Norman R. James F.F.A.R.A.C.S., a pioneer of high quality anaesthesia in Australia.

Dr Norman R. James was a multi-talented, highly accomplished clinician, teacher and innovator broadly recognized on three continents. In the United Kingdom, he served in London's Emergency Medical Service during World War II and was dubbed "England's foremost exponent of regional anaesthesia". In his native land, he was the first Director of Anaesthetics at The Royal Melbourne Hospital with many innovations to his credit including a serious effort to reform anaesthetic practice in Australia. Dr M. T. "Pepper" Jenkins, the charismatic founder of anesthesiology at the University of Texas Southwestern Medical School, recruited him to Dallas in 1960, where he taught the art and science of anesthesiology at Parkland Memorial Hospital until his retirement in 1974. He died in 1987 and is buried in Winnsboro, Texas. A brief story of his life and career follows.

Ketamine suppresses endotoxin-induced NF-kappaB expression.

PURPOSE: Ketamine reduces endotoxin-induced production of proinflammatory cytokines, including tumour necrosis factor-alpha (TNF), in several types of inflammatory cells, including monocytes and macrophages. Transcription of the genes that encode production of these proinflammatory cytokines is regulated by nuclear factor-kappa B (NF-kappaB). Cytoplasmic B protein is activated by endotoxin (LPS) as well as by TNF, allowing B protein to migrate into the cell nucleus to activate gene transcription for these inflammatory mediators. Because NF-kappaB is likely involved in brain injury and inflammatory neurodegenerative disease, such as multiple sclerosis, we examined whether ketamine inhibits LPS-induced activation of NF-kappaB in human glioma cells in vitro and intact mouse brain cells in vivo. METHODS: Endotoxin-induced NF-kappaB expression in both the human glioma cells in vitro and the intact mouse brain cells in vivo was determined by electrophoretic mobility shift assays (EMSA) of nuclear extracts and measurement of NF-kappaB expression by densitometry. Endotoxin was injected intracerebroventricularly in vivo and intact brain was harvested. Klenow fragment labeling was used to identify NF-kappaB protein for both the in vivo and vitro experiments. RESULTS: Endotoxin treatment increased NF-kappaB expression (P < 0.05) both in vivo and vitro compared with control (untreated) cells. Ketamine suppressed endotoxin-induced neuronal NF-kappaB activation in a dose-dependent manner (P < 0.05, except for the 10(-5) M concentration in vitro) both in vivo and vitro. CONCLUSION: Ketamine inhibits endotoxin-induced NF-kappaB expression in brain cells in vivo and vitro and it is suggested that this may have implications in the neuroprotective effects of ketamine reported by other investigators.

Use of an EEG-bispectral closed-loop delivery system for administering propofol.

Closed-loop control of propofol delivery was instituted in three patients who received a propofol infusion as part of: (Case 1) general "balanced" anesthesia, (Case 2) total intravenous anesthesia, and (Case 3) monitored anesthesia care. The bispectral index was the input variable used in a proportioned, integral and differential controller to determine the infusion rate of propofol required to maintain a stable level of hypnosis (Cases 1 and 2) or sedation (Case 3). This feedback control system provided intraoperative hemodynamic stability and a prompt recovery from the sedative-hypnotic effects of propofol.

Intrathecal fentanyl prolongs sensory bupivacaine spinal block.

The purpose of investigation was to study the effect of intrathecal fentanyl on the onset and duration of hyperbaric bupivacaine-induced spinal block in adult male patients. Forty-three patients undergoing lower extremity or genitourinary surgery were enrolled to receive either 13.5 mg hyperbaric bupivacaine 0.75% + 0.5 ml CSF it, (Group I) or 13.5 mg hyperbaric bupivacaine 0.75% + 25 micrograms fentanyl it, (Group II) according to a randomized assessor-blind protocol. The onset and duration of sensory block were assessed by pinching the skin with forceps in the midclavicular line bilaterally every two minutes for first twenty minutes and then every five to ten minutes. Similarly, the onset and duration of motor block were assessed and graded at the same time intervals using the criteria described by Bromage. The time required for two sensory segment regression and sensory regression to L1 dermatome was 74 +/- 18 and 110 +/- 33 min vs 93 +/- 22 and 141 +/- 37 min in Groups I and II, respectively (P < 0.05). Intrathecal fentanyl did not enhance the onset of sensory or motor block, or prolong the duration of bupivacaine-induced motor spinal block. Fewer patients demanded pain relief in the fentanyl-treated group than in the control group in the early postoperative period (19% vs 59%; P < 0.05). Episodes of hypotension were more frequent in the fentanyl-treated group than in the control group (43% vs 14%; P < 0.05). We conclude that fentanyl, 25 micrograms it, prolonged the duration of bupivacaine-induced sensory block (sensory regression to L1 dermatone) by 28% and reduced the analgesic requirement in the early postoperative period following bupivacaine spinal block.

Randomized comparison of general and regional anesthesia for cesarean delivery in pregnancies complicated by severe preeclampsia.

OBJECTIVE: To evaluate the maternal and fetal effects of three anesthetic methods used randomly in women with severe preeclampsia who required cesarean delivery. METHODS: Eighty women with severe preeclampsia, who were to be delivered by cesarean, were randomized to general (26 women), epidural (27), or combined spinal-epidural (27) anesthesia. The mean preoperative blood pressure (BP) was approximately 170/110 mmHg, and all women had proteinuria. Anesthetic and obstetric management included antihypertensive drug therapy and limited intravenous (IV) fluid and drug therapy. RESULTS: The mean gestational age at delivery was 34.8 weeks. All infants were born in good condition as assessed by Apgar scores and umbilical arterial blood gas determinations. Maternal hypotension resulting from regional anesthesia was managed without excessive IV fluid administration. Similarly, maternal BP was managed without severe hypertensive effects in women undergoing general anesthesia. There were no serious maternal or fetal complications attributable to any of the three anesthetic methods. CONCLUSION: General as well as regional anesthetic methods are equally acceptable for cesarean delivery in pregnancies complicated by severe preeclampsia if steps are taken to ensure a careful approach to either method.

Clinical audit of anaesthesia practice and adverse peri-operative events at Parkland Memorial Hospital, Dallas, Texas.

A study was undertaken to compare the quantity and nature of adverse event data collected during two equivalent time periods in 1990-1991 and 1991-1992 respectively. During the first period adverse event data were collected and reviewed sporadically, critical incidents were not specifically identified and no formal mechanism for regular presentation of these data existed. During the second period a new and detailed data collected from was introduced. The resulting data were analysed and presented to trainee and senior anaesthetists during formal clinical education sessions. Adverse incident reporting was significantly increased during the later period. Unsafe clinical practices and common errors were also more easily identified.

Relationship between diabetic autonomic neuropathy and gastric contents.

Delayed gastric emptying secondary to diabetic autonomic neuropathy (DAN) is a recognized risk factor for aspiration pneumonitis. The purpose of this study is to determine whether bedside autonomic function tests (AFTs) would predict gastric contents. Gastric volume and its pH were measured in 36 patients with diabetes mellitus (DM) and 15 nondiabetic patients at induction of general anesthesia for elective ambulatory surgery. Manifestations of autonomic dysfunction were assessed preoperatively in all 51 patients with five commonly used cardiovascular AFTs. According to the results of these five tests, 16 patients with DM met the criteria for the diagnosis and are called "DAN positive." The remaining 20 diabetics did not meet the criteria and are called "DAN negative." Fifteen patients without DM did not meet the criteria and are called "nondiabetics." Diabetic patients were significantly older and more obese than nondiabetics and those with DM more than 10 yr were more often DAN positive. Solid, undigested food particles were found more often in the gastric contents of DAN-positive patients compared to nondiabetics. Gastric liquid volume and pH were similar in diabetic patients (DAN positive and DAN negative) and nondiabetic controls. These results demonstrate that diagnosis of DAN by commonly used cardiovascular AFTs does not predict larger gastric liquid volume or lower pH, but does predict the presence of solid food particles.

Autonomic reflex dysfunction in patients presenting for elective surgery is associated with hypotension after anesthesia induction.

BACKGROUND: Autonomic reflex dysfunction in patients with diabetes is associated with an increased incidence of hypotension after induction of anesthesia. Whether this finding can be extrapolated to patients with autonomic dysfunction from other causes (e.g., advanced age, hypertension, altered ventricular function) has not been established. METHODS: The authors investigated whether autonomic reflex dysfunction in a more generalized patient group (26 consecutively consenting day-surgery patients older than 39 yr) was similarly associated with the occurrence of hypotension after induction. Preoperative tests of autonomic function included: Valsalva maneuver, change in heart rate with forced breathing, change in heart rate and blood pressure with standing, and spectral analysis of heart rate variability. Anesthesia was induced with 3-5 mg/kg thiopental, 2 micrograms/kg fentanyl, and 60% N2O; 0.1 mg/kg vecuronium was used for paralysis; 0-1.5% isoflurane was added for maintenance of anesthesia after intubation. Noninvasive measurements of mean blood pressure were obtained every minute for 10 min after induction and then every 3 min until skin incision. RESULTS: Twelve patients developed hypotension (mean blood pressure < 70 mmHg), and 14 patients did not. Measurements of autonomic reflex function were significantly more abnormal in the patients who developed hypotension (P < 0.006 for Valsalva measurements, heart rate variability parameters, and change in heart rate with forced breathing). Using critical test values for autonomic tests, the incidence of hypotension was 67-83% in patients with autonomic nervous system dysfunction versus 9-17% in other patients. CONCLUSIONS: The results document that: (1) some degree of autonomic reflex dysfunction is not uncommon in patients older than 39 yr presenting for elective surgery, and (2) such dysfunction is associated with an increased incidence of hypotension when using the described induction technique.

Airway management for patients with penetrating neck trauma: a retrospective study.

Airway management in patients with penetrating neck trauma is controversial. We reviewed the records of 107 patients with penetrating neck trauma from 1989 through 1991 for primary intubation technique, mechanism of injury, zone of injury, and structures injured. Six patients (6%) received a surgical airway as the primary choice, 89 (83%) had direct laryngoscopies after rapid sequence induction of anesthesia, eight (7%) had awake fiberoptic bronchoscopies, and four (4%) had awake blind nasotracheal intubation. The success rates for primary surgical were 100%, fiberoptic 100%, direct laryngoscopy 98%, and blind nasal 75%. Two (2%) of the patients in the direct laryngoscopy group required a secondary emergency surgical airway. One failed blind nasal attempt (25%) resulted in the patient's death due to loss of airway during a secondary attempt at an emergency surgical airway. A second patient died as a result of hemorrhage not related to airway management. Success rates were not statistically different with any of the four airway management techniques chosen primarily. However, the one death in the awake nasal intubation group and the technical and time constraints of fiberoptic intubation cause us to prefer rapid sequence induction of anesthesia with direct laryngoscopy or a primary surgical airway in patients with penetrating neck trauma who need an emergency airway.

Effect of radiant heat on the metabolic cost of postoperative shivering.

Hypothermia and postoperative shivering are uncomfortable and may be dangerous. This study demonstrates that postoperative shivering may be controlled quickly and effectively with radiant heat, thereby reducing oxygen consumption and increasing thermal comfort.

Perioperative measurements of interleukin-6 and alpha-melanocyte-stimulating hormone in cardiac transplant patients.

Interleukin-6 (IL-6) and alpha-melanocyte-stimulating hormone (alpha MSH) are important modulators of the immunologic response to tissue injury and antigenic challenge. Serial changes in the plasma concentrations of these two peptides were measured in 12 patients undergoing heart transplantation. Tissue concentrations of IL-6 in atrial samples from both donor and recipient hearts were also compared. Plasma IL-6 concentration remained stable prior to cardiopulmonary bypass (CPB), initially decreased with the onset of CPB, and then increased significantly over control values at the end of CPB (180 +/- 40 v 53 +/- 60 pg/mL). Plasma IL-6 remained elevated for at least 60 minutes after CPB, and then it returned to control values by 24 hours postoperatively (67 +/- 9 pg/mL). Examination of IL-6 changes after CPB in 10 additional patients undergoing nontransplant cardiac surgery with CPB revealed a similar elevation in IL-6 at 60 minutes after CPB (290 +/- 76 pg/mL). However, IL-6 in the nontransplant group remained significantly elevated at 24 hours (138 +/- 42 pg/mL). These combined results suggest that CPB causes a marked increase in IL-6, and that implantation of a new heart in transplant patients does not augment this increase. The return of IL-6 to control values by 24 hours in the patients who have had transplants suggests that immunosuppression has an appreciable effect on IL-6 at this time. In contrast to IL-6, plasma alpha MSH never increased above control values.(ABSTRACT TRUNCATED AT 250 WORDS)