Severe cardiovascular depression with remifentanil.

UNLABELLED: We compared the hemodynamic effects of a bolus administration of 1 microg/kg remifentanil for 1, 3, and 5 min (1, 0.33, and 0.2 microg. kg(-1). min(-1), respectively) in patients scheduled for coronary artery bypass grafting anesthetized with small-dose propofol. The study was terminated after only eight patients had been enrolled (three received remifentanil at a rate of 1.0 microg. kg(-1). min(-1), two at 0.33 microg. kg(-1). min(-1), and three at 0.2 microg. kg(-1). min(-1)) because of severe hemodynamic instability, which was particularly marked in four patients and consisted of severe bradycardia in one patient and severe hypotension with a reduction in systemic vascular resistance in three others. One patient showed evidence of myocardial ischemia. All patients responded to therapeutic interventions. The results show that remifentanil should be given only by slow infusion to such patients. IMPLICATIONS: This study investigates the effect on the heart and blood vessels of various rates of administration of boluses of a relatively new potent opiate, remifentanil, to patients with coronary artery disease. The results show that remifentanil should be given only by slow infusion to such patients.

An unusual iatrogenic cause of right coronary air embolism.

A 62-year-old woman undergoing redo mitral valve replacement was noted to have persistent intracardiac air following standard deairing procedures. Transesophageal echocardiography (TEE) identified air bubbles entering the left atrium from the right superior pulmonary vein. Exploration of the pleural cavity revealed a fistula between the pulmonary parenchyma and the right superior pulmonary vein caused by the atriotomy closure suture transfixing the edge of the lung, which was repaired with immediate disappearance of the air emboli. This demonstrates that transesophageal echocardiography is an invaluable aid to ensuring complete deairing after open heart procedures.

Haemodynamic effects of rapacuronium in adults with coronary artery or valvular disease.

We have assessed the haemodynamic effects of rapacuronium (Org 9487) in adults undergoing cardiac surgery and compared these with vecuronium and placebo. We studied 56 adult patients undergoing coronary artery bypass grafting or valve replacement surgery using a fentanyl-based anaesthetic technique. A pulmonary artery flotation catheter was inserted before induction of anaesthesia. After induction, tracheal intubation and stabilization of haemodynamic measurements, subjects were allocated randomly to receive rapacuronium 1.5 mg kg-1 vecuronium 0.1 mg kg-1 or saline placebo. Haemodynamic measurements were made before drug administration and 1, 3, 5 and 10, and if possible, 15 min after administration. Rapacuronium was associated with statistically significant increases in heart rate (17%) and cardiac index (15%) and decreases in mean arterial pressure (11%) and systemic vascular resistance (18%), whereas vecuronium and placebo were associated with significant decreases in heart rate only (14-15%) (P < 0.05). No cutaneous signs of histamine release were observed. Clinically, the results were within acceptable limits. Our results suggest that administration of rapacuronium may be associated with significant changes in heart rate and arterial pressure in patients undergoing coronary artery bypass grafting.

Propofol and alfentanil total intravenous anaesthesia: a comparison of techniques for major thoracic surgery.

BACKGROUND: Previous work has highlighted the disadvantages of propofol as a sole agent for total intravenous anaesthesia (TIVA). This randomised study investigated three combinations of propofol and alfentanil as TIVA for major thoracic surgery. METHODS: In 73 patients undergoing elective thoracic surgery, anaesthesia was conducted either with sodium thiopentone induction and inhalational maintenance (incorporating isoflurane) or with TIVA using propofol with alfentanil (by infusion at one of two rates or in incremental doses). Vital signs and recovery characteristics were recorded. RESULTS: There were no significant differences in heart rate or blood pressure between groups during either induction or maintenance. Depth of anaesthesia was controlled satisfactorily in all groups. Recovery characteristics were similar between treatment groups, although there was a trend towards earlier orientation in the group which received the highest infusion rate of alfentanil. CONCLUSION: Continuous infusions of propofol and alfentanil provide safe and reliable TIVA for major thoracic surgery. TIVA was found to be a satisfactory technique in more elderly patients than previously described. The higher of the two alfentanil infusion rates may result in a better combination of propofol and alfentanil with respect to recovery times than the lower.

Total intravenous anaesthesia with propofol or inhalational anaesthesia with isoflurane for major abdominal surgery. Recovery characteristics and postoperative oxygenation--an international multicentre study.

Two hundred and ten adult patients undergoing open cholecystectomy, vagotomy or gastrectomy were included in a randomised multicentre study to compare postoperative nausea and vomiting, oxygen saturations for the first three postoperative nights, time to return of gastrointestinal function, mobilisation, and discharge from the hospital following induction and maintenance of anaesthesia with propofol and alfentanil or with thiopentone, nitrous oxide, isoflurane and alfentanil. Recovery from anaesthesia was significantly faster in the propofol group (mean (SD) times to eye opening and giving correct date of birth of 14.0 (SD 13.8) and 25.5 (SD 29.5) minutes, and 18.5 (SD 14.8) and 35.5 (SD 37.2) minutes in the propofol and isoflurane groups respectively). There was significantly less nausea in the propofol group (15.4%) than in the isoflurane group (33.7%) in the first two postoperative hours (p < 0.003) but not thereafter. There were no significant differences between the groups in any other recovery characteristics. The incidence of hypoxaemia (arterial oxygen saturation less than 93%) was close to 70% in both groups for the first three postoperative nights, indicating the need for oxygen therapy after major abdominal surgery.

Leader-follower exchange quality: the role of personal and interpersonal attributes.

A field study of 84 registered nurses and their supervisors revealed that leaders' perceptions of leader-follower attitudinal similarity and follower extraversion were positively related to the quality of leader-follower exchanges. Neither followers' locus of control nor growth need strength was found to be significantly correlated with the quality of the exchange between leaders and followers.

Propofol-fentanyl anesthesia: a comparison with isoflurane-fentanyl anesthesia in coronary artery bypass grafting and valve replacement surgery.

The hemodynamic effects of propofol-fentanyl and isoflurane-fentanyl anesthesia during the prebypass period were compared in 42 patients undergoing coronary artery bypass grafting (CABG) and 22 patients undergoing valve replacement (VR) for stenotic lesions. Anesthesia was induced with fentanyl, 25 micrograms/kg, and pancuronium, 0.1 mg/kg, and was maintained with a propofol infusion commenced at 4 mg/kg/h (range 1 to 10 mg/kg/h) or with isoflurane commenced at 1% (range 0 to 2%). Additional fentanyl, 7.5 micrograms/kg, was given before sternotomy. Hemodynamic measurements were made before induction of anesthesia and at various times in the prebypass period. In the VR group, there were no significant differences between the two anesthetics in any hemodynamic variables during the study. Significant decreases (P < 0.05) in mean arterial pressure (MAP 14%), left ventricular stroke work index (LVSWI 29%), and stroke volume index (SVI 24%) occurred after 15 minutes of propofol anesthesia in the CABG group. With isoflurane MAP was well maintained with reductions in LVSWI and SVI of 22% and 20%, respectively. Isoflurane was, however, associated with a significant increase in heart rate (HR) in the CABG group (P < 0.05), whereas no significant change in HR occurred in CABG or VR patients receiving propofol. With both techniques there were no significant changes in right-sided or left-sided filling pressures or in systemic vascular resistance index in the CABG or VR groups, except for a decrease in pulmonary artery occlusion pressure in the propofol VR group and isoflurane CABG group at the time of aortic cannulation. Propofol produced similar hemodynamic changes in the CABG and VR groups. Both anesthetic techniques caused myocardial depression and effectively controlled the autonomic responses to sternotomy in both groups. The study suggests that propofol-fentanyl anesthesia is an acceptable technique for CABG surgery and for VR in patients with stenotic valvular heart disease.

Comparison of the effects of isoflurane and propofol on hepatic glutathione-S-transferase concentrations during and after prolonged anaesthesia.

We have studied the effects of isoflurane or propofol anaesthesia on hepatic glutathione-S-transferase (GST) concentrations in 20 patients during and after prolonged plastic and reconstructive surgery (approximately 10 h). Mean plasma concentrations of GST did not exceed the normal range in any sample from any patient. Although GST concentrations in the propofol group were smaller than those in the isoflurane group, these differences were not statistically significant. These data show that prolonged propofol or isoflurane anaesthesia has no statistically significant effect on plasma concentrations of GST during and after extended surgery.

Propofol-fentanyl anaesthesia in cardiac surgery: a comparison in patients with good and impaired ventricular function.

The haemodynamic effects of propofol-fentanyl anaesthesia for elective cardiac surgery were compared in 24 patients with good left ventricular function (ejection fraction > 45%, left ventricular end-diastolic pressure < 16 mmHg) and nine patients with impaired function. Anaesthesia was induced with fentanyl 25 micrograms.kg-1 and pancuronium 0.1 mg.kg-1 and was maintained with a variable rate propofol infusion, mean rate 2.61 mg.kg-1 x h-1 in the good ventricular function group and 2.71 mg.kg-1 x h-1 in the impaired function group. Additional fentanyl 7.5 micrograms.kg-1 was given before sternotomy. Ventilation to normocarbia was with air and oxygen (FIO2 0.6). Haemodynamic measurements were made before induction, after tracheal intubation, before and after sternotomy and before aortic cannulation. There were no significant differences between the groups in any haemodynamic variables during the study. Twenty minutes after intubation both groups showed a decrease from pre-induction values in mean arterial pressure (p < 0.05) and left ventricular stroke work index (p < 0.05), the reduction in left ventricular stroke work index remaining significant during the prebypass period in both groups. There were no significant changes in right or left sided filling pressures, systemic vascular resistance or heart rate. The technique decreased cardiac work and effectively controlled the autonomic responses to sternotomy in both groups. This study suggests that propofol may be a suitable adjunct to opioid anaesthesia in patients with impaired ventricular function having cardiac surgery.

Birth order and selected work-related personality variables.

PIP: A possible link between birth order and various individual characteristics (e. g., intelligence, potential eminence, need for achievement, sociability) has been suggested by personality theorists such as Adler for over a century. The present study examines whether birth order is associated with selected personality variables that may be related to various work outcomes. 3 of 7 hypotheses were supported and the effect sizes for these were small. Firstborns scored significantly higher than later borns on measures of dominance, good impression, and achievement via conformity. No differences between firstborns and later borns were found in managerial potential, work orientation, achievement via independence, and sociability. The study's sample consisted of 835 public, government, and industrial accountants responding to a national US survey of accounting professionals. The nature of the sample may have been partially responsible for the results obtained. Its homogeneity may have caused any birth order effects to wash out. It can be argued that successful membership in the accountancy profession requires internalization of a set of prescribed rules and standards. It may be that accountants as a group are locked in to a behavioral framework. Any differentiation would result from spurious interpersonal differences, not from predictable birth-order related characteristics. A final interpretation is that birth order effects are nonexistent or statistical artifacts. Given the present data and particularistic sample, however, the authors have insufficient information from which to draw such a conclusion.^ieng

Bromomonamycins, unnatural analogues of the monamycin cyclodepsipeptide antibiotics: production, isolation, and biological activity.

Growth of Streptomyces jamaicensis in a low-chloride medium supplemented with NaBr resulted in the biosynthesis of brominated analogues of the natural chlorinated monamycins. Purification of these new compounds was undertaken by Craig countercurrent distribution studies. Diffusion and dilution assays indicated that antibiotic activity of a monamycin was inversely proportional to its unsolvated molecular weight. The bromo analogues were the least active of the series.

Biosynthesis of vasopressin in vitro and ultrastructure of a bronchogenic carcinoma. Patient with the syndrome of inappropriate secretion of antidiuretic hormone.

Tumors from patients with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) have been found to contain large amounts of the antidiuretic hormone vasopressin. A lung tumor from a patient with hyponatremia most likely due to SIADH was removed at surgery and found to contain 23.5 mU vasopressin/g wet weight by radioimmunoassay Slices of this tumor were incubated with phenylalanine-(3)H. Arginine vasopressin-(3)H was purified from the incubate by Sephadex G-25 column chromatography in two different systems, performic acid oxidation, and gradient elution column chromatography with diethylaminoethyl Sephadex. As oxidation of vasopressin results in drastic conformational change with breaking of the ring of the cyclic polypeptide and addition of two cysteic acid residues per molecule, the radioactive material which eluted coincident with vasopressin both before and after this procedure was considered to be arginine vasopressin-(3)H. To our knowledge this is the first demonstration of in vitro biosynthesis of vasopressin by a tumor from a patient with SIADH.Ultrastructurally, the bronchogenic carcinoma was composed of small undifferentiated and granulated cells. The granulated neoplastic cells had well developed organelles (endoplasmic reticulum, free ribosomes) concerned with protein synthesis. Secretion granules present in the tumor cells were small, surrounded by a limiting membrane, and resembled those reported in polypeptide hormone-secreting cells.