For perioperative volume therapy in infants and young children, human albumin has frequently been the colloid of choice. Recently, HES 130/0.4 (6% hydroxyethyl starch, Voluven®; Fresenius Kabi, Bad Homburg, Germany) was developed, which demonstrated improved pharmacokinetics and a favourable safety profile in adults compared with hydroxyethyl starch products with a less rapid metabolization.

Our prospective, controlled, randomized, open, multicentre pilot study was designed to obtain data on the effects of HES 130/0.4 compared with human albumin 5% with regard to haemodynamics in children <2 yr scheduled for elective non-cardiac surgery.

A total of 81 patients were treated. Comparable amounts of both study solutions (16.0 mL kg−1 hydroxyethyl starch 130/0.4 vs. 16.9 mL kg−1 human albumin 5%) as well as add-on crystalloids were used until 4–6 h postoperatively. No differences were detected between the two treatment groups regarding perioperative stabilization of haemodynamics, coagulation parameters, blood gas analyses or other laboratory values. Blood loss was 96 ± 143 mL for hydroxyethyl starch and 145 ± 290 mL for human albumin (P > 0.05). There were no relevant differences in the amount of red blood cells, fresh frozen plasma or platelet concentrates in both treatment groups. Median length of ICU stay was 3.5 days (range 1–57 days, mean ± SD 7.6 ± 11.5 days) in the hydroxyethyl starch group and 6.0 days (range 1–71 days; mean ± SD 9.1 ± 14.2 days) in the human albumin group. There was no difference for hospital stay (median: 12 days for both groups).

Both HES 130/0.4 and human albumin 5% were effective for haemodynamic stabilization in non-cardiac surgery of young infants with no adverse impact on coagulation or other safety parameters in our study population.

Difficult airways present a clinical challenge for anaesthetists. The Truphatek Truview EVO2© (Truphatek International Ltd, Netanya, Israel) is a new laryngoscope blade used for endotracheal intubation that could be used where there is difficulty in visualizing the laryngeal inlet.

Twenty anaesthetists (12 trainees and eight consultants) compared the Truphatek Truview EVO2© with a conventional Macintosh size 3 blade. The Trucorp Airsim Bronchi© (Trucorp Ltd, Belfast, Northern Ireland, UK) manikin was intubated under normal conditions and under simulated difficult conditions such as tongue inflation and neck rigidity. In each scenario, the Cormack–Lehane grade, time needed for successful intubation, perceived difficulty of tracheal intubation and personal preference of blade were compared. The results were analysed with t-test (time of intubation), Wilcoxon signed-rank sum (Cormack–Lehane grade, ease of manoeuvre, preferred blade) and analysis of variance with Bonferroni correction (augmentation of difficulties in different scenarios).

The Truview EVO2 blade allowed the best laryngeal view as judged by the Cormack–Lehane grade (P < 0.05) in two separate situations: under simulated tongue inflation and under simulated neck rigidity. However, this blade did not reduce the intubation time or the ease of tracheal tube placement with respect to conventional Macintosh blade.

Compared with the classical Macintosh blade, the Truview EVO2 blade allowed a better view of the larynx, but did not facilitate endotracheal intubation in any of the difficult scenarios created with the adjustable manikin and in most scenarios in fact prolonged the intubation time.

The inhibition of thermoregulatory control by anaesthesia is manifested by reduced vasoconstriction and shivering thresholds. As intraoperative bleeding can result in haemodynamic changes, including vasoconstriction, we investigated the effect of experimental bleeding on the shivering threshold in rabbits.

Twenty-four rabbits were randomly assigned to one of three treatment strategies: (1) no blood removal (control), (2) 5 mL kg−1 isovolaemic blood removal and (3) 10 mL kg−1 isovolaemic blood removal. After tracheal intubation under isoflurane anaesthesia, anaesthesia was maintained with 50% nitrous oxide in oxygen. The removed blood volume was replaced with the same volume of warm hydroxyethyl starch colloid solution. Oesophageal temperature was measured as a core temperature at 1-min intervals. After blood removal, the animal’s body was cooled at a rate of 2–3°C h−1 by perfusing water at 10°C through a U-shaped thermode positioned in the colon. Hypothermic shivering was evaluated by visual inspection, and the core temperature at which shivering was triggered was identified as the thermoregulatory threshold for this response.

Just before the cooling, the body temperature of the animals was around 38.6°C in all of the three groups. The shivering threshold in the control group was 37.2 ± 0.2°C (mean ± SD). The shivering thresholds in the 5 mL kg−1 (36.9° ± 0.3°C) and 10 mL kg−1 (36.5° ± 0.5°C) blood removal groups were significantly lower and in proportion with the volume of blood removed than that in the control group.

Isovolaemic haemodilution decreased the shivering threshold in rabbits in proportion with the volume of blood removed.

Aortic ischaemia and reperfusion may induce pulmonary sequestration of neutrophil granulocytes. Preconditioning and postconditioning with volatile anaesthetics confer protection against reperfusion injury in various organs, such as heart, kidneys or brain. We tested the hypothesis that pre- or postconditioning with Sevoflurane attenuates pulmonary neutrophil accumulation after ischaemia/reperfusion injury of the aorta.

Anaesthetized and mechanically ventilated Wistar rats underwent laparotomy and were randomly assigned to one of the following groups: Sham (n = 10), ischaemia/reperfusion (n = 8, lower body ischaemia by clamping of the infrarenal aorta for 2 h followed by 3 h of reperfusion), preconditioning (n = 10, 2.0% Sevoflurane administered over 30 min prior to ischaemia) and postconditioning (n = 9, 2.0% Sevoflurane during reperfusion). Following reperfusion, the lungs were removed for microscopic determination of neutrophil accumulation.

Ischaemia/reperfusion induced a significant increase in pulmonary neutrophil accumulation (mean ± SD, 29.9 ± 7.4 vs. 15.8 ± 6.6 neutrophils per microscopic field in ischaemia/reperfusion vs. Sham, respectively, P < 0.001). Sevoflurane preconditioning resulted in a lower neutrophil count (20.3 ± 7.1 neutrophils, P < 0.001 vs. ischaemia/reperfusion), while postconditioning showed no effects (25.8 ± 9.8 neutrophils vs. ischaemia/reperfusion, not significant).

Preconditioning, but not postconditioning, with Sevoflurane reduces pulmonary neutrophil accumulation after ischaemia/reperfusion injury of the lower body. Since neutrophil accumulation plays a major role in the pathophysiology of acute lung injury, our data suggest a protective effect of Sevoflurane preconditioning on remote pulmonary ischaemia/reperfusion injury.

A randomized and prospective study was performed to compare anaesthetic characteristics and stress hormone responses of two anaesthetic techniques.

Forty-two patients undergoing day case excisional biopsy of breast mass were randomly assigned to receive propofol–remifentanil or sevoflurane–N2O. Anaesthesia was induced and maintained either with sevoflurane and 50% N2O in oxygen or with target-controlled remifentanil and propofol in 50% oxygen and air. Anaesthetic depth was monitored by the bispectral index.

The times for induction (2.9 vs. 1.7 min) and for laryngeal mask insertion (5.7 vs. 3.3 min) were longer in the sevoflurane–N2O group than in the propofol–remifentanil group. However, apnoea (57.1% vs. 9.5%) and bradycardia (23.8% vs. 0%) were more prevalent with propofol–remifentanil. In the sevoflurane–N2O group, the emergence times to a verbal response (10.6 vs. 3.7 min), to extubation (11.8 vs. 4.0 min) and to orientation (14.7 vs. 4.8 min) were longer than in the propofol–remifentanil group. There were significantly more nausea (38.1% vs. 4.8%) and vomiting (19.2% vs. 0%) in the sevoflurane–N2O group than in the propofol–remifentanil group. The time to discharge was similar although there was less postoperative pain in the sevoflurane–N2O group. There were no differences in the perioperative cortisol responses in the two groups.

Smoother induction of anaesthesia was seen with sevoflurane–N2O. Propofol–remifentanil showed a quicker emergence with less nausea/vomiting. There were similar perioperative cortisol responses in the two anaesthetic techniques.

Postoperative shivering and pain are frequent problems in patients recovering from anaesthesia with particularly high incidences being observed after remifentanil–isoflurane-based general anaesthesia. The opioid tramadol is generally effective in preventing shivering and treating pain, but its effects are not characterized after remifentanil-based general anaesthesia. This randomized, placebo-controlled, double-blind study evaluated the effects of intraoperative intravenous tramadol on postoperative shivering and pain after remifentanil-based general anaesthesia.

After Ethics Committee approval, 60 patients scheduled for lumbar disc surgery were included. Surgery was performed under general anaesthesia (remifentanil, isoflurane). Patients were randomly assigned to receive 2 mg kg−1 tramadol in 30 mL 0.9% saline infused intravenously (n = 30) or 30 mL saline (n = 30) 45–30 min before skin closure. The following parameters were assessed every 10 min for 2 h: shivering, pain, postoperative nausea and vomiting, sedation, heart rate, non-invasive blood pressure and peripheral oxygen saturation. The primary outcome variable was the incidence of shivering during the first 2 postoperative hours. Secondary variables were: shivering intensity, pain, postoperative nausea and vomiting, sedation, heart rate, non-invasive blood pressure and peripheral oxygen saturation.

Shivering was less frequent in patients treated with tramadol (20% vs. 70%, P = 0.0009) and was of lower intensity (severe shivering: 10% vs. 46.7%, P = 0.003). Pain scores were similar between the groups and all other secondary outcome variables failed to reveal significant differences.

Compared with placebo, intraoperative intravenous administration of 2 mg kg−1 tramadol reduces the incidence and extent of postoperative shivering without alterations in pain perception after lumbar disc surgery under remifentanil–isoflurane-based general anaesthesia.

Patients exhibiting considerable blood loss are prone to develop dilutional coagulopathy following volume supply. In such patients, in addition to transfusing stored blood components, cell saver systems are used to minimize allogeneic transfusion. Since red cell transfusion might influence the haemostatic system by further dilution, we investigated the effects of re-transfusion of salvaged washed red blood cells on the haemostatic process in an animal model of controlled haemorrhage using rotational thrombelastometry (ROTEM®; Pentapharm Co., Munich, Germany).

Anaesthetized pigs (n = 20) developed coagulopathy following haemorrhagic shock (withdrawal of 66% of estimated blood volume) and volume resuscitation with 6% hydroxyethyl starch 130/0.4. The shed blood was processed in a Cellsaver device (CATS ®; Fresenius AG, Bad Homburg, Germany), and the resulting salvaged red blood cells were re-transfused. ROTEM assays were performed at baseline, after blood loss, after volume resuscitation and following re-transfusion of salvaged red blood cells.

As compared with baseline, blood loss and subsequent volume resuscitation resulted in significantly increased median values of clotting time (CT: 47.0, 5 .3 and 103.5 s), and clot formation time (CFT: 36.0, 40.0 and 186.0 s), whigggle maximum clot firmness decreased (MCF: 72.0, 68.5 and 39.5 mm). After re-transfusion of salvaged red blood cells (805 ± 175 mL) all these parameters improved (CT: 80.5 s; P = 0.05, CFT: 144.0 s; P = 0.0008, MCF: 42.0 mm; P = 0.0019) although baseline values were not reached.

In the case of extreme isovolaemic haemodilution, increasing the circulating red cell mass by re-transfusing salvaged red blood cells did not worsen the findings of dilutional coagulopathy but interestingly, at least partially, improves the clot formation process.

This study was designed to investigate the potential existence of the response of neurons in the parafascicular nucleus of the thalamus to acute myocardial ischaemia induced by selective coronary artery occlusion and the effects of midazolam on the response in rats.

The left anterior descending branch of the coronary artery was instrumented with a snare occluder in anaesthetized Sprague-Dawley rats. A single-barrel glass microelectrode was used for recording the unit discharges of the neuron in the parafascicular nucleus. The neuron responding only to noxious somatic stimulation was further examined for the response to coronary artery occlusion. Once the effect of coronary artery occlusion on the discharges was detected, the pharmacological effects of midazolam and flumazenil were examined.

It was observed that the discharge rate of the neuron was markedly increased following coronary artery occlusion. Midazolam attenuated the increase in the discharges of the neuron induced by coronary artery occlusion (P < 0.05). The effect of midazolam was reversed by flumazenil.

The parafascicular nucleus is involved in the modulation of cardiac nociception and midazolam possesses antinociceptive property in modulating cardiac pain.

Continuous monitoring of cardiac output during liver transplantation is essential to evaluate the patient’s haemodynamic tolerance to acute volume variations. The aim of this study was to compare the cardiac output values obtained with a transoesophageal echo-Doppler and those obtained with a continuous thermodilution cardiac output pulmonary artery catheter.

Twenty adult patients were prospectively studied during a 5 min hepatic vascular exclusion test performed at the end of the dissection phase. Echo-Doppler and continuous thermodilution cardiac output, mean arterial pressure and end-tidal CO2 were measured before and at the end of the test.

Before the test, echo-Doppler cardiac output was 7.0 ± 2.7 L min−1 and thermodilution was 9.4 ± 3.1 L min−1, (R = 0.85, P < 0.001). The end test values were, respectively, 3.5 ± 2.7 and 7.8 ± 3.5 L min−1 (R = 0.23, P = 0.34). Bland and Altman analysis showed a bias of −2.2 before the test, which increased to −4.4 at the end of the test. Mean arterial pressure decreased from 85.5 ± 15 to 66.8 ± 16 mmHg, end-tidal CO2 from 31.4 ± 2.3 to 23.8 ± 2.7 mmHg.

Echo-Doppler cardiac output values are different from those measured by thermodilution cardiac output in these patients. Echo-Doppler cardiac output monitoring seems to detect the output changes, which can occur during acute haemodynamic changes more rapidly than thermodilution cardiac output in the course of liver transplantation.

A single cardiac troponin I (cTnI) 24-h measurement is an independent predictor of short- and long-term adverse outcome after coronary surgery. We compared a single cTnI 24-h measurement and kinetic analysis of cTnI release in predicting in-hospital outcome in unselected cardiac surgery patients.

Consecutive patients (n = 184) undergoing cardiac surgery with cardiopulmonary bypass were included and divided into two groups according to the time course of postoperative peak serum cTnI (6 or 24 h after surgery). Serial measurements of cTnI were performed the day before surgery, at the end of surgery and 6, 24 and 120 h after surgery in all patients. The total amount of cTnI released (integrated area under the curve), postoperative major adverse cardiac events (ventricular arrhythmias, myocardial infarction and congestive heart failure) and in-hospital death were recorded. Data are expressed as median (95% CI).

In all, 152 (83%) patients had an early peak cTnI (6 h after surgery) and 32 (17%) patients had a late peak cTnI (24 h after surgery). The integrated area under the curve differed between both groups: 159 (142–178) vs. 321 (255–590), respectively, P < 0.001. Major adverse cardiac events and/or death (22 vs. 9%, P = 0.04) was greater in patients with a late peak cTnI. The integrated area under the curve and the peak value of cTnI were no more accurate than a single 24-h measurement in predicting the occurrence of major adverse cardiac events and/or death.

Kinetic analysis of cTnI release was no more accurate than a single 24-h measurement in predicting in-hospital poor outcome.

Although the association of tissue coring and development of epidermoid tumour has been proposed, the extent and frequency of such coring is still controversial and the viability of carried cells has not been substantiated. In the present study, we used an experimental model without needle removal to investigate the incidence of tissue coring using two different needle types.

We inserted 22-G caudal (n = 34) or 22-G hollow (n = 25) needles to the tumour-free areas of fresh modified mastectomy specimens. The specimen was stretched and needles were inserted perpendicular to the skin and forced to penetrate the full thickness of the specimen. Without removing the needle, the needle cavity was then washed with 2 mL of RPMI 1640 with l-Glutamine and the washings were collected in a 15-mL falcon tube. The tubes were sealed and labelled and processed to obtain cytologic preparations. The slides were evaluated under a light microscope.

A high rate of epithelial cell transportation was noted. All the carried cells were stratum corneum cells with no nucleus. No nucleated cells were seen. The incidence of carried cells was 64.7% and 72.0% in the caudal and hollow needle groups, respectively (P > 0.05).

Only cells from the outermost layer, stratum corneum, which is made of dead flat skin cells, were transported with needle puncture. The risk of epidermoid tumour development after regional anaesthesia must therefore be low. The incidence of transporting non-nucleated stratum corneum cells was similar between hollow and caudal needles.

Postoperative regional analgesia for total knee replacement can provide excellent pain control and speedy rehabilitation compared with systemic opioid analgesia but the optimal technique to provide best analgesia with minimal adverse effects remains unclear. We carried out an observer-blinded randomized trial of side-directed epidural infusion with lumbar plexus infusion after total knee arthroplasty.

Sixty patients scheduled for total knee replacement were randomized to receive epidural or lumbar plexus infusions of levobupivacaine and clonidine. Pain, sensory and motor block were assessed at 0, 6, 24 and 48 h postoperatively. Range of knee movement and mobility were assessed on the first and second postoperative days.

No significant differences were detected between the epidural and lumbar plexus groups in 24-h pain scores at rest (median visual analogue scale, 30 mm (interquartile range, 10–45) vs. 39 mm (17–51), P = 0.286), and on movement (48 mm (20–66) vs. 60 mm (47–81), P = 0.068). The only statistically significant difference in pain scores in favour of the epidural groups was at 6 h postoperatively (P < 0.001). Median morphine usage in the epidural group was 0 mg (interquartile range, 0–35) compared with 14.5 mg (0–44) in the lumbar plexus group (P = 0.33). Range of movement (epidural: median 70° (interquartile range, 58–75) vs. lumbar plexus: 70° (50–75), P = 0.79) or mobility was similar between groups. Adverse effects were also similar between groups, apart from a higher incidence of bladder catheterization in the epidural group (37.9% vs. 12.5%, P = 0.04). Conclusions: Lumbar plexus infusion is a reasonable alternative to epidural anaesthesia for total knee arthroplasty.