Certain opioids release histamine from cutaneous mast cells to produce local wheal and flare responses and adverse hemodynamic effects. In vivo responses to opioids suggest that cutaneous responses ...result from the interaction of opioids with opioid receptors on human mast cells. There are no data evaluating or comparing the opioids currently used in anesthesia. Volunteers were injected intradermally with different opioids as well as with naloxone and antihistamines to evaluate their effects on cutaneous mast cell reactivity and cutaneous vascular responses. Fentanyl and morphine produced concentration-dependent wheal and flare responses in the range of 5 X 10(-6) M to 1.5 X 10(-3) M. Volunteers were then tested intradermally with different opioids and histamine at a 5 X 10(-4) M concentration to determine their relative cutaneous effects. Morphine, meperidine, fentanyl, and sufentanil produced both wheal and flare responses that were significantly greater than those due to saline (P less than 0.05). Naloxone, alfentanil, and nalbuphine did not produce significant wheal or flare responses. Butorphenol was followed by a significant wheal but no flare. Naloxone attentuated cutaneous wheal and flare responses to fentanyl and the flare response to morphine. Intradermal antihistamines (diphenhydramine and cimetidine) produced significant wheal and flare responses. Electron micrographs of biopsies from fentanyl-induced wheals demonstrated normal mast cell architecture with no evidence of mast cell degranulation. Opioid effects on wheal and flare responses and mast cell degranulation appear independent of opioid analgesic potency. Opioids produce cutaneous vascular responses dependent on both histamine release from mast cells and direct effects on the vasculature.
Objectives: To identify the remifentanil dosing regimen providing safe and optimal anesthetic conditions during coronary artery bypass graft surgery and to evaluate postoperative recovery ...characteristics. Design: Open-label, randomized, parallel group. Setting: Three centers in the United States. Participants: Seventy-two patients with left ventricular stroke volumes ≥50 mL. Interventions: Patients were randomized to remifentanil doses of 1 μg/kg/min (group 1, n = 23); 2 μg/kg/min (group 2, n = 24), or 3 μg/kg/min (group 3, n = 25). Somatic, sympathetic, and hemodynamic responses indicating inadequate anesthesia were treated with bolus doses of remifentanil, 1 to 2 μg/kg, and infusion rate increases, and, if necessary, isoflurane 0.5% to 1.0% was added as a rescue anesthetic. In the intensive care unit, the remifentanil infusion was reset to 1 μg/kg/min, with midazolam administered for supplemental sedation and morphine for analgesia. Measurements and Main Results: The durations of anesthesia, surgery, and cardiopulmonary bypass were similar for the 3 study groups. In addition, dose of lorazepam premedication, time to loss of consciousness, preoperative left ventricular ejection fraction, age, weight, and sex were similar for the 3 study groups. Remifentanil alone (infusion and boluses) prevented and controlled all responses to stimulation in 44% of group 3, 37% of group 2 and 9% of group 1 patients intraoperatively. Isoflurane (0.5%-1% inspired) rescue was successful in the remaining patients in each group. Hypotension indicating discontinuation of isoflurane and reductions of remifentanil infusion rates occurred in 64% to 75% of all patients. The optimal range of remifentanil infusion was 2 to 4 μg/kg/min with isoflurane to supplement the opioid. Fifty-one patients (71%) met the criteria for extubation within 6 hours postoperatively; because of surgical practice differences, only 30 patients (59%) were actually extubated. Conclusions: After lorazepam premedication, remifentanil infusion (2-4 μg/kg/min) supplemented intermittently with low inspired concentrations of isoflurane provided an effective anesthetic regimen for coronary artery bypass graft surgery. Early extubation times were feasible after remifentanil continuous infusions (1-5 μg/kg/min) used as the primary anesthetic component intraoperatively and for analgesia (≤1 μg/kg/min) in the immediate postoperative setting. Copyright 2003, Elsevier Science (USA). All rights reserved.
A new precision measurement of the branching ratio of the rare pion decay into a positron and a neutrino (pir arrowital enu) has been completed. A beam of positive pions was stopped in an active ...target of plastic scintillator surrounded by a 4pi BGO calorimeter. 3times10sup 5 rare decays and 1.2times10sup 6 normal pion decays (pir arrowmunu) were recorded. The branching ratio was finally calculated from 1.2times10sup 5 rare decays after various cuts in the time window from 7.5 to 200 ns after pion stop. The errors of the result (1.235plus minus0.005)times10sup minus4 are 0.28% statistical and 0.29% systematical.
Amrinone is a nonglycosidic noncatecholamine with both vasodilator and positive inotropic effects that may be administered to patients undergoing cardiac surgery. As an initial step toward ...elucidating the optimal dosage of amrinone for cardiac surgical patients we studied the pharmacokinetics of amrinone during and after cardiac surgery requiring cardiopulmonary bypass. The study population comprised 35 adult patients, each receiving a single dose of amrinone (0.75, 1.5, 2.0, or 2.5 mg/kg) administered into the venous reservoir near the end of cardiopulmonary bypass. Additionally, 15 of the 35 patients also received intravenous infusions of either 5 or 10 micrograms.kg-1.min-1. Arterial blood was sampled over the next 22 h, and plasma concentrations of amrinone were determined by high-performance liquid chromatography. Protein binding of amrinone, assayed by equilibrium dialysis, was 21.6 +/- 2.5%. The decay of amrinone concentrations in plasma over time was fit to a biexponential equation by nonlinear least-squares regression. The manufacturer's recommended dose of 0.75 mg/kg followed by an infusion of 10 micrograms.kg-1.min-1 was inadequate to maintain the plasma concentration within the therapeutic range based on the pharmacodynamics of amrinone in patients with chronic congestive heart failure. This was due to significant redistribution of amrinone in the body after the loading dose. To maintain a therapeutic plasma concentration of 1.5-2.0 micrograms/ml, a larger loading dose or a supplemental loading dose as well as a continuous infusion is required.
Hintergrund:
Eine chronische Nierenerkrankung bedeutet nicht, dass junge Frauen einen vorhandenen Kinderwunsch aufgeben müssen. Schwangerschaften unter Dialysetherapie oder nach einer erfolgreichen ...Nierentransplantation sind immer noch sehr selten aber grundsätzlich möglich. Es handelt sich hierbei um Risikoschwangerschaften, die einer besonderen medizinischen Betreuung bedürfen um die Gesundheit von Mutter und Kind nicht zu gefährden.
Wir berichten über den Verlauf und das Outcome von 3 Patientinnen mit einer chronischen Nierenerkrankung.
Kasuistik 1:
33J I/0 mit bekanntem Mittelmeerfieber, amyloidose-assoziiertem akutem Nierenversagen mit nephrotischem Syndrom in der 21 SSW. Die bisherige Therapie mit Colchicin wurde beendet und eine Therapie mit dem Interleukin1-Rezeptor-Antagonist Anakinra gestartet. Die Patientin befindet sich aktuell in der 24 SSW und erhält 3 × pro Woche Dialysetherapie.
Kasuistik 2:
23J I/0 die sich in der ca. 14 SSW erstmalig mit diffusen Unterbauchschmerzen bei bekannter chronischer Niereninsufffizienz Stadium 5 bei pyelonephritischen Schrumpfnieren bds. in unserer Ambulanz vorstellte. Die Schwangerschaft war bis zu diesem Zeitpunkt nicht bekannt. Die Dialysetherapien wurden aufgrund der Schwangerschaft auf 7 x pro Woche angepasst. Aktuell befindet sich die Patientin in der 19 SSW.
Kasuistik 3:
29-jährige I/0 in der 29 SSW im Z.n. Nierentransplantation 2003 links. Bei einer Proteinurie von 2,6 g im Eiweiss-Kreatinin Quotienten haben wir für die differentialdiagnostische Abklärung des Risikos einer Präeklampsie den sFlt-1/PIGF Quotienten verwendet.
Schlussfolgerung:
Nur wenn eine sorgfältige Überwachung der Schwangerschaft in Zusammenarbeit mit den werdenden Eltern, Nephrologen und Gynäkologen gewährleistet ist und einer Schwangerschaft im Einzelfall keine besonderen medizinischen Probleme entgegenstehen, kann das Risiko als vertretbar gelten.
To determine the "therapeutic window" for sufentanil in cardiac surgery, nine hemodynamically stable, lightly premedicated patients were anesthetized with sufentanil to undergo coronary artery bypass ...grafting. Sufentanil was administered by a computer-controlled infusion pump programmed with an infusion scheme based on average sufentanil pharmacokinetics. The presence of somatic or hemodynamic responses to tracheal intubation, skin incision, sternotomy, and during electrocauterization, to isolate the internal mammary artery were correlated with plasma concentrations of sufentanil. The concentration versus response/no response relationships were analyzed by application of the logistic (Hill) equation. The CP50 of sufentanil to suppress responses to intubation, incision, and sternotomy was 7.1 ng/mL and for mediastinal dissection it was 12.7 ng/mL. Interpatient variability was as much as that reported previously for other opioids in other types of surgical patients. The computer-controlled infusion scheme consistently produced sufentanil plasma concentrations in excess of the target concentrations, but there was a strong correlation between target and actual sufentanil concentrations (r = 0.88, P < 0.05).
Phase II and III studies are tightly controlled trials investigating adverse effects before government approval of a new drug. However, because postapproval Phase IV studies involve a much larger and ...more complex population, the true nature of adverse effects can be seen. We analyzed Phase IV data for the new drug propofol with regard to the incidence of adverse events, and evaluations of such events by anesthesiologists versus postanesthesia care unit (PACU) nurses. Data pertained to 25,981 patients, 1722 institutions, and 1819 anesthesiologists giving propofol in three anesthetic regimens. Inclusion criteria were liberal: age, 18-80 yr; ASA physical status I-III; no continuing pregnancy; and no prior adverse anesthetic experience. Anesthesiologists and PACU nurses used data collection forms to record demographic, perioperative, and outcome variables; to evaluate recovery (excellent, good, or poor); and to describe adverse events. Adverse events were reported for 2813 patients (10.8%); the most common events were pain on injection (5.2%), hypotension (1.1%), nausea/vomiting (1.9%), and excitement (1.3%). The incidences of pain on injection and nausea/vomiting were approximately one-half and one-fifth, respectively, the values reported in earlier studies. Six hundred thirty-three patients (2.4%) had a "poor" recovery according to one or both of the evaluators (the anesthesiologist or PACU nurse). The PACU nurse was more influenced by nausea, vomiting, or postoperative pain; and the anesthesiologist was more influenced by postoperative confusion or delayed emergence from anesthesia. For only 0.6% of patients did both evaluators rate recovery as poor. Anesthesiologists gave more weight to intraoperative adverse events, and nurses to postoperative events.
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