Adequate restoration of intravascular volume remains an important therapeutic maneuver in managing the surgical patient. Definition of the ideal volume replacement strategy still remains one of the burning problems. Firstly, the choice between colloid and crystalloid solutions continues to generate controversy. Secondly, the highly controversial crystalloid/colloid dispute has been enlarged to a colloid/colloid debate because of the increasing number of colloids that are available. And lastly, whether high or low volume replacement strategies are favorable for the surgical patient is an another issue for the anesthesiologists. Volume replacement has been hitherto often based on art, dogma and personal beliefs. It was the aim of this overview to present the different solutions and to facilitate the strategies for above three main issues in the field of intraoperative fluid therapy.
Burns ; Colloids ; Dissent and Disputes ; Fluid Therapy ; Humans ; Isotonic Solutions ; Plasma ; Plasma Substitutes ; Plasma Volume

No abstract available.
Critical Care ; Intensive Care Units

As in type 1 diabetes, the loss of pancreatic β-cells leads to insulin deficiency and the subsequent development of hyperglycemia. Exercise has been proposed as a viable remedy for hyperglycemia. Lithium, which has been used as a treatment for bipolar disorder, has also been shown to improve glucose homeostasis under the conditions of obesity and type 2 diabetes by enhancing the effects of exercise on the skeletal muscles. In this study, we demonstrated that unlike in obesity and type 2 diabetic conditions, under the condition of insulin-deficient type 1 diabetes, lithium administration attenuated pancreatic a-cell mass without altering insulin-secreting β-cell mass, implying a selective impact on glucagon production.Additionally, we also documented that lithium downregulated the hepatic gluconeogenic program by decreasing G6Pase protein levels and upregulating AMPK activity.These findings suggest that lithium’s effect on glucose metabolism in type 1 diabetes is mediated through a different mechanism than those associated with exerciseinduced metabolic changes in the muscle. Therefore, our research presents the novel therapeutic potential of lithium in the treatment of type 1 diabetes, which can be utilized along with insulin and independently of exercise.

BACKGROUND: Intubating conditions would be excellent and hemodynamic variables would be relatively stable during rapid- sequence anesthesia induction if tracheal intubation was performed at a proper time. The purpose of this study was to identify the ideal intubation time after rocuronium with either thiopental or propofol. METHODS: 113 patients, ASA physical status I or II, were randomly divided into four groups. Patients in group TR60 (thiopental-rocuronium) and in group PR60 (propofol-rocuronium) were intubated within 60 s, while groups TR90 and PR90 were intubated within 90 s after the administration of rocuronium. Intubating conditions were graded by an experienced anesthesiologist, and hemodynamic variables were noted just before induction (baseline), immediate after induction, immediate after intubation, and 5 min after intubation. RESULTS: Clinically acceptable intubating conditions (good or excellent) were not statistically different among the four groups. However, 55 and 64% of patients in groups TR90 and PR90, respectively, had excellent intubating conditions compared to only 39 and 38% in groups TR60 and PR60 (P < 0.05). Mean arterial pressure and rate pressure product (RPP) immediately after intubation were relatively stable in groups TR90 and PR90 compared to those in groups TR60 and PR60 (P < 0.05). CONCLUSIONS: The intubation time after rocuronium, rather than the choice of induction agent, is the deciding factor affecting intubating conditions and hemodynamic variables during rapid-sequence anesthesia induction. Ninety seconds after the administration of rocuronium with either thiopental or propofol might be an ideal intubation time.
Anesthesia ; Arterial Pressure ; Hemodynamics* ; Humans ; Intubation* ; Propofol ; Thiopental

BACKGROUND: There is a well recognized interlaboratory variation in the results using the polymerase chain reaction(PCR) to detect the IS6110 sequence. The clinical utility of a commercially developed PCR test(Amplicor) in bronchial washings for detecting pulmonary tuberculosis in smear negative patients was evaluated. The sensitivity and specificity of Amplicor was compared with that of an in-house PCR test used for detecting the IS6110 sequence of Mycobacterium tuberculosis(M.tbc) in the bronchial washing fluid. METHODS: 66 patients whose sputum smear for M.tbc were negative or who could not produce any sputum were recruited from January 1999 to July 1999. They all had a bronchoscopy performed to determine if there were signs of hemoptysis, patients who could not cough up sputum, lung lesion that exclude pulmonary tuberculosis. Pulmonary tuberculosis was diagnosed on the basis of a positive culture or a response to anti-tuberculosis therapy. RESULTS: 19 patients with tuberculosis were identified and samples from 16 patients were later confirmed by culture. Bronchial washing for Amplicor PCR revealed a sensitivity, specificity, positive and negative predictive values of 94.7%, 97.9%, 94.7%, 97.9%, respectively. Using IS6110 based PCR, the sensitivity, specificity, positive and negative predictive values were of 73.7%, 87.2%, 70%, 89.1% respectively. CONCLUSION: Bronchial washing for Amplicor PCR proved to be more useful than IS6110 based PCR in rapidly diagnosing smear negative pulmonary pulmoary tuberculosis in patients where tuberculosis was likely to be differential and rapid diagnosis was essential for optimal treatment.
Bronchoscopy ; Cough ; Diagnosis* ; Hemoptysis ; Humans ; Lung ; Mycobacterium ; Polymerase Chain Reaction* ; Sensitivity and Specificity ; Sputum ; Tuberculosis ; Tuberculosis, Pulmonary*

No abstract available.

BACKGROUND: Laparoscopic surgery may affect the coagulation system in several ways. The purpose of this study was to compare the hemostatic changes between open and laparoscopic colorectal surgery by using thromboelastography. METHODS: Forty patients who were undergoing open (n = 15) or laparoscopic (n = 25) colorectal cancer surgery were included in this prospective study. Blood samples were drawn from a forearm vein by fresh venipunctures for determining the thromboelastography (TEG) parameters at after induction of anesthesia T0, 2 hours after the beginning of surgery T1, and immediately before discharge from the recovery room T2. RESULTS: The PT-INR and aPTT did not show significant differences between laparoscopic and open colorectal surgery. There were no significant differences of the TEG parameters (R, K, MA, alpha angle, CI, LY30 and CL30) between the two groups. CONCLUSIONS: The overall coagulation and fibrinolysis detected by TEG were not different between laparoscopic and open colorectal surgery
Anesthesia ; Colorectal Neoplasms ; Colorectal Surgery ; Fibrinolysis ; Forearm ; Humans ; Laparoscopy ; Phlebotomy ; Prospective Studies ; Recovery Room ; Thrombelastography ; Veins

Severe portopulmonary hypertension (PPHT) is considered a contraindication for liver transplantation (LT) because of the associated high mortality and poor prognosis. We report the case of a 57-year-old cirrhotic woman with severe PPHT (mean pulmonary artery pressure [mPAP] > 65 mmHg), who underwent a successful living donor LT. Intra-operative use of inhaled iloprost, milrinone, dobutamine, and postoperative use of inhaled nitric oxide and oral sildenafil failed to lower the pulmonary artery pressure (PAP). The patient responded only to nitroglycerin and drainage of massive ascites. Meticulous intra-operative volume control, which included minimizing blood loss and subsequent transfusion, was carried out. The use of vasopressors, which may have elevated the PAP, was strictly restricted. Intra-operative PAP did not show an increase, and the hemodynamics was maintained within relatively normal range, compared to the preoperative state. The patient was discharged without any complications or related symptoms.
Ascites ; Dobutamine ; Drainage ; Female ; Hemodynamics ; Humans ; Hypertension* ; Iloprost ; Liver Transplantation* ; Living Donors ; Middle Aged ; Milrinone ; Mortality ; Nitric Oxide ; Nitroglycerin ; Prognosis ; Pulmonary Artery ; Reference Values ; Sildenafil Citrate

BACKGROUND: Recent studies have produced conflicting results on the influence of hemodilution on the coagulation system. Furthermore, only a few clinical studies have been conducted regarding actual blood loss and associated hemodilution. The purpose of this study was to investigate changes in thromboelastograph (TEG) findings after moderate bleeding-induced hemodilution in patients undergoing radical hysterectomy. METHODS: 23 patients scheduled for radical hysterectomy were included. No patient had a preoperative coagulation abnormality or was receiving anticoagulant or antiplatelet medication. TEG findings 15 min after induction of anesthesia and after an estimated blood loss equaling 15% of the estimated blood volume were compared. Only crystalloid solution was administered until the second blood sampling for TEG analysis in order to produce a hemodilution state. RESULTS: After hemodilution R time, K time and coagulation time (r + k) showed significant reductions, and alpha angle and TEG index showed significant increases (P < 0.01), and increased coagulability. MA increased after hemodilution, but this was not statistically significant. A60 and CL60 also increased, showing decreased fibrinolysis (P < 0.05). CONCLUSIONS: Moderate bleeding-induced hemodilution increased coagulability according to TEG compared to pre-hemodilution findings. We recommend that the decision to replace coagulation factors and/or platelets should not be based on empirically derived, arbitrary standards.
Anesthesia ; Blood Coagulation Factors ; Blood Volume ; Fibrinolysis ; Hemodilution* ; Humans ; Hysterectomy*