Etomidate--a review of robust evidence for its use in various clinical scenarios.

Etomidate is an intravenous hypnotic with a favourable clinical profile in haemodynamic high-risk scenarios. Currently, there is an active debate about the clinical significance of the drug's side effects and its overall risk-benefit ratio. Etomidate-induced transient adrenocortical suppression is well documented and has been associated with increased mortality in sepsis. In surgical patients at risk of hypotensive complications, however, a review of current literature provides no robust evidence to contraindicate a single-bolus etomidate induction. Large randomised controlled trials as well as additional observational data are required to compare safety of etomidate and its alternatives.

Survey on controversies in airway management among anesthesiologists in the UK, Austria and Switzerland.

BACKGROUND: While surveys about anesthesia practice appear regularly in the anesthesia literature, they are usually bound to one country. We compared the approach to specific airway management issues among anesthesiologists from three different European countries. METHODS: A questionnaire was distributed during the main session of three anesthesia meetings in Austria (A), the UK, and Switzerland (CH). Questions concerned whether anesthesiologists routinely check for risk factors associated with difficult mask ventilation; whether anesthesiologists are used to mask ventilate prior to administering neuromuscular blocking drugs (NMBD); whether anesthesiologists apply cricoid pressure. RESULTS: We evaluated 266 questionnaires. No significant differences in the frequency of checking predictors were found, except for "age" (UK: 28%, A: 13%, CH:11%, P=0.01). Fewer anesthesiologists from the UK always check mask ventilation before NMBD (UK: 34%, A: 72%, CH: 67%, P<0.001); but they check mask ventilation more often when risk factors are present (UK: 36%, A: 13%, CH: 20%, P=0.004). Very few anesthesiologists from the UK never apply cricoid pressure (UK: 2%, A: 40%, CH: 49%, P<0.001), but almost all of them apply it in case of rapid sequence intubation (UK: 96%, A: 52%, CH:30%, P<0.001). CONCLUSION: Answers from anesthesiologists in the UK differed significantly from those in A and CH. Anesthesiologists in the UK check mask ventilation after induction less frequently, but they check more often when risk factors of difficult mask ventilation are present. Cricoid pressure seems to remain an important part of the rapid sequence induction technique in the UK, whereas anesthesiologists in Austria and Switzerland rely less on this technique.

[HELLP Syndrome as an indication for liver transplantation]. / HELLP-Syndrom als Indikation für eine Lebertransplantation.

Liver rupture followed by multiorgan failure is perhaps the most catastrophic complication of the HELLP syndrome (hemolysis, elevated liver function, low platelets). Specific treatment options are currently limited and not routinely clarified. Here, we present a patient successfully managed by an innovative surgical approach consisting of combined total hepatectomy, portacaval shunt, and liver transplantation. A 26-year-old primipara (39th week of gestation) who suffered liver rupture as a complication of HELLP syndrome after delivery underwent a portacaval shunt after total hepatectomy. This combination was sufficient until the patient underwent orthotopic liver transplantation. The patient was discharged from the hospital after a dramatic recovery. Bridging portacaval shunt and consecutive orthotopic liver transplantation represented an effective therapy for this patient and should be considered early as a treatment option in patients with liver rupture complicating severe HELLP syndrome.

Chronic effects of an aminosteroid on microdialytically measured parameters after experimental middle cerebral artery occlusion in the rat.

The effects of the neuroprotective aminosteroid U74006F (tirilazad mesylate, Freedox) were monitored microdialytically in rat cortex during three 4h periods beginning immediately, 25h and 49h after permanent middle cerebral artery occlusion. Either U74006F or vehicle only was administered 15 min, 2h, 6h, 12h and 24h after operation. The dialysate was analysed for on-line pH, ascorbic acid, uric acid, glucose and lactate. The efficacy of post-ischaemic treatment was shown by: a) lesion volume 53h after operation was significantly smaller in U74006F-treated animals; b) microdialytic findings were very similar to those found previously with pre-ischaemic drug application (reduction in release of ascorbic acid, uric acid and lactate, increased pH); c) an effect of U74006F on lactate release could still be seen on days 2 and 3; and d) increases in uric acid on days 2 and 3, possibly reflecting delayed cell death, were smaller in aminosteroid treated animals.

Acute effects of an aminosteroid on microdialytically measured parameters after experimental middle cerebral artery occlusion in the rat.

The effects of the neuroprotective aminosteroid U74389G were monitored microdialytically in rat cortex during 4 h after permanent middle cerebral artery occlusion. Either U74389G or vehicle only was administered one hour before and 2 h after operation. The dialysate was analysed for on-line pH, ascorbic acid, uric acid, glucose and lactate. In aminosteroid treated animals the levels of ascorbic and uric acids were lower in dialysates after occlusion, total release of lactate was significantly reduced and on-line pH was significantly higher than in control animals. Lesion volume at 4 h, which was significantly reduced in treated animals, correlated positively with ascorbic acid release and on-line pH. Results suggest that neuroprotective effects of aminosteroids might be explained by: (a) preservation of intracellular levels of the radical scavenger ascorbic acid with possible concomitant reduction of glutamate release; and (b) reduced lactate release and increased pH which might influence oedema positively. Copyright 1999 Harcourt Publishers Ltd.