Clinical comparison of 'single agent' anaesthesia with sevoflurane versus target controlled infusion of propofol.

The introduction of total intravenous anaesthesia (TIVA) and the use of volatile induction/maintenance anaesthesia (VIMA) has led to the rediscovery of 'single agent' anaesthesia, eliminating the transition phase from induction to maintenance. We compared quality, patient acceptability and cost of TIVA using target control infusion (TCI) with propofol and VIMA with sevoflurane. Forty patients undergoing spinal surgery of 1-3 h were assigned to one of two groups. Group I received propofol-air-oxygen for induction followed by propofol-air-oxygen for maintenance. Group II received 8% sevoflurane-oxygen for induction and sevoflurane-oxygen-nitrous oxide for maintenance. Propofol had a significantly faster mean (SD) induction time (67 (20) s) than sevoflurane (97 (38) s) but was associated with double the incidence of involuntary movements. Although not significant, twice the number of interventions by the anaesthetist were required to maintain an adequate level of anaesthesia in the sevoflurane group. Emergence times, characteristics, postoperative nausea, vomiting and pain were unaffected by the anaesthetic technique. However, a more predictable emergence time was found following sevoflurane. Cardiovascular stability was good and comparable in both groups. The majority of patients found either technique acceptable and would choose the same anaesthetic again. Induction and maintenance was substantially cheaper with sevoflurane (28.06 Pounds) compared with propofol (41.43 Pounds).

Combined use of Orgaran and Reopro during coronary angioplasty in patients unable to receive heparin.

Orgaran, a heparinoid, has been used successfully in patients with heparin-induced thrombocytopenia. We report three cases in which Orgaran was combined with the glycoprotein IIbIIa receptor antagonist Reopro during coronary angioplasty. Orgaran was given as a single intravenous bolus of 1500 anti-factor Xa units. No ischemic or hemorrhagic complications occurred during or following the procedure.

Lupus anticoagulant: a potential risk factor for complication following percutaneous transluminal coronary angioplasty.

A patient is described with antiphospholipid antibodies who died approximately 24 hr after an uncomplicated balloon angioplasty. Since the literature suggests a relationship between the presence of antiphospholipid antibodies and thromboses, we suggest that these antibodies may be a risk factor for abrupt closure after percutaneous transluminal coronary angioplasty.

Mitral balloon valvuloplasty in pregnancy: advantages of a unique balloon.

The burden of pregnancy in patients with severe mitral stenosis continues to present a therapeutic challenge. We present two such cases successfully treated with balloon valvuloplasty using the Inoue balloon. The unique features of this balloon may render it the technique of choice for selected pregnant patients with severe mitral stenosis.

Elevated left atrial pressure does not cause left-to-right shunting after mitral balloon valvuloplasty.

To assess the hemodynamic factors affecting left-to-right shunting following balloon mitral valvuloplasty we studied 10 patients at 3 points during the procedure: pre-septal dilation, post-septal dilation pre-valvuloplasty, and post-valvuloplasty. Hemodynamic parameters were recorded and an oximetry run was obtained at each stage. Mitral valvuloplasty was successful in 8 and unsuccessful in 2 patients. No patient had a significant oxygen step-up at any stage, including the 2 patients with unsuccessful valvuloplasty. Significant left-to-right shunting through the atrial septal puncture in mitral valvuloplasty is infrequent, even before successful balloon valvuloplasty when left atrial pressure is maximally elevated.

Cancer of prostate metastatic to the skin diagnosed by immunoperoxidase staining.

The authors present a case in which the diagnosis of prostate cancer metastatic to the skin was made by skin biopsy with immunoperoxidase stains for prostatic specific antigen and prostatic acid phosphatase. These are tests that should be performed when the location of the primary malignancy is not otherwise evident.

Effects of hemoperfusion during percutaneous transluminal coronary angioplasty on left ventricular function.

The effect of autologous blood perfusion, delivered through an angiographic power injector, on alleviating left ventricular (LV) hemodynamic deterioration during percutaneous transluminal coronary angioplasty (PTCA) was examined. LV systolic and diastolic pressures, LV peak positive and peak negative first derivative of LV pressure (dP/dt), and ST-segment shift were recorded in 9 patients with and without hemoperfusion. Hemoperfusion resulted in an improved LV hemodynamic profile during balloon occlusion, as reflected in LV systolic pressure (127 +/- 14 vs 120 +/- 15 mm Hg, p = 0.01), LV end-diastolic pressure (17 +/- 14 vs 25 +/- 6 mm Hg, p less than 0.001), peak positive (1,237 +/- 240 vs 1,149 +/- 225 mm Hg/s, p less than 0.05) and peak negative (1,666 +/- 357 vs 1,485 +/- 385 mm Hg/s, p = 0.003) dP/dt. Hemoperfusion provides substantial protection for significant LV dysfunction induced by conventional PTCA in 1-vessel angioplasty and is a feasible option to protect against potential cardiovascular collapse in high-risk PTCA.

Hemodynamic response to balloon occlusion of the left main coronary artery during balloon angioplasty supported by cardiopulmonary bypass: a case report.

Four coronary lesions, including a severe left main stenosis, were successfully dilated in a patient with poor left ventricular function; the procedure was supported by percutaneous cardiopulmonary bypass. During left main occlusion there was a loss of phasic systemic arterial pressure, while pulmonary arterial pressure was maintained. The ischemic myocardial depression occurring during left main occlusion was not prevented by percutaneous cardiopulmonary bypass, indicating inadequate myocardial protection.

Preservation of left ventricular performance with reduced ischemic dysfunction by intravenous nisoldipine.

The effect of intravenous nisoldipine on cardiac performance was examined during pacing-induced ischemia in 14 patients with coronary artery disease. The relative contributions of afterload reduction or prevention of myocardial ischemia were assessed using load-independent global (peak-systolic pressure/end-systolic volume) and regional (peak-systolic pressure/end-systolic radial length) "contractile" indexes. Nisoldipine decreased aortic pressure (predrug, 109 +/- 14 vs postdrug, 88 +/- 13 mm Hg, p less than 0.01) and prevented elevation of left ventricular end-diastolic pressure during rapid atrial pacing (predrug, 7.9 +/- 5.7 vs postdrug, -0.5 +/- 4.9 mm Hg, p less than 0.001). Resting cardiac index (predrug, 3.3 +/- 0.6 vs postdrug, 4.2 +/- 0.7 liters/min/m2, p less than 0.05), and left ventricular ejection fraction (predrug, 68.1 +/- 9.0 vs postdrug, 74.2 +/- 9.4%, p less than 0.05) increased after nisoldipine, which also prevented the deterioration in left ventricular ejection fraction (predrug, -8.1 +/- 7.9 vs postdrug, -1.0 +/- 3.7%, p less than 0.05) and fractional radial shortening (predrug, -8.7 +/- 13.1 vs postdrug, 3.7 +/- 16.4%, p less than 0.01) during rapid atrial pacing. Under these conditions, nisoldipine preserved myocardial function, as determined by global peak-systolic pressure/end-systolic volume (predrug, -0.82 +/- 0.39 vs postdrug, 0.17 +/- 1.54 mm Hg/ml, p less than 0.05) and regional (peak-systolic pressure/end-systolic radial length, predrug, -23.8 +/- 36.1 vs postdrug, 12.7 +/- 36.3 mm Hg/cm, p less than 0.01) "contractile" indexes. Intravenous nisoldipine maintains ventricular performance during rapid atrial pacing via a combination of systemic vasodilation and amelioration of ischemic myocardial dysfunction.

Cutaneous mucormycosis in a heart transplant patient.

We present the first case of cutaneous mucormycosis reported in a patient who had undergone a heart transplant operation. This appeared to be a localized infection without a predisposing local factor such as a surgical adhesive and without evidence of dissemination. Prompt treatment with intravenous amphotericin B resulted in an apparent cure.

A QSAR study of the acute toxicity of some industrial organic chemicals to goldfish. Narcosis, electrophile and proelectrophile mechanisms.

1. A baseline toxicity QSAR model was derived for the 24-h LC50 to the goldfish, Carassius auratus. 2. The QSAR-predicted LC50 values for six epoxide derivatives were 2.8-985 times greater than measured. The excess toxicity of these epoxides and other compounds was ascribed to an electrophile molecular mechanism involving SN2 reaction with sulphydryl and other neucleophile groups present in enzymes and other biological macromolecules. 3. The excess toxicities of allyl alcohol and pentaerythritol triallyl ether were interpreted in terms of proelectrophile mechanisms. For the latter compound, this involves a monooxygenase-mediated free radical proton abstraction to a stable allyl radical. The allyl-free radical can undergo enzymic free radical hydroxylation to afford the corresponding acetal, which on decomposition yields the Michael acceptor electrophile acrolein.

Cryptococcal cellulitis with multiple sites of involvement.

Cryptococcal cellulitis is an uncommon cutaneous manifestation of generalized cryptococcal disease. We describe the only reported incidence with multiple sites of cutaneous involvement. In an immunosuppressed patient an apparent cellulitis, even with multiple sites of involvement, that does not respond to appropriate antibiotics should alert one to the possible diagnosis of cryptococcal cellulitis.

Data regarding blood drawing sites in patients receiving intravenous fluids.

Intravenous fluids were infused into the forearms of 18 volunteers. Baseline hematologic and serum biochemical profiles were obtained from each volunteer prior to starting the IV. After the intravenous fluids had infused for 30 minutes, blood was drawn from the opposite arm, and above and below the IV in the same arm. The intravenous fluids were then stopped, and after waiting two minutes, another blood sample was drawn from the IV needle. The deviation from the baseline value was determined for each analyte by sampling site for each volunteer and the mean deviation was calculated for each analyte from each sample site. Drawing blood from above the infusing IV line resulted in a dilutional effect for most of the analytes. Most analytes were not affected when blood was drawn from the other sites. Serum glucose and phosphorus had mean deviations greater than two standard deviations from the baseline, regardless of where they were drawn. Serum glucose was the only analyte with values higher than the baseline values. We recommend that serum biochemical and hematologic profiles not be drawn above an infusing IV, but should be drawn from the opposite arm or below the IV while it is infusing or out of the IV needle after the intravenous fluids have been stopped for two minutes.