[ABC ahead of rewarming in the treatment of accidental hypothermia]. / ABC kommer før genopvarmning ved behandling af svær hypotermi.

The treatment of accidental hypothermia is still controversial and is missing detailed evidence-based guidelines. Current knowledge suggests that advanced trauma life support principles must be prioritized ahead of rewarming. In case of cardiac arrest, initiation of extracorporeal circulation before rewarming and prolongation of hypothermia at 33 °C to reduce reperfusion injury and cerebral hyperthermia is recommended but is not as yet implemented as standard treatment. We propose a simplified clinical approach to on-site triage of hypothermia: 1. Awake below 35 °C (Glasgow Coma Scale > 8). 2. Unconscious below 32 °C. 3. Absent respiration and circulation below 32 °C.

Intraoperative cardiac arrest: was it the ACE inhibitor?

Continuing renin-angiotensin-aldosterone system antagonist therapy on the day of surgery is controversial, and appears to contribute to intraoperative hypotension. A patient presenting for cerebral aneurysm clipping continued her angiotensin-converting enzyme inhibitor on the morning of surgery, and subsequently experienced significant postinduction hypotension that culminated in cardiac arrest. Following successful resuscitation, she returned 6 weeks later to have her aneurysm clipped using identical anesthetic management; her blood pressure medications were held on the day of surgery.

Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study.

BACKGROUND AND OBJECTIVES: Femoral nerve block (FNB), a commonly used postoperative pain treatment after total knee arthroplasty (TKA), reduces quadriceps muscle strength essential for mobilization. In contrast, adductor canal block (ACB) is predominately a sensory nerve block. We hypothesized that ACB preserves quadriceps muscle strength as compared with FNB (primary end point) in patients after TKA. Secondary end points were effects on morphine consumption, pain, adductor muscle strength, morphine-related complications, and mobilization ability. METHODS: We performed a double-blind, randomized, controlled study of patients scheduled for TKA with spinal anesthesia. The patients were randomized to receive either a continuous ACB or an FNB via a catheter (30-mL 0.5% ropivacaine given initially, followed by a continuous infusion of 0.2% ropivacaine, 8 mL/h for 24 hours). Muscle strength was assessed with a handheld dynamometer, and we used the percentile change from baseline for comparisons. The trial was registered at clinicaltrials.gov (Identifier: NCT01470391). RESULTS: We enrolled 54 patients, of which 48 were analyzed. Quadriceps strength as a percentage of baseline was significantly higher in the ACB group compared with the FNB group: (median [range]) 52% [31-71] versus 18% [4-48], (95% confidence interval, 8-41; P = 0.004). There was no difference between the groups regarding morphine consumption (P = 0.94), pain at rest (P = 0.21), pain during flexion of the knee (P = 0.16), or adductor muscle strength (P = 0.39); neither was there a difference in morphine-related adverse effects or mobilization ability (P > 0.05). CONCLUSIONS: Adductor canal block preserved quadriceps muscle strength better than FNB, without a significant difference in postoperative pain.

Fasting serum concentration of short-chain fatty acids in subjects with microscopic colitis and celiac disease: no difference compared with controls, but between genders.

BACKGROUND: Short-chain fatty acids (SCFAs), particularly propionic and butyric acids, have been shown to have many positive health effects. The amount and type of SCFAs formed from dietary fibre by the colonic microbiota depends on the substrate available and is reflected in blood. The total intake and type of dietary fibre in people with gastrointestinal diseases differs considerably from healthy subjects. OBJECTIVE: To compare fasting SCFA concentrations in subjects with microscopic colitis (MC), celiac disease and controls without these diseases. SCFAs were also analysed over 6.5 h in young healthy subjects, who had eaten a fibre-rich breakfast, to identify a possible peak concentration of SCFAs after a meal. METHODS: SCFAs in serum were pre-concentrated using hollow fibre-supported liquid membrane extraction and gas chromatography. RESULTS: The MC group had a higher concentration of valeric acid than the control group (p < 0.01). No significant differences in other SCFA concentrations were seen between groups, but the control group tended to have higher concentration of acetic acid (p = 0.1). Furthermore, males had higher concentrations of SCFAs (with the exception of valeric acid) than females (p < 0.05), which were independent of groups. The peaks for acetic, propionic and butyric acids came approximately 5 h, 6.5 h and 2-3 h, respectively, after breakfast. CONCLUSION: The fasting concentrations of SCFAs were quite similar, although the fibre intake had probably been quite different for a long time. The results might have been different if SCFAs had been recorded over a longer period.

Occurrence of severe hypotension after indocyanine green injection during the intraoperative period.

Indocyanine green (ICG) is generally considered to be safe for IV administration and has a very low incidence of complications. We report 2 cases of severe hypotension immediately after low dose administration of IV ICG. The first case is a 69-year-old woman who developed severe hypotension after a second 5 mg IV bolus of ICG given shortly after the placement of an aneurysm clip during an otherwise uneventful surgery performed under general anesthesia. The second case is a 56-year-old woman with moyamoya disease who became hypotensive subsequent to a 2.5 mg ICG bolus at the conclusion of an external-carotid to internal-carotid bypass procedure under general anesthesia. Anesthesiologists and surgeons are increasingly likely to encounter or request the intraoperative administration of ICG, and they need to be aware of this potential for an adverse reaction, particularly with the repeated doses. Anesthesia and other intraoperative conditions may mask the typically mild adverse reactions usually associated with ICG.

[Fatal Clostridium sordellii infection originated in an ovarian cyst]. / Fatal Clostridium sordellii-infektion udgået fra ovariecyste.

Clostridium sordellii is a Gram-positive bacterium which can cause a serious toxic shock syndrome with a mortality of up to 69%. C. sordellii is a part of the normal vaginal flora in up to 10% of all women. This case describes a fatal case of a healthy 49 year-old woman with a C. sordellii-infection originating from an ovarian cyst. Quick diagnosis is difficult because of the non-specific flu-like symptoms. Survival requires immediate source control and specific antibiotic therapy capable of suppressing toxin production. In rodents superantigen antibodies have shown neutralizing effects.

Catalytic implications from the Drosophila protein L-isoaspartyl methyltransferase structure and site-directed mutagenesis.

Protein L-isoaspartyl methyltransferases (PIMT; EC 2.1.1.77) catalyze the S-adenosylmethionine-dependent methylation of L-isoaspartyl residues that arise spontaneously in proteins with age, thereby initiating a repair process that restores the normal backbone configuration to the damaged polypeptide. In Drosophila melanogaster, overexpression of PIMT in transgenic flies extends the normal life span, suggesting that protein damage can be a limiting factor in longevity. To understand structural features of the Drosophila PIMT (dPIMT) important for catalysis, the crystal structure of dPIMT was determined at a resolution of 2.2 A, and site-directed mutagenesis was used to identify the role of Ser-60 in catalysis. The core structure of dPIMT is similar to the modified nucleotide-binding fold observed in PIMTs from extreme thermophiles and humans. A striking difference of the dPIMT structure is the rotation of the C-terminal residues by 90 degrees relative to the homologous structures. Effectively, this displacement generates a more open conformation that allows greater solvent access to S-adenosylhomocysteine, which is almost completely buried in other PIMT structures. The enzyme may alternate between the open conformation found for dPIMT and the more closed conformations described for other PIMTs during its catalytic cycle, thereby allowing the exchange of substrates and products. Catalysis by dPIMT requires the side chain of the conserved, active site residue Ser-60, since substitution of this residue with Thr, Gln, or Ala reduces or abolishes the methylation of both protein and isoaspartyl peptide substrates.