Biomedical subjects
Publications and source records attributed to M A Nalda.
We describe a case of a patient subjected to what proved to be an epidural puncture with catheter placement resulting in persistent unilateral analgesia. The epidurographic study by contrast medium injection through the catheter showed unilateral distribution of the contrast following the cranio-caudal axis in the anterior epidural space.
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OBJECTIVE: To compare the hemodynamic stability and time to recovery of consciousness after long-duration (> 3 h) neurosurgery with 2 anesthetic protocols: total intravenous anesthesia with propofol as the single hypnotic agent and inhalational anesthesia with isoflurane. PATIENTS AND METHOD: We studied 58 middle-aged patients (range 40-50 years) scheduled for intracranial surgery. The patients, who all scored over 13 on the Glasgow coma scale before surgery, were randomly divided into two groups: 27 in group I received isoflurane and 31 in group II received propofol. Anesthetic induction was with sodium thiopental 4 mg/kg i.v. in group I and with propofol 2.5 mg/kg i.v. in group II. Both groups then received fentanyl 2 micrograms/kg i.v., lidocaine 1.5 mg/kg i.v. and vecuronium 0.2 mg/kg i.v. Before placement of the Mayfield head grip, with clamps, or before start of surgery in those cases in which the head grip was not used, all patients were given a 3 micrograms/kg i.v. dose of fentanyl. Hypnosis was maintained in group I with concentrations of isoflurane that were adequate for keeping minimum alveolar concentration (MAC) between 0.6 and 1. In group II maintenance was by continuous i.v. perfusion of propofol 10 mg/kg/h for 30 min., followed by 8 mg/kg/h for 30 min. and 6 mg/kg/h until the end of surgery. N2O was never used. RESULTS: After induction systolic and mean arterial pressures (SAP and MAP) decreased significantly in both groups in comparison with baseline values (SAP: 113.1 +/- 30.0 vs. 140.9 +/- 27.08 mmHg in group I and 109.6 +/- 22.1 vs. 135.0 +/- 19.7 mmHg in group II; MAP: 76.8 +/- 18.7 vs. 95.6 +/- 17.0 mmHg in group I and 74.9 +/- 13.2 vs. 93.4 +/- 13.7 mmHg in group II). The patients in group II showed less tendency to develop arterial hypertension in response to orotracheal intubation (SAP and MAP at the moment of intubation: 156.4 +/- 33.7 and 104.6 +/- 18.1 mmHg, respectively, in group I as compared to 135.1 +/- 31.2 and 93.5 +/- 22.4 mmHg in group II; p < 0.05 between the 2 groups and p < 0.05 for the baseline and intubation pressures in group I). Time to recovery of effective, spontaneous breathing was shorter in group I (5.9 +/- 4.9 and 8.9 +/- 5.7 min.) than in group II (10.9 +/- 9.6 and 13.0 +/- 7.4 min.) and tubes could be extracted earlier from patients in the isoflurane group (10.4 +/- 6.1 min. vs. 17.6 +/- 12.8 min.; p < 0.01). We found no differences between the 2 groups for time until eye opening, response to verbal orders or time until start of spontaneous movement. CONCLUSIONS: Propofol can be considered an alternative to the traditional thiopental-isoflurane sequence in neurosurgery lasting more than 3 h. In our study the hypertensive response to the stimulus of orotracheal intubation was lower in the propofol group than in the thiopental-isoflurane group.
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To identify the cis-acting elements responsible for cAMP stimulation of human prolactin (hPRL) promoter activity, pituitary GC cells were transfected with 5'-deleted hPRL promoters fused to the chloramphenicol acetyltransferase reporter gene. The proximal regulatory region (coordinates -250 to -42) was sufficient to confer strong cAMP stimulation (+/- 25 fold). Further 5' and 3' deletions performed within this proximal region demonstrated that two types of cis-acting elements are involved in the cAMP regulation: (i) the binding sites of the pituitary-specific factor Pit-1, and (ii) the sequence between coordinates -115 and -85 (named fragment A), which contains a TGACG motif. We show by gel-shift and Southwestern experiments that fragment A binds Pit-1 monomer and also a ubiquitous factor that is neither cAMP-responsive element-binding protein nor activator protein-1. Strong cAMP induction was observed when fragment A was juxtaposed to a Pit-1 binding site. That Pit-1 plays an important role was supported further by the finding that the hPRL proximal region conferred cAMP regulation when linked to the herpes simplex virus thymidine kinase promoter only in pituitary GC cells and not in other heterologous cells, which do not express Pit-1. Furthermore, we observed that concatenated Pit-1 binding sites were able to confer cAMP responsiveness to the thymidine kinase promoter in GC cells.
Several adverse effects of vancomycin have been reported. The aim of this study was to assess the incidence of adverse responses to antibiotic prophylaxis with vancomycin in cardiac surgical patients. Prospectively, 116 consecutive patients (106 adults and 10 children) undergoing cardiac surgical procedures in this institution from January to June 1990 were studied. After the anesthetic induction, vancomycin, 1 g in adults and 10 mg/kg in children, was intravenously administered over 30 minutes. The infusion rate was slowed if any adverse effect was observed. As a control group, 10 similar patients were evaluated during the same period of 30 minutes after anesthetic induction but prior to vancomycin administration and surgical stimulation. Thirty-one patients (26.72%) developed an adverse effect, mainly hypotension (29 patients, 25%), which was considered severe in 15 patients (12.93%). Seven patients (6.03%) developed a maculopapular erythema that was associated with hypotension (Red-Man's syndrome) in 5 patients and with bronchospasm in 1 patient. The incidence of adverse reactions in children (20%) was similar to the overall incidence. Only 1 patient in the control group (10%) developed hypotension during the period studied. The incidence of adverse reactions was not related to age, body weight, vancomycin dose administered per kilogram body weight, type of surgical procedure, or associated disease. Mean duration of the infusion was similar in patients with and without adverse responses (34.60 +/- 12.41 minutes and 37.38 +/- 14.55 minutes, respectively). It is concluded that perioperative prophylaxis with vancomycin in cardiac surgery produces a high and unpredictable risk of significant hypotension.
Two cases are reported of brachial plexus anaesthesia and palsy after catheterization of the subclavian vein. This very rare complication occurred after several unsuccessful attempts to catheterize one or both subclavian veins. This was due to inexperience, with insufficient knowledge of clinical anatomy, infiltration with unnecessarily high doses of local anaesthetic, and accidental puncture of the brachial plexus by an infraclavicular approach. One of the patients also had iatrogenic pneumothorax.
Amrinone has been shown to have a beneficial effect on left ventricular function in low output syndrome (LOS), but its use after open-heart surgery has not been extensively revised. We studied 10 patients with LOS post-cardiopulmonary bypass (CPB), who failed to respond to conventional treatment (vasoactive drugs plus intraaortic balloon pump) and were treated with amrinone, 0.75 mg.kg-1 followed by a continuous infusion of 5 to 10 micrograms.kg-1-min-1. One patient failed to respond to the treatment and subsequently died, but in the other nine patients blood pressure and cardiac index increased, left filling pressure decreased and they were successfully weaned from the CBP and survived. These results suggest that amrinone, either alone or combined with other inotropic drugs and mechanical support, is a valuable drug in the management of LOS after CPB.
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Venous carbon dioxide embolism is a rare but potentially lethal complication of laparoscopy. The risk is increased when it is associated with hysteroscopy. A case is presented of a young women undergoing laparoscopy and hysteroscopy for infertility. Cardiovascular collapse and cardiac arrest, associated with a mill-wheel murmur, occurred during hysteroscopy at the time of a change of position. The patient had irreversible brain damage and died a week later. Early diagnosis and prevention of this serious complication are discussed.
The pharmacokinetics of picobenzide was studied in 14 adult patients undergoing neuroleptoanalgesic sessions. The dose of picobenzide administered was 10 mg/kg by i.v. injection. The pharmacokinetic parameters obtained revealed a good distribution capacity with an average value of the apparent distribution volume at steady state of 28.29 +/- 4.98 1. The drug was also seen to be eliminated rapidly from the organism with an average value of the serum half-life of 2.05 +/- 0.42 h. The determination of the initial distribution kinetics of picobenzide shows that the use of a conventional kinetic model induces an overestimation of the initial distribution volume in turn caused by an underestimation of the initial serum concentration.
Two homogeneous groups of 20 healthy women submitted to elective gynaecological surgery, who presented after anaesthesia with peripheral vasoconstriction and shivering, were included in a randomized, double-blind study. The first group received 10 mg ketanserin, a new pure antagonist of serotoninergic S2 receptors. The second group received 10 ml saline as placebo. Blood pressure, heart rate, pulse wave amplitude, and rectal and cutaneous temperatures were measured before and 5, 15 and 30 min after treatment. Vasoconstriction, shivering and discomfort were classified as intense, moderate or absent at these times. Venous and arterial blood gases were determined before and 15 min after treatment. Blood pressure and heart rate decreased slightly after ketanserin administration and this decrease was statistically significant. Increases in rectal temperature were similar in both groups. Peripheral temperature, measured in the big toe, significantly decreased in the placebo group but did not change after ketanserin. Vasoconstriction, shivering, discomfort and pulse wave amplitude improved significantly following ketanserin. We conclude that ketanserin may be effective in treating this post-operative complication, the possible mechanism being the vasodilatation it causes; a central serotoninergic blockade could also be implied.
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A case is presented of a pregnant heroin addict patient, with a septic sacro-iliitis due to Staphylococcus aureus. The incidence of joint infections in heroin addicts and the difficulty of diagnosis is discussed with the potential risks of spinal or extradural anaesthesia when there is infection in joints close to the needle site. Caution is advised with patients addicted to heroin who have low back pain and may have infectious sacro-iliitis.
Serum tyrosine levels were determined in two groups of women. First group included 30 healthy volunteers and the second group was formed by 83 patients submitted to gynecological surgery under anesthesia with fentanyl (0.05 mg/kg). The results showed that preoperative tyrosine levels were higher than control values and decreased under fentanyl anesthesia. Surgical stimulation did not modify tyrosine levels. When surgery was ended serum tyrosine levels reached control values. Under fentanyl-anesthesia a direct relationship between serum tyrosine levels, cardiovascular parameters and catecholamine changes as reported by other authors is suggested. We think tyrosine serum determination could be an indirect, easy and unexpensive measure of hormonal stress response.