Volume 96, Number 2

ANESTHESIA & ANALGESIA”Journal of the International Anesthesia Research Society@, the Society of Cardiovascular

Anesthesiologists, the Society for Pediatric Anesthesia, the Society for Ambulato y Anesthesia,the International Society fey Anaestketic Pkamcology, and tke Society for Technology in Anesthesia

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EDITORIALS

The Large Cost of Critical Care: Realities andChallengesNeil1 Adhikari and William Sibbald

When It Comes to Outcome, We Need to DefineWhat a Perioperative Epidural Technique IsOscar A. de Leon-Casasola

Missing the Informed in ConsentJeremy Sugarman

CARDIOVASCULAR ANESTHESIA(Society of Cardiovascular Anesthesiologists)

Intermittent or Continuous Carbon DioxideInsufflation for De-Airing of the CardiothoracicWound Cavity? An Exderimental Study with aNew Gas-DiffuserIMPLICATIONS: Carbon dioxide insufflation into a cardiothoracic woundmodel was studied with a new device. Efficient air removal (~0.65%remaining air) required a continuous carbon dioxide flow of 25 L/min afterinitial fillrng during 1 min at IO L/mm. A conventional tube failed toprovrde efficrent de-airing (282% remaining air).

Peter Svenarud, Mikael Persson, and Jan van der Linden

Strict Thermoregulation Attenuates MyocardialInjury During Coronary Artery Bypass GraftSurgery as Reflected by Reduced Levels ofCardiac-Specific Troponin IIMPLICATIONS: Maintenance of normothermia throughout the nonbypassphases of coronary artery bypass graft surgery is important in the atten-uation of myocardial ischemic injury as assessed by mtraoperativecardrac-specific troponin I measurements. It may also provide a method ofassessing the eff icacy of current cardioprotective strategies, as well as offuture pharmacological and mechanical approaches.

Nahum Nesher, Eli Zisman, Tamir Wolf, Ram Sharony,Gil Bolotin, Miriam David, Gideon Uretzky, and Reuven Pizov

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Bispectral Index-Guided Anesthesia in PatientsUndergoing Aortocoronary Bypass GraftingIMPUCATIONS: &spectral index @IS)-guided anesthesia may allow re-ductions in anesthetic medication and costs without increasrng the risk ofintraoperative awareness. However, total costs may be Increased bymonitoring 61s.

Andreas Lehmann, Julia Karzau, Joachim Boldt, Elfi Thaler,Johannes Lang, and Frank Isgro

Patients with a History of Type II Heparin-InducedThrombocytopenia with Thrombosis RequiringCardiac Surgery with Cardiopulmonary Bypass:A Prospective Observational Case SeriesIMPLICATIONS: We report a case series of 12 patients with a clinicalhistory of type II heparin-induced thrombocytopenia and describe theirhematologic management during cardiac surgery wrth cardiopulmonarybypass.

Gregory A. Nuttall, William C. Oliver, Jr, Paula J. Santrach,Robert D. McBane, Daniel B. Erpelding, Christina L. Marver,and Kenton J. Zehr

Blood-Transfusion Requirements and Blood Salvagein Donors Undergoing Right Hepatectomy forLiving Related Liver TransplantationIMPLICATIONS: Avoidance of heterogenous blood transfusion in the do-nor operation for living donor liver transplantation is crucial. We describeour experience wrth the first 44 liver donors under special consideationof state-of-the-art blood-saving techniques applied.

Jiirgen T. Lutz, Camino Valentin-Gamazo, Klaus Gorlinger,Massimo Malago, and Jtirgen Peters

Isoflurane and Desflurane Uptake During LiverResection and TransplantationIMPLICATIONS: The uptake of isoflurane and desflurane during prolongedsurgery did not consistently correlate with cardrac output and patlentcharacterist ics and differed from two frequently used uptake models. Theslowly decreasing rate of uptake implies that the number of vaporizeradjustments during prolonged low-flow anesthesia should be limited.

Jan F.A. Hendrickx, Michael K. Dishart, andAndre M. De Wolf

IARS Board of Trustees

Chairman Vice-ChairmanDavid R. Bevan, MB J. G. Reves, MD

Toronto, Ontario, Canada Charleston, South Carolina

Tatsuru Arai, MD Joy L. Hawkins, MDShigenobu, Ehime, Japan Denver, Colorado

Michael K. Cahalan, MD Donald S. Prough, MDSalt Lake City, Utah Galveston, Texas

TreasurevAdrian W. Gelb, MB, ChBLondon, Ontario, Canada

James G. Ramsay, MDAtlanta, Georgia

Debra A. Schwinn, MDDurham, North Carolina

SecretaryPatricia A. Kapur, MDLos Angeles, California

Robert N. Sladen, MDNew York, New York

Hugo Van Aken, MD, PhDMiinster, Germany

ANESTHESIA & ANALGESIA, 1SSN 0003-2999, is issued monthly for the IARS in two indexed volumes per year by Lippincott Williams 6 Wilkins, Inc., 16522Hunters Green Parkway, Hagerstown, MD 21740.2116. Anesthesia b Analgesia, International Research Society and IARS are Registered Trademarks of thelntcrnational Anesthesia Research Society: Reg. U.S. Pat & Tm Office. The Publisher’s business offices are located at 530 Walnut Street, Philadelphia, PA 29106-3622.Production offices are located at 351 West Camden Street, Baltimore, MD 21201-2436. Periodicals postage paid at Hagerstown, MD and at additional mailing offices.Worldwide annual member subscription rates (include Periodicals delivey in the USA, and Surface Airlift in all other countries): 1ARS $120; SCA $775; SAMBA$160; [oint IARS/SCA $195; Joint IARS/SCA/SPA/SAMBA/ISAP/STA Resident $70. Non-member subscription rates: Personal $372 ($461 international), institu-tional $526 ($615 international), in-training $179 ($268 international), single copy $59. Note: International prices exclude lapan. (See General Information for details.)Subscription prices subject to change. (Tke Canadian GST tax of 7% will be added to the subscription price of al/ orders skipped to Canada. Lippincott Williams 6Wilkins’ GST identification Number is 895524239.) POSTMASTER: Send member address changes to: IARS, 2 Summit Park Drive #140, Cleveland, OH44131-2571; c-mail iarshq@iars.org. The lARS website address is www.iars.org.; non-member address changes to: ANESTHESIA 6 ANALGESIA, PO Box 1.550,Hagerstown, MD 21741. ANESTHESIA & ANALGESIA is abstracted/indexed in: Applied Health Physics Abstracts, BIOSIS (Biolo$ca/ Abstracts), ChemicalAbstracts, CSA Neurosciences Abstracts, Cumulative Index to Nursing & Allied Health Literature (CINAHL), Current Awareness in Brological Sciences, CurrentContents (Clinical Medicine, Life Sciences, Science Citation Index, Index to Scientific Reviews, ISI/BioMed, SciScarck Database, Research Alert), EMBASEIExcerptaMedica, Health & Safety Science Abstracts, Index Medicus (abridged), MEDLINE, Reference Update, the Saciedad Ibevaarnericana dc Informocicin Cicnttfica (SIICJData Bases, Risk Abstracts, and Toxicology Abstracts. On-line text is available at www.anestkcsia-analgesia.org. Printed in the USA on acid-free paper. 0 2003 byInternational Anesthesia Research Society.

CARDIOVASCULAR ANESTHESIA-continued 396

363 The Influence of Crystalloid and ColloidReplacement Solutions in Acute NormovolemicHemodilution: A Preliminary Survey of HemostaticMarkersIMPLICATIONS: Lactated Ringer’s solution, albumin, dextran, andhetastarch were compared as replacement fluids in an acute normovol-emit hemodilution protocol in adult patients undergoing radical prosta-tectomy. Differences in coagulat ion measurements suggest that dextranand hetastarch may attenuate surgically induced hypercoagulability.

Stephanie B. Jones, Charles W. Whitten, George J. Despotis,and Terri G. Monk

369 Reducing Unnecessary Cross-Matching: A Patient-Specific Blood Ordering System Is More Accurate inPredicting Who Will Receive a Blood TransfusionThan the Maximum Blood Ordering SystemIMPLICATIONS: Currently, many units of blood set aside for surgery arenever required, resulting in extra work and expense for blood banks. Aformula that included patient weight and hematocrit and typical surgeryblood loss was used to predict who would require transfusions, Wereduced the predicted number of patients who had blood set aside from178 to 21.

Thalia Palmer, Joyce A. Wahr, Michael O/Reilly, andMary Lou V.H. Greenfield

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MEDICAL INTELLIGENCE

376 Intravascular Volume Replacement Therapy withSynthetic Colloids: Is There an Influence onRenal Function?IMPLICATIONS: Articles on volume replacement published between 1981and 2001 were analyzed. Albumin and gelatin do not predispose todevelopment of kidney dysfunction. Modern hydroxyethyl starch (HES)solutions can be used safely in patients without kidney dysfunction evenin large doses. Safety of HES rn patients with preexisting altered kidneyfunction sti l l remains unclear.

Joachim Boldt and Hans-Joachim Priebe

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CASE REPORT

Bivalirudin Monitored with the Ecarin ClottingTime for Anticoagulation During CardiopulmonaryBypassIMPLICATIONS: Bivalirudin. a new short-acting direct thrombin inhrbitor,provides an eliminatron mechanism independent of specific organ func-tion. We successfully used this new drug, monitored at the point of carevia the ecarin clotting time, for anticoagulation during cardiopulmonarybypass in a patient with heparin-induced thrombocytopenia heparin allergyand impaired renal function.

Andreas Koster, Derek Chew, Marcus Grtindel,Matthias Bauer, Herman Kuppe, and Bruce D. Spiess

PEDIATRIC ANESTHESIAlSoclety for Pediatric Anestbesld

387 Traditional Versus New Needle Retractable IVCatheters in Children: Are They Really Safer, andWhom Are They Protecting?IMPLICATIONS: Use of retractable needle safety IV catheters may in-crease rather than decrease exposure to blood. The choice of IV systemshould be left to the clinician’s best judgment to balance the efficientestablishment of venous access with the least potential for blood con-tamination.

Charles J. Cot& Andrew G. Roth, Melissa Wheeler,Carolyn ter Rahe, Bronwyn R. Rae, Richard M. Dsida,and H. J. Przybylo

392 Midazolam Premedication in Children:A Comparison of Two Oral Dosage Formulationson Sedation Score and Plasma Midazolam LevelsIMPLICATIONS: IV midazolam mixed in Syrpalta” syrup produces agreater sedative effect and higher plasma midazolam levels than thecommercially available syrup when used as an oral anesthetic premedi-cation in pediatric surgical patrents.

Keith K. Brosius and Carolyn F. Bannister

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EMLAO Cream Versus Dorsal Penile Nerve Blockfor Postcircumcision Analgesia in ChildrenIMPLICATIONS: This study shows that topical application of EMLA@cream before circumcision is simple and effect ive with few side effects.

W.Y. Choi, M.G. Irwin, T.W.C. Hui, H.H. Lim, and K.L. Chan

Anesthetic Uptake of Sevoflurane and NitrousOxide During an Inhaled Induction in ChildrenIMPLICATIONS: The wash-in of sevoflurane and nitrous oxide in healthychildren during the mask inductron of anesthesia showed a more rapidequilibrium between alveolar and inspired gas concentrations than inadults. Consistent with therr respective blood/gas partition coefficients.the alveolar concentration for nitrous oxide increased more rapidly to itsinspired concentration than that for sevoflurane. A concentration effectwas confirmed with nitrous oxide and a brief, second gas effect, probablyexplained by the higher solubility of sevoflurane.

Luis J. Goldman

Salicylate Action on Medullary Inspiratory NeuronActivity in a Brainstem-Spinal Cord Preparationfrom Newborn RatsIMPLICATIONS: We investrgated salicylate effects on the medullary re-spiratoty center. Small-dose salicylate (1 mM) directly stimulated therespiratory center. Large-dose salicylate (IO mM) caused central respira-tory depression involving a GABAergic mechanism.

Shinji Akada, Shinhiro Takeda, and Ryo Ogawa

CASE REPORT

Awake Caudal Anesthesia for Inguinal Surgery inOne Conjoined TwinIMPLICATIONS: Conjoined twins have some cross-circulation, whichmakes general anesthesia for only one patient impossible. Using caudalanesthesra in the awake patient, we were able to provide anesthesia foran inguinal central venous catheter placement in one patient withouthaving to unnecessarily anesthetize the other twin.

Christian Seefelder, David R. Hill, Robert C. Shamberggr,and Robert S. Holzman

AMBULATORY ANESTHESIABociety for Ambulatory Anesthesia)

TECHNICAL COMMUNICATION

Patient-Controlled Perineural Analgesia AfterAmbulatory Orthopedic Surgery: A Comparison ofElectronic Versus Elastomeric PumpsIMPLICATIONS: Patient-controlled perineural analgesia techniques usinglnfusor LV5@ disposable elastomeric or two types of electronic pumpsprovide efhcient pain relief at home after ambulatory orthopedic proce-dures. Elastomeric pumps resulted in fewer technical problems and led tobetter patient satisfaction scores than Microjet” electronic pumps.

Xavier Capdevila, Philippe Macaire, Philippe Aknin,Christophe Dadure, Nathalie Bernard, and Sandrine Lopez

TECHNOLGQY, COMPUTING, AND SIMULATIONSociety for Technology by Anesthesia)

REVIEW ARTICLE

The Impact of Economics on Changing MedicalTechnology with Reference to Critical CareMedicine in the United StatesEric L. Bloomfield

Pulse Oximetry for Perioperative Monitoring:Systematic Review of Randomized, Controlled TrialsIMPLICATIONS: We sought to clari fy the effect of monitoring oxygen in theblood in surgical patients and to identify the adverse outcomes, A smallpercentage of oxygen in the blood (hypoxemia) was reduced in a pulseoximetry group: however, the incrdence of postoperative complicationswas the same in a control group. We confirmed that pulse oximetry candetect hypoxemra.

Tom Pedersen, Ann M. Moller, and Bente D. Pedersen

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TECHNOLOGY, COMPUTING, ANDSIMULATION-continued

Endotracheal Intubation Device with a ChargeCouple Device CameraIMPLICATIONS: We developed an orotracheal intubation device equippedwith a charge couple device (CCD) camera, providing a wide field of vision.We used this device to perform endotracheal intubations in 62 anesthe-tized patients undergoing dental treatment and oral surgery. Endotrachealintubation can be easily performed with this device.

Hikaru Kohase, Hiroshi Sehata, Hirohito Inada, Yoko Ikeda,and Masahiro Umino

CASE REPORTThe Bispectral Index in the Diagnosis ofPerioperative Stroke: A Case Report and DiscussionIMPLICATIONS: We describe a case where the frequently used bispectralindex (BIS) monitor provided the f irst indication of a massive stroke. Thediagnosis of stroke should be considered in the event of an unexplained,sudden, and sustained decrease in the BIS.

Ian J. Welsby, J. Mark Ryan, John V. Booth, Ellen Flanagan,Robert H. Messier, and Cecil 0. Bore1

ANESTHEllC PHARMACOLOGYltnternational Society for Anaesthetic Pharmacology1

The Duration of Immobilization Causes theChanging Pharmacodynamics of Mivacurium andRocuronium in RabbitsIMPLICATIONS: In the present study, we examined, in viva, whether theduration of immobilization can alterthe pharmacodynamics of mivacuriumand rocuronium in an immobilized limb and/or a contralateral limb inrabbits. The immobilization disuse atrophy produced by casting led to thedevelopment of resistance to both drugs but no resistance was shown inthe contralateral l imb.

Kyo S. Kim, Jeong W. Jeon, Myoung S. Koh, Jae H. Shim,Sang Y. Cho, and Jung K. Suh

Nitrous Oxide and Xenon Inhibit the Human (c&Nicotinic Acetylcholine Receptor Expressed inXen opus OocyteIMPLICATIONS: The neuronal nicotinic acetylcholine (nACh) receptorshave received attention as a potential target for general anestheticsbecause many general anesthetics inhibit their functions. However, ef-fects of gaseous anesthetics, nitrous oxide, and xenon on the (01~)sreceptor, a subtype of the nACh receptor, have not been examined. Wereport that these anesthetics inhibit the (a7)s nACh receptor at clinicalconcentrations.

Takahiro Suzuki, Kazuyoshi Ueta, Masahiro Sugimoto,Ichiro Uchida, and Takashi Mashimo

Propofol Impairs the Central but Not the PeripheralPart of the Motor SystemIMPLICATIONS: Propofol bolus administration provides some degree ofmuscle relaxation in humans, We demonstrated a decrease of motoneu-ron excitabil ity in the spinal cord, measured by F-wave analysis, a lateelectromyographic signal. No effects on neuromuscular transmission ormuscle contracti l i ty, measured by electromyography and mechanomyogra-phy, were observed.

Michael H. Dueck, Aloys Oberthuer, Christoph Wedekind,Matthias Paul, and Ulf Boerner

The Dose-Dependent Effects of Fentanyl on RatSkeletal Muscle Microcirculation In VimIMPLICATIONS: Fentanyl is used as a pain kil l ing drug during surgery, butits effects on small blood vessels are uncertain. We implanted chambersinto a skin f lap in rats to study skeletal muscle microcirculation. Fentanylcaused a decrease in blood vessel diameter that could potentially reduceblood f low to t issues during surgery.

206 L. S Brookes, Nicola J. Brown, and Charles S. Reilly

PAIN MEDICINEEpidural Injections of Indomethacin forPostlaminectomy Syndrome: A Preliminary ReportIMPLICATIONS: lndomethacrn IS an antiinflammatory medication thatseems to have similarly effective pain-relief action, when given epidurally,as one of the most frequently used corticosteroids which has l imitationsbecause of common side effects. An added advantage is that indometh-acin seems to also “tame” pain transmission.

J. Antonio Aldrete

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A Comparison of Multimodal PerioperativeAnalgesia to Epidural Pain Management AfterGastric Bypass SurgeryIMPLICATIONS: We compared pain intensity, analgesic consumption,length of stay, and patient satisfaction in patients undergoing gastricbypass surgery randomized to one of three treatment groups. In respond-ers, infiltration analgesia as part of a multimodal postoperative painmanagement regimen offered a simple, safe, and inexpensive alternativeto epidural pain control.

Roman Schumann, Scott Shikora, Jocelyn M. Weiss,Heinrich Wurm, Scott Strassels, and Daniel B. CarrPostoperative Pain Relief After Hepatic Resection inCirrhotic Patients: The Efficacy of a Single SmallDose of Ketamine Plus Morphine EpidurallyIMPLICATIONS: This is a clinical prospective and randomized trial. Thestudy shows the efficacy and safety of a single-dose administration ofepidural morphine plus small-dose ketamine given as the only treatmentfor postoperative pain relief in cirrhotic patients having liver resection.

Pilar Tam& Josep Fuster, Anabel Blasi, Julia Martinez-Ocon,Teresa Anglada, Joan Beltran, Jaume Balust, Javier Tercero,and Juan-Carlos Garcia-ValdecasasRelease of /3-Endorphin Immunoreactive MaterialUnder Perioperative Conditions into Blood orCerebrospinal Fluid: Significance for PostoperativePain?IMPLICATIONS: P-Endorphin immunoreactive material has been deter-mined in plasma and cerebrospinal fluid under perioperative conditions,Its release into the cardiovascular compartment is related to postopera-tive pain severity, although its analgesic significance remains to beelucidated.

Reginald Matejec, Ralph Ruwoldt, Rolf-Hasso Bodeker,Gunter Hempelmann, and Hansjorg TeschemacherThe Significance of Intrathecal Catheter Locationin RatsIMPLICATIONS: This study has shown that detection of the paralyticand/or antinociceptive effect of small-dose lidocaine before planned ex-periments is a simple and reliable method for prediction of the location ofthe catheter t ip. We suggest that the posit ion of the catheter might causeside differences in the drug effect.

Ildiko Dobos, Kalman Toth, Gabriella Kekesi, Ga$riella Joo,Emese Csullog, Walter Klimscha, Gyorgy Benedek, andGyongyi HorvathMinute Sphere Acupressure Does Not ReducePostoperative Pain or Morphine ConsumptionIMPLICATIONS: Minute sphere therapy is a form of acupuncture. Wetested whether minute spheres placed on three acupressure points rele-vant to abdominal surgery reduced pain and morphine requirements afterabdominal surgery. Treatment and control patients received a similarcovering. Neither pain nor morphine requirements were different betweenthe groups.

Masatomo Sakurai, Muhammad-Irfan Suleman,Nobutada Morioka, Ozan Akca, and Daniel I. Sessler

ECONOMICS, EDUCATION, AND HEALTH SYSTEMSRESEARCHThe Influence of Protocol Pain and Risk on Patients’Willingness to Consent for Clinical Studies:A Randomized TrialIMPLICATIONS: We tested the hypothesis that the risk or discomfortassociated with a clinical trial influence a patient’s decision to participate.Patients who understand the risks involved are twice as likely to consent.In contrast, those who feel pressured do not agree to participate. Manypatients are will ing to participate in risky or painful studies, apparently foraltruistic reasons.

Tanja A. Treschan, Thomas Scheck, Alexander Kober,Edith Fleischmann, Beatrice Birkenberg, Brigitte Petschnigg,Ozan Akca, Franz X. Lackner, Elisabeth Jandl-Jager, andDaniel I. SesslerHow to Release Allocated Operating Room Time toIncrease Efficiency: Predicting Which SurgicalService Will Have the Most Underutilized OperatingRoom TimeIMPLICATIONS: When a service has filled its allocated operating room(OR) trme and has a new case to schedule, OR efficiency is maximized byscheduling the case into the OR trme of another service. The servicewhose OR time is released can be the service with the largest differencebetween allocated and scheduled OR time at the time when the new caseis scheduled.

Franklin Dexter, Rodney D. Traub, and Alex Macario

ECONOMICS, EDUCATION, AND HEALTHSYSTEMS RESEARCH-continued

513 Declining Proportion of Publications by AmericanAuthors in Major Anesthesiology JournalsIMPLICATIONS: In the period 1980-2000, there was an Increase in thenumber of research articles published in the three main anesthesiajournals: Anesthesiology, Anesthesia &Analgesia, and Pain. Despite thisincrease in research activity, there was a significantly disproportionatedecrease in the United States versus non-US authorship.

Joseph W. Szokol, Glenn S. Murphy, Michael J. Avram,Martin Nitsun, Theodore M. Wynnychenko, andJeffery S. Vender

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CRITICAL CARE AND TRAUMA

Adrenaline Inhibits Lipopolysaccharide-InducedMacrophage Inflammatory Protein-la in HumanMonocytes: The Role of /3-Adrenergic ReceptorsIMPLICATIONS: Macrophage inflammatory protein-la (MIP-la) has animportant role in the development of inflammatory responses. In thisstudy, adrenaline was found to inhibit lipopolysaccharide-induced MIP-lolproduction and messenger RNA expression via padrenergic receptors inhuman monocytes. Our results suggest that adrenaline may modulateMIP-lol production in inflammatory diseases and sepsis.

Chi-Yuan Li, Tz-Chong Chou, Chian-Her Lee,Chien-Sung Tsai, Shih-Hurng Loh, and Chih-Shung Wong

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NEUROSURGICAL ANESTHESIA

The Effect of the a,-Agonist Dexmedetomidine andthe N-Methyl-D-Aspartate Antagonist St+)-Ketamineon the Expression of Apoptosis-Regulating ProteinsAfter Incomplete Cerebral Ischemia and Reperfusionin RatsIMPLICATIONS: This study shows that dexmedetomidine and S(+)-ketamine influence the expression of apoptosis-regulating proteins in ratbrains 4 h after cerebral ischemia/reperfusion. Therefore, it is possiblethat the neuroprotection seen with dexmedetomidine and S(c)-ketaminemight also involve antiapoptotic mechanisms in addition to reducingnecrotic cell death.

Kristin Engelhard, Christian Werner, Eva Eberspgcher,Monika Bachl, Manfred Blobner, Eberhard Hildt,Peter Hutzler, and Eberhard Kochs

532 Potent a,-Receptor Ligand 4-Phenyl-1-(4-Phenylbutyl)Piperidine Provides Ischemic NeuroprotectionWithout Altering Dopamine Accumulation In Vivoin RatsIMPLICATIONS: u,-Receptor ligands decrease infarction size in the stri-atum when given before or after onset of stroke without affectingischemia-evoked dopamine efflux.

Toru Goyagi, Anish Bhardwaj, Raymond C. Koehler,Richard J. Traystman, Patricia D. Hurn, and Jeffrey R. Kirsch

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OBSTErRIC ANESTHESIA

The Vasodilatory Effects of Hydralazine,Nicardipine, Nitroglycerin, and Fenoldopam in theHuman Umbilical ArteryIMPLICATIONS: We conclude that currently used drugs to treat acutehypertension have no adverse effects on umbilical artery tone; however,larger concentrations (Z10m5 M) of fenoldopam may produce contractionof the umbil ical artery.

Nobukazu Sato, Kenichi A. Tanaka, Fania Szlam,Atsushi Tsuda, Maria E. Arias, and Jerrold H. Levy

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CASE REPORT

Spinal Anesthesia for Cesarean Delivery ShortlyAfter an Epidural Blood PatchIMPLICATIONS: The use of central neuraxial anesthesia techniquesshortly after an epidural blood patch (EBP) has not been described. Theauthors discuss the potential concerns and report a unique case of apatient who underwent a cesarean delivery under spinal anesthesia 6 hafter an EBP.

John I’. R. Loughrey, Sunil Eappen, and Lawrence C. Tsen

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REGIONAL ANESTHESIA

Perioperative Epidural Analgesia and Outcome AfterMajor Abdominal Surgery in High-Risk PatientsIMPLICATIONS: Secondary analysis of data from a large randomized trialof perioperative epidural analgesia demonstrates no beneficial effect onmajor postsurgical morbidity or mortal i ty from epidural analgesia.

Philip J. Peyton, Paul S. Myles, Brendan S. Silbert,John A. Rigg, Konrad Jamrozik, and Richard Parsons

555 Perioperative Glucose Infusion and the CatabolicResponse to Surgery: The Effect of Epidural BlockIMPLICATIONS: We investigated the effect of epidural block on perioper-ative glucose and protein kinetics in patients receiving IV glucose infu-sion. Endogenous glucose production and plasma glucose concentrationwere smaller in the presence of epidural block. However, epidural blockdid not modify perioperative protein metabolism during the administrationof IV glucose.

Ralph Lattermann, Franc0 Carli, Linda Wykes, andThomas Schricker

563 Pharmacokinetics of Ropivacaine in Uremic and, Nonuremic Patients After Axillary Brachial Plexus

BlockIMPLICATIONS: In uremic patients, enhanced absorption and reducedclearance of ropivacaine and reduced urinary excretion of the ropivacainemetabolites could lead to toxicity. Increased plasma protein binding ofropivacaine in uremic patients reduces elimination of the local anestheticbut may protect against acute toxicity despite large total plasma concen-trations of ropivacaine.

Pertti Pere, Merja Salonen, Mika Jokinen, Per H. Rosenberg,Pertti J. Neuvonen, and Juhani Haasio

570 Hypercarbic and Hypoxic Ventilatory ResponsesAfter Intrathecal Administration of Bupivacaineand SameridineIMPLICATIONS: lntrathecal administration of sameridine, a new m’oleculewith both local anesthetic and opioid properties, compared with bupiva-Caine, a well-known local anesthetic, produces similar and minor effectson respiration over a 24-h observation period.

Asa Osterlund Modalen, Lars Westman, Eva Arlander,Lars I. Eriksson, and Sten G. E. Lindahl

576 The Dose Response and Effects of Dexamethasoneon Bupivacaine Microcapsules for IntercostalBlockade (T9 to Tll) in Healthy VolunteersIMPLICATIONS: The incorporation of dexamethasone into bupivacaine-loaded microcapsules reduces the onset time and prolongs the durationof bupivacaine analgesia over the 0.3125%5.0% dose range. Bupiva-Caine microcapsules appear safe for use in intercostal blockade in thispreliminary study in volunteers.

Dan J. Kopacz, Peter G. Lacouture, Danlin Wu,Partha Nandy, Ruth Swanton, and Craig Landau

GENERAL ARTICLES

583 Prognostic Significance of Postoperative In-HospitalComplications in Elderly Patients. I. Long-TermSurvivalIMPLICATIONS: Elderly surgical patients who have had an in-hospitalpostoperative complication have increased mortality, particularly in thefirst 3 mo after surgery. Efforts to improve perioperat ive care del ivery toelderly surgical patients must include measures to minimize in-hospitalpostoperative complications, particularly those involving the pulmonaryand renal systems.

Kawalpreet Manku, Peter Bacchetti, and Jacqueline M. Leung

590 Prognostic Significance of Postoperative In-HospitalComplications in Elderly Patients. II. Long-TermQuality of LifeIMPLICATIONS: In a group of geriatr ic patients, the occurrence of post- -operative complications did not independently predict long-term quality oflife or functional status. The important independent predictors were co-morbid conditions, age, and new hospitalization after discharge.

Kawalpreet Manku and Jacqueline M. Leung

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GENERAL ARTICLES-continued

A Comparison of the Upper Lip Bite Test (a SimpleNew Technique) with Modified MallampatiClassification in Predicting Difficulty inEndotracheal Intubation: A Prospective BlindedStudy

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627IMPLICATIONS: Airway management continues to be a challenge despitesubstantial advances in this f ield. We found that the upper l ip bite test, areasonably easy test, was more predictive of a diff icult airway than themodified Mallampati score.

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Zahid Hussain Khan, Arash Kashfi, and Elham Ebrahimkhani

600 A Comparison of the ProSealTM Laryngeal Mask andthe Laryngeal Tube@ in Spontaneously BreathingAnesthetized Patients

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IMPLICATIONS: In this prospective, randomized study, we found that theProSealTM laryngeal mask airway was easier to insert and permitted abetter delivery of hands-free anesthesia than the Laryngeal Tube”. Theincidence of postoperative laryngopharyngeal discomfort was similar forboth devices.

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Eduardo Figueredo, Miguel Martinez, and Teresa Pintanel629

606 The BrandtTM Tube System Attenuates the CuffDeflationary Phenomenon After Anesthesia withNitrous Oxide

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629IMPLICATIONS: We demonstrated that the BrandtTM tube system atten-uates a decrease in cuff pressure after cessation of nitrous oxide (N,O)administration, whereas a method of repeated cuff deflation to avoidexcessive pressure during N,O anesthesia causes deflationary phenom-enon of the cuff after cessation of N,O administration, result ing in pos-sible risk of air leaks.

Fujio Karasawa, Akira Takita, Tomohisa Mori,Isao Takamatsu, Yasushi Kawatani, and Takashi Oshima

611 Intraoperative Colloid Administration ReducesPostoperative Nausea and Vomiting and ImprovesPostoperative Outcomes Compared with CrystalloidAdministration

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IMPLICATIONS: lntraoperative resuscitation with colloid reduces postoperative nausea and vomiting and improves the quality of postoperativerecovery when compared with crystalloid resuscitation.

Eugene W. Moretti, Kerri M. Robertson, Habib El-Moalem,and Tong J. Gan

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TECHNICAL COMMUNICATION

The Laryngeal Tube S: A Modified Simple AirwayDevice

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IMPLICATIONS: The Laryngeal Tube S, f i t ted with a second lumen servingfor suctioning and free gastric drainage, but not for venti lat ion, as with theCombitube, can be inserted without additional equipment, and wasproven in a preliminary cl inical tr ial to effectively venti late patients withrespiratory arrest and to evacuate stomach contents.

Volker Diirges, Hartmut Ocker, Volker Wenzel,Markus Steinfath, and Klaus Gerlach

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SPECIAL ARTICLE 634

622 The Contributions of A. W. HofmannIMPLICATIONS: A. W. Hofmann broadly influenced anesthesiologythrough his seminal work on amine structures and synthetic amine drugs.Many drugs in addition to atracurium should invoke his memory.

Theodore A. Alston

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LEllERS TO THE EDITOREpidural Ketamine in Healthy Children-What’s thePoint?James C. Eisenach and Tony L. YakshIn Response:Peter Marhofer and Margot SemsrothYet Another Bend in the Wand!Wasimul Huda, Rashid M. Kahn, Moied Ahmad, andManpreet SinghAgitation After Desflurane and Dixon and MasseyUp-and-Down MethodHernan R. Mmioz and Mauricio E. IbacacheIn Response:Ira Todd CohenEffects of Systemic Local Anesthetics onPerioperative Ischemia Reperfusion May BeBeneficialDominic Harmon and Wei LanIn Response:K. Hahnenkamp and C. W. HoenemannA Misleading Conclusion and AbstractBee Beng LeeCombined Spinal and Epidural Anesthesia forCesarean Section in a Patient with HypertrophicObstructive CardiomyopathyTadahiko Ishiyama, Takeshi Oguchi, Tetsuya Iijima,Takashi Matsukawa, Satoshi Kashimoto, andTeruo KumazawaA Structural Complication in the Torque ControlBlocker Univent@: Fracture of the Blocker CapConnectorJavier H. Campos and Kemp H. Kernstine .

Profound Pain Due to Propofol Injection TriggeredMyocardial Ischemia in a Patient with a SuspectedPheochromocytomaTetsuro Morishima, Kazuya Sobue, Hajime Arima,Sayuki Tanaka, MinHye So, Hiroshi Ando, andHirotada KatsuyaRapacuronium: Premarket Drug Evaluation Can BeVery Effective for the Identification of Drug RisksRobyn LimOther Stimuli Add to Effect of Remifentanil on BISG. D. PuriIn Response:Jay W. Johansen and Peter S. SebelKinking of the Pilot Tube Presents Inflation of theCuffCarla St. Laurent, Daniel Lee, and Jonathan Benumof

BOOK AND MULTIMEDIA REVIEWSMalignant HyperthermiaJordan MillerNotable Names in AnesthesiaElliott V. MillerAnesthesia PearlsBenjamin Kohl