[Clinical experiences with the double jet technique superimposed HFJV (high frequency jet ventilation) during larygotracheal surgery]. / Klinische Erfahrungen mit der Doppel-Jet-Technik: Die Superponierte Hochfrequenz-Jet-Ventilation in der Larynxchirurgie.

OBJECTIVE: Single-frequency high-frequency jet ventilation (HFJV) is an established ventilatory technique during laryngotracheal surgery. This study describes the clinical use of combined HFJV, characterised by the simultaneous application of a low-frequent (LF) and a high-frequent (HF) jet stream. METHODS: Two jet streams with different pulsatile frequency (HF approx. 10 Hz, LF 10-30 bpm) and adjustable driving pressures were applied supraglottically by means of a special jet laryngoscope in patients undergoing elective laryngotracheal surgery during total intravenous anaesthesia. HFJV was performed using a pneumatic or electronic jet respirator connected to the central gas supply. RESULTS: 134 patients were submitted to tubeless HFJV applying the double-jet technique using the jet-laryngoscope. Duration of HFJV was < or = 30 min in 60 patients (45%), between 30 and 60 min in 49 patients (36%), and > or = 60 min in 25 patients (19%). Classification into 3 groups according to weight ((I < 65 kg, II = 65-84 kg, III > or = 85 kg) using driving pressures of 1.52 +/- 0.47 bar, 1.64 +/- 0.78 bar, and 1.69 +/- 0.67 bar for the HF jet and 1.78 +/- 0.54 bar, 1.90 +/- 0.48 bar, and 2.00 +/- 0.49 bar for the NF jet demonstrated differences in paO2 (156 +/- 45 [I] vs 126 +/- 34 [II] vs 96 +/- 18 [III] mm Hg) and paCO2 (42 +/- 9 und 44 +/- 8 vs 48 +/- 8 mm Hg) using comparable FjetO2 (0.6 +/- 0.2). Supraglottic pressures were 11.6 +/- 6.8, 11.5 +/- 7.0, und 12.6 +/- 7.1 cm H2O (I-III). No ventilator-related adverse events were observed. CONCLUSION: Tubeless supraglottic HFJV utilizing two jet streams with low and high frequency was effective in patients during laryngotracheal surgery. The application of two jet streams results in phasic changes of airway pressures between an inspiratory and expiratory pressure level, and facilitates application of enlarged tidal volumes. As demonstrated, oxigenation and ventilation is compromised by increased body weight. Superimposed HFJV (double-jet technique) enables the supraglottic ventilation of heavy patients and/or in the presence of airway stenoses during laryngotracheal surgery without need to use maximum driving pressures.

Aggressive warming reduces blood loss during hip arthroplasty.

UNLABELLED: We evaluated the effects of aggressive warming and maintenance of normothermia on surgical blood loss and allogeneic transfusion requirement. We randomly assigned 150 patients undergoing total hip arthroplasty with spinal anesthesia to aggressive warming (to maintain a tympanic membrane temperature of 36.5 degrees C) or conventional warming (36 degrees C). Autologous and allogeneic blood were given to maintain a priori designated hematocrits. Blood loss was determined by a blinded investigator based on sponge weight and scavenged cells; postoperative loss was determined from drain output. Results were analyzed on an intention-to-treat basis. Average intraoperative core temperatures were warmer in the patients assigned to aggressive warming (36.5 degrees +/- 0.3 degrees vs 36.1 degrees +/- 0.3 degrees C, P< 0.001). Mean arterial pressure was similar in each group preoperatively, but was greater intraoperatively in the conventionally warmed patients: 86+/-12 vs 80+/-9 mm Hg, P<0.001. Intraoperative blood loss was significantly greater in the conventional warming (618 mL; interquartile range, 480-864 mL) than the aggressive warming group (488 mL; interquartile range, 368-721 mL; P: = 0.002), whereas postoperative blood loss did not differ in the two groups. Total blood loss during surgery and over the first two postoperative days was also significantly greater in the conventional warming group (1678 mL; interquartile range, 1366-1965 mL) than in the aggressively warmed group (1,531 mL; interquartile range, 1055-1746 mL, P = 0.031). A total of 40 conventionally warmed patients required 86 units of allogeneic red blood cells, whereas 29 aggressively warmed patients required 62 units (P = 0.051 and 0.061, respectively). We conclude that aggressive intraoperative warming reduces blood loss during hip arthroplasty. IMPLICATIONS: Aggressive warming better maintained core temperature (36.5 degrees vs 36.1 degrees C) and slightly decreased intraoperative blood pressure. Aggressive warming also decreased blood loss by approximately 200 mL. Aggressive warming may thus, be beneficial in patients undergoing hip arthroplasty.

Perioperative collagen deposition in elderly and young men and women.

HYPOTHESIS: Women deposit more collagen after major abdominal surgery than men. DESIGN: A post hoc analysis of data obtained from 2 prospective, randomized, double-blind clinical trials. SETTING: University hospital general surgical service. PATIENTS: One hundred sixteen patients undergoing colon resection. MAIN OUTCOME MEASURES: Protein and hydroxyproline (collagen) deposition during the first 7 postoperative days in expanded polytetrafluoroethylene implants positioned subcutaneously. RESULTS: On univariate analysis, men and women deposited comparable amounts of collagen (257 +/- 120 vs 281 +/- 117 ng/mm, respectively). When potential confounding factors were entered into a generalized mixed-effects model, only the interaction between age and sex was a significant factor (P = .047). Collagen deposition decreased with age in men, being 317 +/- 133 ng/mm in men younger than 45 years, but only 238 +/- 113 ng/mm in those older than 45 years (P = .03). In contrast, collagen deposition was virtually identical in women younger than 45 years (280 +/- 133 ng/mm) and in those older than 45 years (281 +/- 110 ng/mm). Only 3 of these women were receiving hormone replacement therapy. CONCLUSIONS: Collagen deposition after surgery decreased significantly with age in men, while remaining unchanged in women. Younger men and women deposited similar amounts of collagen. Therefore, older men made less collagen after surgery than older women, perhaps explaining the consistent observation that wound dehiscence is twice as common in men than in women. Our results differ from previous studies conducted in healthy, nonsurgical volunteers, which showed that (1) young women made significantly more collagen than young men and (2) collagen deposition was reduced in postmenopausal women, but deposition returned to premenopausal values with hormone replacement therapy. Differences between our results and those reported previously likely stem from the populations studied. In particular, multiple perioperative factors decrease collagen deposition, which apparently obscures the differences observed previously in healthy, unstressed volunteers.

Mild intraoperative hypothermia prolongs postanesthetic recovery.

BACKGROUND: Intraoperative hypothermia is common and persists for several hours after surgery. Hypothermia may prolong immediate recovery by augmenting anesthetic potency, delaying drug metabolism, producing hemodynamic instability, or depressing cognitive function. Accordingly, the authors tested the hypothesis that intraoperative hypothermia prolongs postoperative recovery. METHODS: Patients undergoing elective major abdominal surgery (n = 150) were anesthetized with isoflurane, nitrous oxide, and fentanyl. They were randomly assigned to routine thermal management (hypothermia) or extra warming (normothermia). Postoperative surgical pain was treated with patient-controlled analgesia. Fitness for discharge from the postanesthesia care unit was evaluated at 20-min intervals by investigators blinded to group assignment and postoperative core temperatures. Scoring was based on a modification of a previously published system that included activity, ventilation, consciousness, and hemodynamic responses. Patients were considered fit for discharge when they sustained a score of 80% (13 points) for at least two consecutive measurement periods. RESULTS: Morphometric characteristics and anesthetic management were similar in each group. Final intraoperative core temperatures differed by approximately 2 degrees C: 34.8 +/- 0.6 versus 36.7 +/- 0.6 degrees C (mean +/- SD, P < 0.001). Postoperative pain scores and postoperative use of patient-controlled opioid were similar. Hypothermic patients required approximately 40 min longer (94 +/- 65 vs. 53 +/- 36 min) to reach fitness for discharge, even when return to normothermia was not a criterion (P < 0.001). Duration of recovery in the two groups differed by approximately 90 min when a core temperature >36 degrees C was also required (P < 0.001). CONCLUSION: Maintaining core normothermia decreases the duration of postanesthetic recovery and may, therefore, reduce costs of care.

Evaluation of the Abbott TDx for determination of phenobarbital in forensic blood specimens.

The Abbott TDx was evaluated for determination of phenobarbital (PB) levels in postmortem (PM) blood. Because hemolysis does not interfere with fluorescence polarization assays, the TDx could be a fast, efficient alternative to gas chromatography (GC). The linearity and precision of the TDx assay were evaluated using postmortem blood that was spiked with phenobarbital and serially diluted. The relationship between nominal and measured values was linear for phenobarbital concentrations up to 150 mg/L (r = 0.999) in two separate postmortem bloods. Precision was excellent with run-to-run coefficients of variation of 10% or less. The TDx results for phenobarbital in spiked PM blood were compared to those determined by GC. An excellent correlation (r = 0.999) between the TDx results and GC results was achieved. PM blood specimens from ten forensic cases were assayed for PB by GC and compared with PB results from the TDx. Comparison of these results also showed good correlation (r = 0.959). These data indicate that the Abbott TDx can be used reliably in the estimation of PB levels in postmortem whole blood samples.

Cytochrome P-450-mediated denitrification of 2-nitropropane in mouse liver microsomes.

Enzymatic denitrification of 2-nitropropane (2NP) was investigated in an NADPH-dependent hepatic microsomal system from male CD1 mice. The involvement of cytochrome P-450 (P-450) as the catalyst in 2NP denitrification was revealed by the induction of nitrite-releasing activity following phenobarbital (PB) pretreatment, by a decrease in activity with carbon tetrachloride pretreatment, by the inhibition of the reaction with classical P-450 inhibitors, and by the observation of a type I binding spectrum. Under optimal conditions, two pH-dependent peaks of activity were observed at pH 7.6 and pH 8.8, each with its own optimal substrate concentration. Inhibition of the reaction by metyrapone and carbon monoxide (CO) (among others) produced differential responses dependent on pH. These results, along with two pH optima and two substrate optima, suggested the involvement of multiple P-450 isozymes. Average specific activities were 8.05 nmoles of nitrite released per minute per milligram microsomal protein at pH 7.6 and 6.44 nmoles of nitrite released per minute per milligram microsomal protein at pH 8.8. Acetone was identified as the second product of the reaction by gas chromatography/mass spectrometry (GC/MS). Stoichiometry studies indicated that the acetone production was slightly less than expected (about 70%) from nitrite release. Up to 25% residual activity was observed under anaerobic conditions. These results suggested that though the predominant reaction mechanism was oxidative, oxygen-independent metabolism of 2NP also occurred to some extent. In contrast to the reported lack of activity in untreated rat, the observed denitrification in uninduced mouse liver microsomes was significant and suggested that major species-specific differences exist in the in vitro metabolism of 2NP.

Cumene hydroperoxide-supported denitrification of 2-nitropropane in uninduced mouse liver microsomes.

Cumene hydroperoxide supported oxidative denitrification of 2-nitropropane was investigated in uninduced mouse liver microsomes. The cytochrome P-450 peroxygenase catalyzed reaction resulted in the production of nitrite and acetone. Several lines of evidence suggested the involvement of multiple forms of cytochrome P-450. Acetone production was at least two times greater than nitrite release possibly due to sequestration of nitrite in the reaction mixtures.

Enzymatic denitrification of 2-nitropropane in uninduced mouse liver microsomes.

Hepatic microsomes from 5 strains of untreated mice were tested for the ability to enzymatically cleave the nitro group from 2-nitropropane (2NP). All strains showed significant NADPH-dependent nitrite release at pH 7.6 and pH 8.8. Statistical differences in nitrite-releasing activity between strains were found between BALB and PL/J and ATH strains at pH 7.6. At pH 8.8, BIO.M differed from CD-1 and BALB. These results are in contrast to a report of little or no denitrification activity in uninduced rats and suggest that the 2NP microsomal metabolism may be of greater importance than previously thought.

Hepatic bromobenzene epoxidation and binding: prevention by ascorbyl palmitate.

Bromobenzene undergoes metabolic activation via 2,3- and 3,4-epoxidation catalyzed by the hepatic cytochrome P-450 mixed-function oxidase system. Its reactive metabolites, especially bromobenzene 3,4-oxide, presumably lead to severe centrolobular necrosis. A study of relative rate of binding of 14C-bromobenzene metabolites to hepatic microsomal protein indicated a significant difference in the rate of binding of the bromobenzene 3,4-oxide compared to its positional isomer, bromobenzene 2,3-oxide. However, the rate of bromobenzene metabolism indicated no significant difference in the formation of products o-bromophenol and p-bromophenol. A search for protective agents revealed that 6,7-dimethyl-5,6,7,8-tetrahydropterine and ascorbyl palmitate were very effective in protecting against macromolecular adduct formation at a concentration of 1 mM-in fact, at least a twofold increase in protection compared to the known protective agents such as glutathione or cysteine. Furthermore, 6,7-dimethyl-5,6,7,8-tetrahydropterine and ascorbyl palmitate inhibited the metabolism of bromobenzene over 90% at a concentration of 2.5 mM.