airway management, by far one of the most challenging skills with major consequences upon failure. SETTING: The setting for this study was the helicopter emergency medical service at the Vrije Universiteit Medical Center, Amsterdam, the Netherlands. METHODS: We conducted a retrospective analysis of all medical charts of intubated trauma patients in the period from May 1995 to May 2000. We focused on intubation reasons and conditions. RESULTS: In 43 of 653 patients (7%) the process of intubation was recorded as being difficult, leading to 5 failed intubations (11.6%). In 432 of 653 trauma victims (66%), general anaesthesia was required before intubation. Forty (9%) of these patients died, most soon after arrival in the hospital. The clinical condition of 221 (34%) patients was so poor that they did not require additional drugs for intubation; 73% of those patients died, with two-thirds dying at the accident site. CONCLUSION: The rate of difficult intubation in this analysis is low (7%). The overall airway failure (11.6%) is the same as seen in the literature when sedation and relaxation are used. An adult trauma victim with a Revised Trauma Score of 0 has a very poor prognosis of survival.

Dosage scheme for propofol in children under 3 years of age.

BACKGROUND: Propofol is a well-known drug for adults for total intravenous anaesthesia. Since 1999, the use of propofol has been approved for children less than 3 years of age. However, a suitable dosage scheme for these age groups was not available. The purpose of this study was to describe our clinical experience with the use of a new dosage scheme for propofol in patients under 3 years of age, based on experimental data and known pharmacological principles in children. METHODS: A pilot study of 50 patients undergoing TIVA was performed to adapt the existing adult dosage scheme to the requirements of the younger population. Total number and time of administration of boluses and time to awakening were registered and used as criteria to adjust the dosage scheme. The subsequent dosage scheme was then evaluated in 2271 children undergoing anaesthesia for various procedures. Usual anaesthetic parameters were measured to monitor the safety of the patient: ECG, O2 saturation, respiratory frequency and blood pressure. Most of the patients were mechanically ventilated; only 15% were breathing spontaneously. RESULTS: Overall, few side effects were recorded [bradycardia (12%), blood pressure fall (8%), desaturation (1%)], which were easily countered by routine measures. CONCLUSIONS: This dosage scheme provides safe and smooth anaesthesia in children less than 3 years of age and is therefore a useful tool for a TIVA technique in small children.

Effect of sevoflurane on the ex vivo secretion of TNF-alpha during and after coronary artery bypass surgery.

BACKGROUND AND OBJECTIVE: Sevoflurane has been used for the induction and maintenance of anaesthesia during cardiac surgery owing to its favourable haemodynamic effects. It has been suggested that it offers protection against myocardial ischaemia-reperfusion injury. METHODS: We investigated the effect of sevoflurane on plasma concentrations of tumour necrosis factor-alpha (TNF-alpha) after ex vivo stimulation of whole-blood leukocytes by lipopolysaccharide from 20 patients undergoing coronary artery bypass surgery. The patients were randomized to two groups. Group 1 patients were induced and maintained with sevoflurane; those in Group 2 were anaesthetized with moderate doses of midazolam-sufentanil. Blood samples were drawn from the patients on seven occasions from before induction of anaesthesia until 24 h after skin closure. RESULTS: Plasma concentrations of TNF-alpha were lower in Group 1 than in Group 2 after cessation of cardiopulmonary bypass (median (interquartiles): 25 (21-30) versus 37 (28-79) pg mL(-1); P < 0.05) and 24h after skin closure (196 (100-355) versus 382 (233-718) pg mL(-1); P < 0.05). Postoperatively, two cases of myocardial infarction were recorded, one in each group. Six patients in Group 2 needed continued inotropic support after the first morning to maintain haemodynamic stability versus one patient in Group 1 (P < 0.05). The length of stay in the intensive care unit was significantly lower in Group 1 than in Group 2 (mean +/- SD: 25 +/- 16 versus 54 +/- 30 h; P < 0.05). CONCLUSIONS: Sevoflurane reduces production of TNF-alpha more than total intravenous anaesthesia with midazolam-sufentanil during cardiac surgery. This may reduce cardiac morbidity and the length of stay in the intensive care unit.

The treatment of complex regional pain syndrome type I with free radical scavengers: a randomized controlled study.

To compare the effects of two free radical scavengers, dimethylsulfoxide 50% (DMSO) and N-acetylcysteine (NAC), for treatment of complex regional pain syndrome I (CRPS I), a randomized, double-dummy controlled, double-blind trial was conducted. Two outpatient clinics of two university hospitals in The Netherlands participated in the study and 146 patients, were included over a period of 24 months. Patients were randomized into two treatment groups, one was instructed to apply DMSO 50% five times daily to the affected extremity, the second was treated with NAC 600mg effervescent tablets three times daily, both combined with placebo. Interventions were accompanied by pain medication, occupational therapy for upper extremity CRPS I and physical therapy for lower extremity CRPS I in specific circumstances. Treatment was given for 17 weeks, with a possibility to continue or switch medication after this period, up to 1 year following the onset of treatment. An impairment level sum score was the primary outcome measure. Upper and lower extremity skills and functions, and general health status were also evaluated. Overall, no significant differences were found between NAC and DMSO after 17 and 52 weeks on impairment level and general health status. Significant differences were found for subscores of lower extremity function, in favor of DMSO-treatment. Subgroup analysis showed more favorable results for DMSO for warm CRPS I and significantly better performance of NAC for patients with a cold CRPS I. Results tended to be negatively influenced if the duration of the complaint was longer. Treatment with DMSO and NAC are generally equally effective in treatment of CRPS I. Strong indications exist for differences in effects for subgroups of patients with warm or cold CRPS I: for warm CRPS I, DMSO-treatment appears more favorable, while for cold CRPS I, NAC-treatment appears to be more effective.

Dexamethasone decreases the pro- to anti-inflammatory cytokine ratio during cardiac surgery.

BACKGROUND: Cytokines regulate inflammation associated with cardiopulmonary bypass (CPB). Pro-inflammatory cytokines may cause myocardial dysfunction and haemodynamic instability after CPB, but the release of anti-inflammatory cytokines is potentially protective. We studied the effects of dexamethasone on pro- and anti-inflammatory cytokine responses during coronary artery bypass grafting surgery. METHODS: Seventeen patients were studied: nine patients received dexamethasone 100 mg before induction of anaesthesia (group 1) and eight patients acted as controls (group 2). Plasma levels of tumour necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8, IL-10 and IL-4 were measured perioperatively. RESULTS: TNF-alpha and IL-8 did not increase significantly in group 1 whereas they increased in group 2 to greater than preoperative values (P<0.05). IL-6 increased in both groups, with lower values in group 1 than in group 2 (P<0.05). IL-10 increased in both groups, with higher values in group 1 (P<0.05). IL-4 did not change in group 1 but decreased in group 2 compared with pre-induction values (P<0.05). After surgery, patients in group 2 had tachycardia, hyperthermia, a greater respiratory rate and higher pulmonary artery pressure, and a longer stay in the intensive care unit. CONCLUSION: Dexamethasone given before cardiac surgery changes circulating cytokines in an anti-inflammatory direction. Postoperative outcome may be improved by inhibition of the systemic inflammatory response.

Effect of VIMA with sevoflurane versus TIVA with propofol or midazolam-sufentanil on the cytokine response during CABG surgery.

BACKGROUND AND OBJECTIVE: Cardiac surgery with cardiopulmonary bypass triggers an inflammatory response involving pro-inflammatory cytokines such as tumour necrosis factor-alpha (TNF-alpha), interleukin 6 (IL-6) and interleukin 8 (IL-8). We investigated whether different anaesthetic techniques alter the pro-inflammatory cytokine response to cardiac surgery. METHODS: Thirty patients scheduled for elective coronary artery bypass grafting (CABG) surgery were randomized into three groups of 10 patients. They received either volatile inhalation induction and maintenance (Group 1) or total intravenous anaesthesia with propofol and a minimal dose sufentanil (Group 2) or a moderate dose midazolam-sufentanil (Group 3). The effect of the different anaesthetic techniques on plasma levels of TNF-alpha, IL-6 and IL-8 were examined during and after anaesthesia. RESULTS: Concentrations of TNF-alpha, and IL-8 were comparable in the three groups throughout all measurements. Before the start of cardiopulmonary bypass, IL-6 was significantly higher in Group 1 than in Group 2 (P = 0.009) or Group 3 (P = 0.030), but there were no differences between groups after cardiopulmonary bypass or postoperatively. In the three groups there was a positive correlation between aortic clamping time and serum concentrations of IL-6 (r = 0.54) and IL-8 (r = 0.62). Length of stay in intensive care was correlated with high levels of TNF-alpha (r = 0.78). CONCLUSIONS: Albeit there is difference between the volatile induction and maintenance of the anaesthesia method and the total intravenous anaesthesia technique on the pro-inflammatory cytokine response to surgical stimulation before starting of cardiopulmonary bypass, neither technique can modify the pro-inflammatory cytokine response to ischaemia-reperfusion or extracorporeal circulation.

Interrater reliability of diagnosing complex regional pain syndrome type I.

BACKGROUND: Diagnosis of complex regional pain syndrome type I (CRPS I) is based on clinical observation of symptoms. As little information is available on the reliability of CRPS I diagnosis, we evaluated the agreement between therapists with regard to the presence and severity of CRPS I and its symptoms. METHODS: The interrater reliability was evaluated in 37 presumed CRPS I patients by three observers; one consultant anesthesiologist and two resident anesthesiologists. Patients were assessed on the basis of Veldman's CRPS criteria. RESULTS: The interrater reliability for diagnosing CRPS I was good for the majority of observer combinations. The percentage of agreement for the absence or presence of CRPS I was good (88%-100%). Cohen's Kappa's ranged from 0.60 to 0.86. The agreement for the mean symptom score ranged from 70.2% to 88.6%; Kappa's were lower and showed more variation. Interrater reliability for assessment of the severity of CRPS I and its symptoms was poor. Factors influencing the interrater reliability were symptom type, individual observers and sample population. CONCLUSION: Diagnosing CRPS I can be performed on the basis of clinical observation. Further assessment of severity of CRPS I and its symptoms should be performed with reliable and valid measurement instruments.

[Preoperative examination: anamnesis and physical examination mandatory]. / Het preoperatief onderzoek: anamnese en lichamelijk onderzoek onmisbaar.

Preoperative assessment has been subject to discussion for many years. What should be done and by whom? Fortunately there is a general consensus that routine laboratory and function tests are not only of no benefit to the patient but are also wasteful of resources. The Preoperative Assessment Commission of the Dutch Ministry of Health, Welfare and Sport, supports the initiative for preoperative assessment clinics run by anaesthesiologists. Yet in their advice, this Commission has proposed screening by means of an abridged questionnaire. Efforts to validate this questionnaire have demonstrated that in practice it was not helpful. Therefore it seems justified to conclude that preoperative screening should not fundamentally differ from that performed during a basic clinical examination.