Dynamics of albumin in plasma and ascitic fluid in patients with cirrhosis.

BACKGROUND/AIMS: To determine dynamics of albumin in plasma and ascitic fluid of patients with cirrhosis. METHODS: Forty-seven patients were classified in four groups: I--patients without fluid retention; II--patients with ascites not resistant to subsequent diuretic treatment; III--recompensated patients during diuretic treatment; and IV--patients with diuretic-resistant ascites. Transvascular and transperitoneal albumin transports were quantified by 131I-/125I-labelled human albumin. RESULTS: TER(P) (i.e. the fraction of intravascular albumin (IVM) passing from plasma into the interstitial space per hour) was increased in all groups. In group IV patients the transport rate of albumin from plasma into the ascitic fluid (TER(PA)) was significantly higher than the transport rate from the ascitic fluid back into the plasma: TER(AP) (0.45 vs. 0.26% IVM/h, P < 0.002). In group II patients TER(PA) was similar to TER(AP) (0.27 vs. 0.25% IVM/h, ns). A direct correlation was found between TER(PA) and TER(AP) in both groups of patients (r = 0.78, P < 0.001). CONCLUSION: In non-resistant ascites, there is a steady state between the transport of albumin into the peritoneal cavity and back into the plasma, but in resistant ascites the former transport is elevated. Thus, local factors may be important to treatment of ascites.

Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium.

BACKGROUND: After anaesthesia involving pancuronium a high incidence of both residual neuromuscular block and postoperative pulmonary complications (POPC) has been reported. The aim of this study was to compare the incidence of POPC following the use of pancuronium, atracurium, and vecuronium, and to examine the effect of residual neuromuscular block on the incidence of POPC. METHODS: A total of 691 adult patients undergoing abdominal, gynaecological, or orthopaedic surgery under general anaesthesia were randomised to receive either pancuronium, atracurium, or vecuronium. Perioperatively, the response to train-of-four (TOF) nerve stimulation was evaluated manually. Postoperatively, the TOF ratios were measured mechanomyographically, and through a 6-day follow-up the patients were examined for pulmonary complications. RESULTS: The incidence of residual block, defined as a TOF ratio < 0.7, was significantly higher in the pancuronium group (59/226: 26%) than in the atracurium/vecuronium groups (24/450: 5.3%). In the pancuronium group, significantly more patients with residual block developed POPC (10/59: 16.9%) as compared to patients without residual block (8/167: 4.8%). In the atracurium/vecuronium groups, the incidence of POPC was not significantly different in patients with (1/24: 4.2%) or without (23/426: 5.4%) residual block. Multiple regression analysis indicated that abdominal surgery, age, long-lasting surgery, and a TOF ratio < 0.7 following the use of pancuronium were potential risk factors for the development of POPC. CONCLUSION: Postoperative residual block caused by pancuronium is a significant risk factor for development of POPC.

Sublingual premedication with brotizolam.

This randomized, double-blind and double-dummy study was carried out in order to compare the perioperative sedation after premedication with either brotizolam 0.25-0.50 mg sublingually or diazepam 5-10 mg orally. Sixty-two patients aged 18-60 years scheduled for minor gynaecological surgery in general anaesthesia were included. Assessments were: 1. auditory continued response time (ACRT); 2. coma scale; 3. anxiety scale; and 4. final patient questionnaire. One hour after premedication the brotizolam group was more sedated, based on ACRT (P < 0.01) and the coma scale (P < 0.05). The final questionnaire showed (P < 0.05) that the brotizolam group was more satisfied with the effect of the premedication. Seven hours after the premedication the ACRT scores in both groups were similar to those before premedication and all the patients could walk about freely. In conclusion, as a premedicant in outpatients sublingual brotizolam appears to be a good alternative to diazepam.

Recovery after total intravenous anaesthesia using combined midazolam/alfentanil infusion and reversal with flumazenil.

One of the major problems with total intravenous anaesthesia (TIVA) is postoperative sedation, possibly with respiratory depression. The aim of the present study was to evaluate the recovery characteristics after TIVA using a continuous infusion of a mixture of midazolam and alfentanil with flumazenil reversal before extubation. This method was compared to balanced anaesthesia using midazolam, alfentanil and nitrous oxide without flumazenil reversal. The degree of sedation was measured by reaction time test, Glasgow Coma Scale, cipher copying test and subtraction test. We found significantly faster reaction times postoperatively in the TIVA group (n = 15) compared to the balanced group (n = 13), despite larger doses of both midazolam (median 21 mg versus 9 mg) and alfentanil (median 5.9 mg versus 4.5 mg). The other tests revealed no difference between the groups. One patient became resedated after flumazenil. We conclude that the TIVA technique described here resulted in slightly better recovery characteristics, offering a usable alternative to balanced anaesthesia.

Incidence of spontaneous bacterial peritonitis in patients with ascites. Diagnostic value of white blood cell count and pH measurement in ascitic fluid.

During a 21-month period, 65 consecutive patients admitted with ascites were included in a prospective study of the incidence of spontaneous bacterial peritonitis, and paracentesis was performed on admission. The ascitic fluid was cultured, ascitic leucocytes were counted and pH was measured. Bacterial growth was found in five patients with chronic liver disease, who were diagnosed as having spontaneous bacterial peritonitis (SBP), since no intra-abdominal focus could be demonstrated. Thus, the incidence of SBP in this material was 7.7% (95% confidence limits: 2.5-17%). SBP was caused by Escherichia coli (n = 3), coagulase negative staphylococcus (n = 1), and Bacteroides species (n = 1). Abdominal tenderness, abnormal intestinal sounds, fever and hepatic encephalopathy were equally frequent in the group with SBP and in patients with sterile ascites. Infection was not anticipated in any of the patients with SBP. In contrast to several previous studies, neither ascites pH nor ascites leucocyte counts were any help in obtaining a rapid diagnosis. Survival time of patients with SBP was significantly shorter than of patients without SBP.

Branched chain enriched amino acid versus glucose treatment of hepatic encephalopathy. A double-blind study of 65 patients with cirrhosis.

We studied the effects of infusion of a branched chain enriched amino acid mixture versus glucose on acute hepatic encephalopathy in patients with cirrhosis. Sixty-five patients were randomly treated with 1 g/kg per day of an amino acid mixture with 40% branched chain contents (32 patients), or isocaloric glucose (33 patients) for a maximum of 16 days. The regimens further included glucose infusion to a total of 26.5 kcal/kg per day and lactulose. The patients took part in the study for 5-6 days. In each group 17 patients woke up. In the amino acid group eleven died and four developed renal failure. In the glucose group ten died, three developed renal and two respiratory failure, and one remained encephalopathic. The coma score worsened in three of the patients who died in the amino acid group, but in all patients who died in the glucose group. The negative nitrogen balance on entry reversed in the amino acid group, but not in the glucose group. Thus, the branched chain enriched amino acid supplement did not change the prognosis for wake-up, but had other effects on the cerebral state and on nitrogen homeostasis.

Comparison of induction with and first hour of recovery from brief propofol and methohexital anesthesia.

Anesthesia and recovery during the first hour after propofol and methohexital anesthesia for termination of pregnancy, lasting about 12 min, were compared, the latter in a double-blind manner by means of psychomotor tests (coin counting and continuous auditory reaction time). Muscle movements and hiccups were seen significantly more frequently during methohexital inductions. No differences were seen regarding pain at the site of injection or apnea between the groups. At 15 min after the last dose of anesthetic, recovery after methohexital was ahead of that after propofol, but after 1 h, psychomotor performance was better in the propofol group. Side-effects during recovery were few, and incidences did not differ significantly. Although the difference in reaction time test was significant, it was hardly large enough to be of any clinical importance. Both drugs are useful for brief outpatient anesthesia, but smoother induction gives propofol an edge over methohexital.

Induction and recovery characteristics of propofol, thiopental and etomidate.

Propofol, thiopental and etomidate, with 20 patients in each group, were compared for anesthesia of short duration in women undergoing termination of pregnancy, with respect to: 1: pain on injection (equally often after propofol and etomidate, but more rarely after thiopental); 2: apnea following induction (no difference); 3: involuntary muscular movements more frequent after etomidate); 4: blood pressure (larger drop after propofol); 5: heart rate (greater increase after thiopental); 6: time to eye opening on command (longer after propofol); 7: Steward score on eye opening (no difference); 8: coin counting after 15, 30 and 60 min (performance better after propofol at 15 and 30 min, producing even shorter times than preoperatively at 60 min); 9: reaction time after 15, 30 and 60 min (performance better after propofol, producing even shorter times than preoperatively at 60 min. It is concluded that the faster recovery gives propofol an advantage over thiopental and etomidate in outpatient anesthesia.

Prognosis after the first episode of gastrointestinal bleeding or coma in cirrhosis. Survival and prognostic factors.

Hepatic encephalopathy and gastrointestinal (GI) bleeding are the most serious complications in cirrhosis. The purpose of this study was to examine survival after the first episode of GI bleeding or coma, or both, and to identify variables associated with the subsequent survival in 284 consecutive patients with cirrhosis admitted to one division of hepatology over a period of 81 months. Patients who only bled had markedly longer survival than those who only had coma, whereas those who had both bleeding and coma had by far the poorest survival, only 15% being alive 1 year later. Several other variables showed a significant association with survival. In a Cox multiple regression analysis the following four variables showed significant association with a short survival: coma and bleeding at the episode, ascites, low prothrombin index, and high serum creatinine. The prognostic index derived from the Cox model, which was validated by a split-sample testing technique, may be used to refine prognostic estimation in this subgroup of severely ill cirrhotic patients.

Aminophylline reduces the depth and duration of sedation with barbiturates.

Aminophylline, an inhibitor of cyclic nucleotide phosphodiesterase, has for many years been used to relieve bronchospasm. Recent reports have shown that aminophylline antagonizes morphine and diazepam sedation. To see if aminophylline acts similarly on barbiturate sedation, we examined 24 women undergoing short general anaesthesia with thiopental (7 mg x kg-1), using a double-blind study design. Evaluated by continuous auditory reaction time measurements, aminophylline (5.6 mg x kg-1) reduces the depth and duration of sedation with thiopental. This suggests that aminophylline could be used to diminish an unwanted effect of barbiturate sedation.

Cobalamin binding proteins (haptocorrin and transcobalamin) in human cerebrospinal fluid.

The unsaturated cobalamin binding capacity of transcobalamin and haptocorrin was studied in cerebrospinal fluid (CSF) and plasma (P) from 37 reference individuals. These comprised 27 males and 10 females who underwent minor surgery in spinal anaesthesia. The 5th and 95th percentiles were as follows: P-Transcobalamin 300-870 pmol/l (median 550 pmol/l); CSF-Transcobalamin 90-540 pmol/l (median 194 pmol/l); P-Haptocorrin 75-290 pmol/l (median 159 pmol/l); CSF-Haptocorrin 10-41 pmol/l (median 21 pmol/l). No sex difference was found between the levels of haptocorrin or transcobalamin in plasma or cerebrospinal fluid. A positive correlation between P-Transcobalamin and CSF-Transcobalamin was found, whereas no correlation between P-Haptocorrin and CSF-Haptocorrin values was found. The plasma/CSF ratios of transcobalamin, haptocorrin, albumin and IgG indicated that the binders may be synthetized into the cerebrospinal fluid or are actively being transported into the cerebrospinal fluid.

Pre-operative alcohol infusion. The need for analgesic supplementation in chronic alcoholics.

The influence of pre-operative alcohol infusion on the requirement for analgesic supplementation with fentanyl in chronic alcoholic patients was studied. The chronic alcoholic was defined as a person having a regular daily alcohol consumption of over 70 g pure alcohol for at least 3 years. The mean annual consumption in the patients studied was 52 litres pure alcohol. A positive correlation between requirement for fentanyl and alcohol consumption was found. The amount of fentanyl required to achieve satisfactory analgesia (the 'saturation dose') was significantly higher (61%) in alcoholic than in non-alcoholic patients. Once stable anaesthesia was achieved the maintenance dose was the same in alcoholic and non-alcoholic patients. Pre-operative infusion of alcohol significantly reduced the amount of fentanyl required to achieve anaesthesia in both alcoholic and non-alcoholic patients (by 25% and 29% respectively). Furthermore it prevented some of the catecholamine mediated effects, such as increase in blood pressure, heart rate and blood glucose.

Carbon dioxide elimination after acetazolamide in patients with chronic obstructive pulmonary disease and metabolic alkalosis.

Acetazolamide, an inhibitor of carbonic anhydrase, which catalyzes hydration/dehydration of carbon dioxide, has been used for correction of metabolic alkalosis in patients with chronic obstructive pulmonary disease (COPD). Animal experiments have shown that the gradient between tissue and the alveolar CO2 tension increases after inhibition of carbonic anhydrase, suggesting retention of CO2. In order to determine the true degree of carbon dioxide retention after total inhibition of carbonic anhydrase, 10 patients with COPD and pronounced metabolic alkalosis (base excess above 6) under controlled mechanical ventilation were studied. The study showed that there was a statistically significant increase in tissue PCO2 and a temporary decrease in pulmonary carbon dioxide excretion. Furthermore, it was found that PaO2 and PVO2 increased significantly after inhibition of carbonic anhydrase, which could, at least partly, explain the improvement seen in patients with COPD and metabolic alkalosis after treatment with acetazolamide.