Anesthesiology
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Randomized Controlled Trial
Feasibility of Closed-loop Titration of Propofol and Remifentanil Guided by the Bispectral Monitor in Pediatric and Adolescent Patients: A Prospective Randomized Study.
Closed loop control of propofol/remi TIVA targeting BIS 40-60 is more precise than manual control.
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Randomized Controlled Trial Comparative Study
Randomized Double-blinded Comparison of Norepinephrine and Phenylephrine for Maintenance of Blood Pressure during Spinal Anesthesia for Cesarean Delivery.
During spinal anesthesia for cesarean delivery, phenylephrine can cause reflexive decreases in maternal heart rate and cardiac output. Norepinephrine has weak β-adrenergic receptor agonist activity in addition to potent α-adrenergic receptor activity and therefore may be suitable for maintaining blood pressure with less negative effects on heart rate and cardiac output compared with phenylephrine. ⋯ When given by computer-controlled infusion during spinal anesthesia for cesarean delivery, norepinephrine was effective for maintaining blood pressure and was associated with greater heart rate and cardiac output compared with phenylephrine. Further work would be of interest to confirm the safety and efficacy of norepinephrine as a vasopressor in obstetric patients.
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Most anesthetics, particularly intravenous agents such as propofol and etomidate, enhance the actions of the neurotransmitter γ-aminobutyric acid (GABA) at the GABA type A receptor. However, there is no agreement as where anesthetics bind to the receptor. A novel approach would be to identify regions on the receptor that are state-dependent, which would account for the ability of anesthetics to affect channel opening by binding differentially to the open and closed states. ⋯ These calculations support the conclusion of a recent photolabeling study that propofol acts at a site at the interface between the extracellular and transmembrane domains, close to the top of transmembrane domain 2.
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Despite implementation of lung-protective ventilation strategy, acute respiratory distress syndrome is associated with significant mortality, which necessitates the evaluation of ventilatory modes other than conventional lung-protective strategy. This meta-analysis of the randomized controlled trials has been undertaken to know whether high-frequency oscillatory ventilation (HFOV) provides any mortality benefit over conventional ventilation in adult patients with acute respiratory distress syndrome. ⋯ HFOV should not be used routinely in all adult patients with acute respiratory distress syndrome as primary ventilation strategy in place of conventional lung-protective ventilation.
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Hypoxic pulmonary vasoconstriction (HPV) represents a fundamental difference between the pulmonary and systemic circulations. HPV is active in utero, reducing pulmonary blood flow, and in adults helps to match regional ventilation and perfusion although it has little effect in healthy lungs. Many factors affect HPV including pH or PCO2, cardiac output, and several drugs, including antihypertensives. ⋯ Intravenous anesthetic drugs have little effect on HPV, but it is attenuated by inhaled anesthetics, although less so with newer agents. The reflex is biphasic, and once the second phase becomes active after about an hour of hypoxia, this pulmonary vasoconstriction takes hours to reverse when normoxia returns. This has significant clinical implications for repeated periods of one-lung ventilation.