Minutes Of Induction Research Articles

A Comparative Study of Different Doses of Lignocaine on Prevention of Etomidate Induced Myoclonus during Induction of Anesthesia

Abstract Background and Aims Etomidate, an intravenous (IV) induction agent known for its stable myocardial action, can produce myoclonus which can be detrimental for the cardiac patients. Though lignocaine has proven its efficacy in attenuating the etomidate-induced myoclonus, the ideal dose of lignocaine is not known. The aim of our trial was to analyze two different doses of lignocaine on the occurrence and intensity of etomidate induced myoclonus. Materials and Methods A total of 120 patients were randomly assigned into three groups of 40 each. Patients in group A were injected lignocaine 0.5 mg/kg intravenously, group-B patients were injected lignocaine 1 mg/kg intravenously, and group-C patients were injected saline placebo. After 2 minutes, anesthesia was induced with 0.3 mg/kg of etomidate over 30 seconds. The patients were assessed for myoclonus using clinical severity scoring system during first 2 minutes of induction. Our primary outcome was the incidence of myoclonus. The severity of myoclonus and adverse effects were the secondary outcomes. Results No remarkable variation was found regarding demographic profile among three groups. Incidence of myoclonus in groups A and B was 35% and in group C was 98%, the difference being statistically significant. Both doses of lignocaine reduced the severity of myoclonus up to same extent. Conclusion Pretreatment with IV lignocaine 0.5mg/kg and 1 mg/kg IV remarkably decreased the occurrence and severity of myoclonus induced by etomidate up to same extent.

A PROSPECTIVE RANDOMISED STUDY TO ASSESS WHETHER PROPHYLACTIC ATROPINE ADMINISTRATION ATTENUATES THE NEGATIVE HAEMODYNAMIC EFFECTS OF INDUCTION OF ANAESTHESIA WITH PROPOFOL AND FENTANYL

INTRODUCTION: To provide optimal surgical conditions safely and to avoid particular complications, balanced general anaesthesia by administering a combination of propofol and fentanyl as analgesics. This type of balanced anaesthesia often induces unwanted bradycardia and hypotension, raising concerns regarding haemodynamic stability and tissue oxygenation. It is possible that atropine could replace the common clinical practice of administering vasoactive medication such as phenylephrine or norepinephrine to maintain mean arterial pressure (MAP) levels. AIM OF THE STUDY: To study the effect of atropine in suppressing the negative haemodynamic effects of induction agents- propofol and fentanyl in patients receiving general anaesthesia. MATERIALS AND METHODS: This is a prospective randomised interventional study carried out in Department of Anaesthesiology in Kanyakumari Government Medical College from January 2018 to June 2019. Patients were allocated into two groups (25 patients each) by randomization. After preoxygenation Group A: Patient receives Atropine. Patient in Group S: Receives Saline. BMI, Height, weight, Heart rate, Noninvasive blood pressure, Mean arterial pressure were recorded for every minute for 15 minutes. RESULTS: The demographic parameters like age, height, weight and BMI were similar in both groups. Comparing the SBP of both group, at base and 1 minute the difference of SBP was small. After that, the SBP was increasing trend in Atropine subjects and SBP was decreasing trend in saline subjects (P<0.001). Comparing the DBP between the two groups, Base and 1 minutes, the DBP of both groups were not differed signicantly (P>0.05),after that the DBP of Atropine group DBP was increasing trend and the DBP of saline group was decreasing trend (P<0.001). The HR of the both groups were increasing and decreasing accordingly (P<0.001). Comparing the MAP of both groups at base through 15 minutes,MAP of both group at 1minute was not differed signicantly (P>0.05),after that the MAP of Atropine subjects were increasing and Saline subjects were decreasing trend P<0.001). Percentage of fall of parameters (SBP, DBP, HR, and MAP) was more signicant at 5 and 15 mins compared to 10 mins in both th group. This may be due to the intubation response after the 5 minute of induction. All values were signicant with P<0.001. CONCLUSION: Administration of atropine before Propofol and Fentanyl induction during general anaesthesia can signicantly attenuate the fall in Systolic Blood Pressure, Diastolic Blood Pressure, Heart Rate and Mean Arterial Pressure.

An Evaluation of the Neural Activity Marker c-Fos in the Brain and Gut Following an Acute Dose of the Probios Isolate Enterococcus Faecium

ObjectivesGut microbes, including probiotics, can exert a wide range of effects on the host, such as influencing gastrointestinal function and, in some cases, brain function and behavior. Although long-term exposure to certain probiotics have also been shown to alter brain function via vagal communication routes, it is possible that probiotics may influence the brain more acutely, such as shortly after administration. Indeed, gastrointestinal stimuli can activate vagal-dependent brain reward pathways within minutes of induction. Therefore, this study aimed to examine the short-term effects of acute probiotic exposure on neural activity in the brain and gut. MethodsCF-1 mice were divided into three groups: probiotic (109 CFUs Enterococcus faecium in 200 ul PBS), gavage control (200 ul PBS), control groups (handling only). These groups were further divided into 3 subgroups to evaluate the temporal effects of acute probiotic administration at 3, 5, and 7 hours after a single dose of probiotic. c-Fos immunohistochemistry was used as a marker of neural activity in multiple regions of the brain and gut suggested to be affected by probiotics. ResultsPreliminary findings suggest that c-Fos positive cell density in the dentate gyrus of the hippocampus and ventral tegmental area were unaffected by acute administration of E. faecium. Data collection of c-Fos density is underway in other brain areas (i.e., parabrachial nucleus, bed nucleus of the stria terminalis, caudate putamen, pontine nucleus, and solitary nucleus tract) as well as the intestines (i.e., duodenum, jejunum, ileum, cecum, proximal and distal colon). ConclusionsWhile preliminary evidence indicates that the dentate gyrus and ventral tegmental area were unaffected within the initial hours after a single dose of E. faecium, many brain and gut areas remain to be analyzed. Together, these data may collectively provide insight into the immediate effects of probiotics on gut and brain activity. Funding SourcesThis work was supported by Iowa State University start-up funds.

English

BACKGROUND The present study was done to compare the cardiovascular responses of etomidate and propofol as induction agents of general anaesthesia under Bispectral index (BIS) guidance and evaluate the effect of intravenous induction agent etomidate and propofol on the variation in heart rate and blood pressure during induction of general anaesthesia. METHODS This is a prospective randomized and double blinded comparative study done in Assam Medical College and Hospital on patients scheduled for elective surgeries under general anaesthesia from June 2019 to May 2020. 80 patients were randomly allocated to group E (etomidate group) and group P (propofol group) of 40 each. All patients were pre-medicated with fentanyl 2 microgram / kg intravenously. Group E received etomidate infusion at 0.05 mg / kg / min and group P received propofol infusion at 0.5 mg / kg / min until Bispectral index value dropped to 60. Patients were intubated with vecuronium 0.1 mg / kg and maintenance of anaesthesia was continued according to institutional protocol. At the end of anaesthetic period, extubation was done after acceptable recovery. Haemodynamic parameters were recorded in both the groups until 10 minutes of induction. RESULTS Statistically significant fall in heart rate was seen in group P than that of group E starting from 3 minutes of induction up to 10 minutes with P value < 0.05 and statistically significant fall in systolic, diastolic, and mean arterial pressure (MAP) was seen in propofol group from that of etomidate group starting from 1 minute of induction up to 10 minutes was seen. CONCLUSIONS We conclude that etomidate is haemodynamically more stable than propofol during the time of induction of anaesthesia. KEY WORDS Etomidate, Propofol, Bispectral Index

A Co-Induction Technique Utilizing 4% Sevoflurane Followed by 0.75 mg/kg Propofol in Elderly Patients Undergoing Minimally Invasive Procedures: A Prospective Randomized Control Study.

Background and Objectives: Elderly patients constitute a large segment of healthcare receivers. Considering the functional deterioration of multiple organ systems with aging, achieving a safe perioperative approach is challenging. Our aim is to study the safety and effectiveness of a genuinely regimented co-induction technique in order to minimize anesthesia-related complications. Materials and Methods: One hundred and five patients were assigned to three groups according to the induction technique: propofol, sevoflurane and co-induction group. Inclusion criteria: patients with age ≥65 and American Society of Anesthesiologists physical status classification (ASA) II-III who underwent endoscopic urological procedures. The propofol group received a dose of 1.5 mg kg−1 of propofol over two minutes for induction. The sevoflurane group received 8% of sevoflurane and 100% oxygen through a plastic facemask with the fresh gas flow set at 8 L min−1. The co-induction group received 4% sevoflurane through plastic facemask for two minutes, followed by a 0.75 mg kg−1 dose of propofol. After ensuring full range jaw relaxation, the laryngeal mask airway (LMA) was inserted. Results: Overall, the co-induction technique had a favorable profile in terms of respiratory adverse events, while the sevoflurane group had a favorable profile in terms of hemodynamic stability. Furthermore, 24 (68.6%) patients receiving inhalational sevoflurane had episodes of transient apnea, which constitutes 77.4% of the 31 episodes of transient apnea in the studied sample (p < 0.001). Moreover, six (17.1%) patients in the sevoflurane group had an episode of partial laryngospasm (p = 0.034). Compared with the co-induction group, we found that the propofol group had significantly less systolic and diastolic blood pressures in the second minute, with p values of (0.018) and (0.015), respectively. Conclusions: The co-induction technique utilizing 4% sevoflurane at 8 L min−1 flow of oxygen inhaled over two minutes followed by 0.75 mg kg−1 of propofol achieved less respiratory adverse events compared with the sevoflurane group, and less hemodynamic instability compared with the propofol group.

Anesthesia with mask free sleep inducing balloon in pediatric patients; A tertiary care hospital experience

Introduction: Children are habitually frightened and become combative during the induction of anesthesia. It is challenging for pediatric anesthesiologists to minimize psychological upset by reducing scaring environment of operating room and to facilitate a smooth induction of anesthesia. Use of force to handle severely anxious and scared children may lead to postoperative behavioral problems.&#x0D; Purpose: There is an immense need to develop a simple device to ensure mask free and stress-less induction for children. Sleep Inducing Balloon is the mask-free and stress-less anesthesia delivery system designed for children which is not only fulfilling the criteria of ideal breathing system but also replaces anxiety with amusement and fear with fun!&#x0D; Methods: A study was conducted among 100 children between 6 months to 7 years of age, during the period of Apr 2018 to Dec 2018 to find out the induction time of Sleep Inducing Balloon who were scheduled for elective short surgical procedure under general anaesthesia having ASA grading I and II. While doing so, children receive constant gas mixture of 5L oxygen mixed with 5% sevoflurane till fall asleep.&#x0D; Results: A total 100 patients were included in this study to record induction time, heart rate and oxygen saturation to validate the function of Sleep Inducing Balloon. Mean age of the children was 3.50±1.04 years, mean weight was 10.7±3.24 Kgs and mean heart rate was 120±8.3/min. Most of the children had ASA grade-I (96%) and oxygen saturation was 99%. Induction time was 60-80 seconds in 26% patients, and 81-100 seconds in 45% of the children. In 24% children the induction time was 101-120 seconds, 5% children took more than two minutes for induction. There was no failure and adverse events were easy to manage.&#x0D; Conclusion: Mask free sleep inducing balloon is a safe and successful way of anesthetic induction in pediatric patients. The procedure ensures a stress-free peaceful event in frightened children.&#x0D; J Bangladesh Coll Phys Surg 2021; 39(1): 19-23

Abstract 12938: An Unusual Case of Malignant Hypertension and Stress Cardiomyopathy Originating From the Urinary Bladder

A 39-year-old man with hypertension presented for an elective knee surgery. Within 15 minutes of induction of anesthesia, he developed malignant hypertension and acute hypoxia. Surgery wasaborted and he was subsequently transferred to our facility. High-sensitivity troponin was elevated. Chest X-ray demonstrated bilateral hilar opacities, consistent with pulmonary edema.Transthoracic echocardiography demonstrated mildly depressed left ventricular function with hypokinesis of the septum and inferolateral wall. Cardiac catheterization showed normal filling pressures and no coronary artery disease. Initial work up for secondary hypertension, including Duplex Doppler ultrasonography of renal artery and serum aldosterone level were unrevealing. Because of high index of suspicion, additional workup was pursued for adrenal hypertension. Hewas found to have severely elevated plasma normetanephrine level (36 nmol/L) and 24-hrurinary normetanephrine of 8,990 mcg while plasma metanephrine and epinephrine levels were within normal limits. Computed tomography of abdomen showed no adrenal mass but revealed contrast-enhancing mass in the bladder wall with surrounding lymphadenopathy, suggestive of metastatic paraganglioma. He underwent genetic evaluation which identified a heterozy gouspathogenic variant in the succinate dehydrogenase subunit B (SDHB) gene. He was treated withalpha- and beta-blockade and underwent partial cystectomy with lymph node dissection. Follow-up Gallium-68 DOTATATE scan was positive for uptake in several lymph nodes withsubsequent successful lymph node dissection. He is now asymptomatic. Discussion: This case illustrates the importance of a complete history in the evaluation of hypertension inyoung people. The presence of labile hypertension and acute cardiomyopathy which isprecipitated by stress or noncardiac surgery should prompt an evaluation of pheochromocytoma.The isolated elevation in plasma and urinary normetanephrine with normal plasma/urinarymetanephrine level is consistent with extra-adrenal production of catecholamines, which iscommon in the presence of SDHB mutation.

Lung ultrasonography as a tool to guide perioperative atelectasis treatment bundle in head and neck cancer patients undergoing free flap reconstructive surgeries: a preliminary observational study

IntroductionGeneral anesthesia causes pulmonary atelectasis within few minutes of induction. This can have significant impact on postoperative outcome of cancer patients undergoing prolonged reconstructive surgeries. ObjectiveThe purpose of this study was to evaluate the impact of sonographically detected perioperative atelectasis on the need for postoperative oxygen supplementation, bronchodilator therapy and assisted chest physiotherapy in patients undergoing free flap surgeries for head and neck carcinoma. MethodsTwenty eight head and neck cancer patients underwent bilateral pulmonary ultrasonographic assessments before and after lung surgery. Lung ultrasound scores, serum lactate, and PaO2/FiO2 ratio were measured both at the beginning and at end of the surgery. Patients were scanned in the supine position and the number of single and confluent B lines was noted. These values were correlated with the need for oxygen therapy, requirement of bronchodilators and total weaning time to predict the postoperative outcome. Other factors affecting weaning were also studied. ResultsAmong twenty eight patients, seven had mean lung ultrasound score of ≥10.5 which correlated with prolonged weaning time (144.56±33.5min vs. 66.7±15.7min; p=0.005). The change in lung ultrasound score significantly correlated with change in PaO2/FiO2 ratio (r=−0.56, p=0.03). Elevated total leukocyte count >8200μL and serum lactate >2.1mmoL/L also predicted prolonged postoperative mechanical ventilation. ConclusionThis preliminary study detected significant levels of perioperative atelectasis using point of care lung ultrasonography in head and neck cancer patients undergoing long duration surgical reconstructions. Higher lung ultrasound scores highlighted the need for frequent bronchodilator nebulizations as well as assisted chest physiotherapy and were associated with delayed weaning. We propose more frequent point of care lung ultrasonographic evaluations and use of recruitment maneuvers to reduce the impact of perioperative pulmonary atelectasis.

Orotracheal intubation guided with a vivasight single lumen tube in unanticipated difficult airway

Introduction The management of an unanticipated difficult airway is a challenge for any anesthesiologist. Over the years, devices have been developed to improve intubation in cases of difficulty. Methods We present the case of a patient with an unanticipated difficult airway, who was intubated during the first attempt thanks to the use of a VivaSight tube. The consent for the publication of this case was obtained by the patient. He is a 57-year-old man, who underwent a programmed left upper lobectomy. Predictors of airway assessment performed in preanesthesia classified the patient as low risk. The initial plan included the use of a VivaSight SL tube and a bronchial blocker for left lung collapse under direct vision during surgery. Results The patient underwent general anesthesia. After 2 minutes of induction and verify that the ventilation could be carried out without problem, a direct laryngoscopy was performed. A spheroidal tumor adhered to the epiglottis was visualized (figure 1), turning the patient into a Cormack-Lehane III grade. Because we had prepared a VivaSight single lumen endotracheal tube for intubation, we chose to perform intubation guided by the video of the camera integrated in the VivaSight tube. The intubation sequence can be seen in the images of figure 1. The result was an intubation of less than a minute in duration and without incidents during the first attempt. Discussion VivaSight is a special tracheal tube, which has a built-in direct vision camera. It is used mostly in anesthesia for thoracic surgery. There are 2 models: double lumen and single lumen. The single lumen can usually be used together with bronchial blockers without requiring a fiber optic bronchoscope. The main advantages described with the use of these devices are the visualization of the correct position of the tube and the visualization of the correct position of the bronchial blocker2. Other authors have shown that the use of the VivaSight tube decreases intubation time and number of attempts with respect to video laryngoscopy in emergencies3. In the case that we have described, the camera of the tube allowed us to perform an intubation in a case of unanticipated difficult airway. Therefore, we think that the VivaSight tube should be an option to consider in the cases of patients with anticipated or known difficult airway in thoracic surgery. However, it is necessary to develop prospective studies that provide more evidence.

Brugada syndrome in a patient with amyotrophic lateral sclerosis: a case report

BackgroundAmyotrophic lateral sclerosis is a fatal neuromuscular disorder characterized by progressive death of the upper and lower motor neurons in the central nervous system. Patients with this disease die mostly as a result of respiratory failure; however, owing to prolonged survival through assisted ventilation, cardiovascular causes are increasingly responsible for mortality. We report what is to the best of our knowledge the first case of type 2 Brugada syndrome causing ventricular tachyarrhythmia and cardiac arrest in a patient with upper limb onset amyotrophic lateral sclerosis.Case presentationA 48-year-old Caucasian woman with a significant past medical history of papillary thyroid carcinoma status postresection, pulmonary embolism on anticoagulation, and a recent diagnosis of right upper limb-onset amyotrophic lateral sclerosis presented to the emergency department of our hospital with acute on chronic shortness of breath. On further evaluation, she was found to have hypoxic and hypercapnic respiratory failure and was placed on bilevel positive airway pressure ventilation. Her 12-lead electrocardiogram showed sinus rhythm with J-point elevation, saddle-shaped ST segment elevation, predominantly in V1 and V2 with no significant QTc prolongation. No troponin elevation was noted in her laboratory workup. Because she was unable to protect her airway, a decision was made to intubate her. After 1 minute of induction with etomidate and succinylcholine, she went into pulseless ventricular tachycardia and fibrillation requiring three cycles of cardiopulmonary resuscitation with high-quality chest compressions, three doses of epinephrine, and a loading dose of amiodarone prior to return of spontaneous circulation. She was further evaluated by cardiology services and was diagnosed with type 2 Brugada syndrome, for which she was started on quinidine. Her respiratory failure and the drugs she received for intubation likely caused her ventricular tachycardia to occur in conjunction with an underlying Brugada pattern seen on an electrocardiogram. The results of evaluation of her genetic panel for Brugada syndrome were negative. She was subsequently discharged to home in stable condition after a 10-day hospital stay.ConclusionsAmyotrophic lateral sclerosis is a progressive neuromuscular disorder with significant mortality. Respiratory failure is the leading cause of death, but lately, owing to increased survival associated with early tracheostomy and positive pressure ventilation, there has been an increasing trend in the identification of cardiovascular causes of mortality, especially arrhythmias, that may need periodic electrocardiographic surveillance.

Effects of different doses of remifentanil on hemodynamic response to anesthesia induction in healthy elderly patients

Objective: We compared the effects of three different doses of remifentanil infusion, which were performed for the induction of anesthesia in elder patients, on cardiovascular response.Research design and methods: The present study was designed as a randomized, prospective and double-blind study. A total of 90 ASA I–II patients over the age of 65 years were enrolled. The patients were randomly (by lot) assigned to receive one of the three doses of remifentanil infusion (0.1, 0.2 or 0.3 μg/kg/min) for two minutes. Subsequently, 0.5 mg/kg propofol was administered via IV route and 0.5 mg/kg rocuronium was administered via IV route at the time eyelash reflex disappeared. Intubation was performed after 2 minutes. Patients who had an allergy against opioids, were chronic substance users, were obese, expected to have difficult airway, had hypertension, or were receiving any drug influencing the cardiovascular system were excluded.Main outcome measures: In this study after recording baseline values of heart rate (HR), systolic arterial pressure (SAP), diastolic arterial pressure (DAP) and mean arterial pressure (MAP), these values were recorded at the 1st, 2nd, 3rd, 4th and 5th minutes of induction.Results: A significant increase was observed in heart rate at the 1st and 2nd minutes of induction versus baseline in the Remi 0.1 group and at the 2nd minute of induction versus baseline in the Remi 0.2 group, with no additional significant change in heart rate. A significant decrease was determined in the systolic, diastolic and mean arterial pressures in all groups from the 1st minute of induction of anesthesia to the pre-intubation period compared to baseline (p < .05).Conclusions: It was determined that each dose of remifentanil used was quite high for patients of this age-group.ClinicalTrials.gov trial number: NCT02763098.

Effectiveness of positive end-expiratory pressure, decreased fraction of inspired oxygen and vital capacity recruitment maneuver in the prevention of pulmonary atelectasis in patients undergoing general anesthesia: a systematic review.

General anesthesia causes impairment of gas exchange in the lungs that results in decreased oxygenation of the blood; atelectasis is the principle cause of this impaired gas exchange. Anesthesia delivery varies between providers and there is no standard practice to decrease the incidence of postoperative atelectasis. To assess the effectiveness of three identified interventions, either individually or combined, in the development of postoperative pulmonary atelectasis in patients undergoing general anesthesia. The review considered participants over 18 years for inclusion. The American Society of Anesthesiologists classification of subjects was I, II or III. Participants underwent a variety of surgical procedures during which general anesthesia was administered. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST: The review focused on the following interventions: positive end-expiratory pressure, decreased fraction of inspired oxygen content, and/or a vital capacity recruitment maneuver during general anesthesia in comparison to general anesthesia performed without the use of these interventions. TYPES OF STUDIES: Randomized controlled trials that evaluated the effectiveness of any of the proposed interventions, individually or in combination, in the prevention of postoperative atelectasis during general anesthesia were considered for inclusion. TYPES OF OUTCOMES: This review considered studies that reported the incidence of postoperative atelectasis. Atelectasis was measured by lung density measurements, in Hounsfield units, with computed tomography scans, decreased PaO2 levels (partial pressure of oxygen dissolved in arterial blood), and pulmonary function tests. A three-step search strategy was utilized in this review. Studies published in English, without date limits, were considered for inclusion. Databases searched were: CINAHL, MEDLINE, ISI Web of Science, EMBASE, ProQuest Theses and Dissertations and ClinicalTrials.gov, (specifically the National Heart, Lung, and Blood Institute). Two independent reviewers appraised articles for methodological quality using the JBI Critical Appraisal Checklist for Randomized Control/Pseudo-randomized Trials. All studies included in this review were of high methodological quality. Data was extracted by two independent reviewers from papers using the standardized data extraction tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. Meta-analysis was attempted using STATA 12 software; however, due to the heterogeneity of interventions and outcomes it was not possible to pool data. A narrative summary including tables have been used to report results and findings. This review included ten studies with a total of 427 participants aged from 18-78. Although a decreased inspired oxygen content (less than 60%) was shown to be effective individually at decreasing the incidence of postoperative atelectasis, this intervention in combination with a vital capacity recruitment maneuver (+40cm H20 for 15 seconds, and positive end-expiratory pressure, +10cm H2O) was shown to be statistically significant (relative risk=1.149; 95% confidence interval= 1.018, 1.297; p= 0.024). Anesthesia providers should utilize multiple interventions at their disposal to combat the formation and effects of atelectasis for their patients undergoing general anesthesia. Positive end-expiratory pressure following a vital capacity recruitment maneuver can virtually eliminate atelectasis formation even in the presence of a high inspired oxygen content. The majority of atelectasis occurs within minutes of induction and intubation; therefore, further research is needed for testing interventions during this specific time.

English

Introduction Fifty-two American Society of Anesthesiologists II-III patients undergoing elective coronary artery bypass surgery were included in the study. Materials and methods We examined haemodynamic and cerebral responses to induction and intubation in cardiac surgery using different doses of an opioid. Before induction, T1 values of systolic arterial pressure, mean arterial pressure, diastolic arterial pressure, heart rate, saturation, bispectral index, latencies of auditory evoked potential waves (V. wave, Na wave, Pa wave and Nb wave) and spectral edge frequency values were measured. The patients were divided into four groups, each comprising 13 individuals. During induction, the patients were administered opioids as follows: Group 1: propofol 2.5 mg/kg + rocuronium 0.7 mg/kg Group 2: propofol 2.5 mg/kg + rocuronium 0.7 mg/kg + fentanyl 3 mcg/kg Group 3: propofol 2.5 mg/kg + rocuronium 0.7 mg/kg + fentanyl 6 mcg/kg Group 4: propofol 2.5 mg/kg + rocuronium 0.7 mg/kg + fentanyl 9 mcg/kg Above-mentioned parameters were repeated in the first minute of induction (T2). Intubation was performed in the third minute of induction, then the measurements were repeated (T3). Results Demographics were similar among all four groups. According to the systolic arterial pressure, mean arterial pressure, diastolic arterial pressure and heart rate values, a significant increase was found in group 1 compared to group 4 at T3. There was also a significant difference between group 1 and group 3 in mean arterial pressure and heart rate measures. No significant difference was found between the groups in terms of bispectral index. There was also no significant difference between the groups in terms of spectral edge frequency1-2. Auditory evoked potential wave latencies (V. wave, Na wave, Pa wave, Nb wave) were found to be different between the time intervals. Wave latencies were increased at T2 compared to T1 and decreased at T3 compared to T2 in all the groups. The statistically significant difference was found between fentanyl 0 group and fentanyl 9 mcg/kg group in terms of Nb wave latency values. Conclusion Auditory evoked potential is found to be more reliable than bispectral index and electroencephalogram with regards to the responses to induction and intubation using fentanyl. We also observed that Nb wave latency response is the most significant latency of auditory evoked potential waves. Introduction Recently, various techniques and tools have been introduced in order to be aware of the adverse haemodynamic effects that may arise due to insufficient or overdose of anaesthetic agents and also to avoid economic losses1. Electroencephalogram (EEG), bispectral index (BIS) analysis and auditory evoked potentials (AEPs) are the monitorisation methods developed to determine the intraoperative anaesthetic depth. In this study, haemodynamic and cerebral effects during induction and intubation were evaluated using BIS, AEP and EEG in patients who are undergoing coronary artery bypass surgery. Materials and methods This work conforms to the values laid down in the Declaration of Helsinki (1964). The protocol of this study has been approved by the relevant ethical committee related to our institution in which it was performed. All subjects gave full informed consent to participate in this study. After local ethic committee approval, 52 patients aged > 18 years, American Society of Anesthesiologists (ASA) II-III, undergoing elective coronary artery bypass surgery were included in the study. Exclusion criteria were as follows: ejection fraction (EF) 2 mg/dL, aspartate aminotransferase > 40 U/L, alanine aminotransferase > 40 U/L, hematocrit < 30%), opioid and propofol * Corresponding author Email: drozkanonal@selcuk.edu.tr 1 TurkiyeYuksekIhtisas Education and Research Hospital, Anesthesia Clinic, Ankara, Turkey 2 Medical Faculty, Anesthesia and Reanimation Department, Selcuk University, Konya, Turkey

Identification of the First Functional Toxin-Antitoxin System in Streptomyces

Toxin-antitoxin (TA) systems are widespread among the plasmids and genomes of bacteria and archaea. This work reports the first description of a functional TA system in Streptomyces that is identical in two species routinely used in the laboratory: Streptomyces lividans and S. coelicolor. The described system belongs to the YefM/YoeB family and has a considerable similarity to Escherichia coli YefM/YoeB (about 53% identity and 73% similarity). Lethal effect of the S. lividans putative toxin (YoeBsl) was observed when expressed alone in E. coli SC36 (MG1655 ΔyefM-yoeB). However, no toxicity was obtained when co-expression of the antitoxin and toxin (YefM/YoeBsl) was carried out. The toxic effect was also observed when the yoeBsl was cloned in multicopy in the wild-type S. lividans or in a single copy in a S. lividans mutant, in which this TA system had been deleted. The S. lividans YefM/YoeBsl complex, purified from E. coli, binds with high affinity to its own promoter region but not to other three random selected promoters from Streptomyces. In vivo experiments demonstrated that the expression of yoeBsl in E. coli blocks translation initiation processing mRNA at three bases downstream of the initiation codon after 2 minutes of induction. These results indicate that the mechanism of action is identical to that of YoeB from E. coli.

Evaluation of Outcomes in Patients Given Dexmedetomidine in Functional Endoscopic Sinus Surgery

We aimed to evaluate the effects of dexmedetomidine hydrochloride (DEX) on hemodynamic parameters and on surgeon and patient satisfaction during functional endoscopic sinus surgery (FESS). Forty patients who were to undergo FESS were enrolled in this randomized, prospective, controlled study. In the DEX group, conscious sedation was induced with an infusion of 1 microg/kg of DEX 10 minutes before surgery, followed by an infusion of DEX at 0.2 microg/kg per hour. A control group was given identical amounts of saline solution. During the procedure, hemodynamic data were recorded. The patients evaluated their pain on a visual analog scale (VAS). Intraoperative bleeding was rated on a 6-point scale for evaluation of operative field visibility. We observed that the DEX group had lower bleeding scores (p = 0.019). The heart rates were lower in the DEX group at the time of induction (p = 0.052) and in the 1st (p = 0.009) and 20th minutes (p = 0.039) of induction. The mean blood pressure values were lower in the DEX group in the 5th (p < 0.001), 45th (p = 0.003), and 60th (p = 0.05) minutes of induction. The VAS score was lower in the DEX group in the 30th postoperative minute (p = 0.001); however, the VAS score was lower in the control group after the 12th hour (p < 0.001). Postoperative side effects such as nausea, tachycardia, hypotension, and vomiting were significantly less frequent in the DEX group (p < 0.001). We observed that the intraoperative bleeding, hemodynamic stability, and VAS scores were better and the side effects were less frequent in the DEX group.

Anesthesia Induction With Sevoflurane and Propofol: Evaluation of P-wave Dispersion, QT and Corrected QT Intervals

The present study compared the effects of anesthesia induction with sevoflurane and propofol on hemodynamics, P-wave dispersion (Pwd), QT interval and corrected QT (QTc) interval. A total of 72 adult patients were included in this prospective study. All patients had control electrocardiograms (ECGs) before anesthesia induction. Anesthesia was induced with sevoflurane inhalation or intravenous propofol. Electrocardiography for all patients was performed during the 1(st) and 3(rd) minutes of induction, 3 minutes after administration of muscle relaxant, and at 5 minutes and 10 minutes after intubation. Pwd and QT intervals were measured on all ECGs. QTc intervals were determined using the Bazett formula. There was no significant difference in Pwd and QT and QTc intervals on control ECGs. In the sevoflurane group, except for control ECGs, Pwd and QTc interval on all ECGs were significantly longer than those in the propofol group (p < 0.05). We conclude that propofol should be used for anesthesia induction in patients with a predisposition to preoperative arrhythmias, and in those whose Pwd and QTc durations are prolonged on preoperative ECGs.

Rapid activation of endothelial cells enables Plasmodium falciparum adhesion to platelet-decorated von Willebrand factor strings

AbstractDuring Plasmodium falciparum malaria infections, von Willebrand factor (VWF) levels are elevated, postmortem studies show platelets colocalized with sequestered infected erythrocytes (IEs) at brain microvascular sites, whereas in vitro studies have demonstrated platelet-mediated IE adhesion to tumor necrosis factor-activated brain endothelium via a bridging mechanism. This current study demonstrates how all these observations could be linked through a completely novel mechanism whereby IEs adhere via platelet decorated ultra-large VWF strings on activated endothelium. Using an in vitro laminar flow model, we have demonstrated tethering and firm adhesion of IEs to the endothelium specifically at sites of platelet accumulation. We also show that an IE pro-adhesive state, capable of supporting high levels of binding within minutes of induction, can be removed through the action of the VWF protease ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13). We propose that this new mechanism contributes to sequestration both independently of and in concert with current adhesion mechanisms.

Should patients be manually ventilated during rapid sequence induction of anaesthesia?

Pulmonary aspiration of gastric contents has been recognized as a cause of significant morbidity and mortality during anaesthesia since the classic publication by Mendelson in 1946. The introduction of suxamethonium 5 years later allowed tracheal intubation to be achieved under complete muscle relaxation within 1 minute of induction of anaesthesia. In 1961 Sellick described the use of cricoid pressure to prevent gastric regurgitation.

2-D PAGE analysis of pesticide-induced stress proteins of E. coli

Logarithmically growing batch cultures of Escherichia coli were exposed to sublethal concentrations of pyrethroid and carbamate pesticides of four different technical grades. This induced 17-20 stress proteins, as observed using two-dimensional polyacrylamide gel electrophoresis. An E. coli culture growing exponentially in Luria Bertani medium (cell density approximately 2.3x10(9) cells/ml) was exposed to predetermined sublethal doses of individual pesticides. The cells were harvested after 30 minutes of induction and the stress response was developed in fresh LB medium for three hours under the same growth conditions. Cell pellets were obtained and stored in sonication buffer. Two-dimensional polyacrylamide gel electrophoresis was performed to resolve the proteins. Visualization of the protein spots by rapid silver staining showed 17-20 stress proteins which were absent in the standard protein profile of E. coli. On average 29% of these stress proteins were unique to the pollutant, while the remaining stress proteins overlapped with those of other pesticides. The iso-electric points (PIs) and molecular weights of the proteins were determined by comparing with protein markers with known PIs and molecular weights. Furthermore, upon comparing the pesticide-induced proteins within the same class and between the two different classes (pyrethroid and carbamate), it was apparent that the general nature of the stress remained the same throughout, which indirectly proved that the gene or set of genes responsible for stress expression are also the same, irrespective of the chemical nature of the substituents of the pesticides.

Vital capacity and patient-controlled sevoflurane induction

To the Editor: We read with interest the article by Yogendran et al.1 comparing patient controlled inhalation induction (PCI) with the most commonly used vital capacity induction (VCI). The authors concluded that PCI was comparable to VCI in sevoflurane induction with respect to the speed of induction, side effects during induction and patient satisfaction. We partially disagree with this conclusion because we believe that there was a problem with the VCI in the study. Considering that the volume of gas inhaled in a vital capacity inspiration is 70 mL·kg–1 (5.6 L for an 80-kg patient) and requires a very high peak flow that current vaporizers cannot accommodate, and considering that the authors used a circle breathing system connected to a Datex-Ohmeda® AS/3 unit with a canister volume of 900 mL and a 2-L reservoir (information obtained from authors), and assuming the average patient’s weight is 80 kg, the primed circuit afforded half of the volume needed for a VCI induction. Consequently, patients in the VCI group didn’t breath sevoflurane 6 to 8%, but instead received diluted sevoflurane 3 to 4% during the first minute of induction. This might explain the 1.5-min necessary to achieve loss of eyelash reflex in the VCI group in the present study, in contrast to the induction times (32 to 54 sec) generally reported by other authors,2–4 even without N2O. 5 Five-litre reservoir bags should be used, and fresh gas flow can be reduced to 2 L·min–1 after loss of conciousness to diminish sevoflurane consumption in VCI.