Assessment of cerebral hemodynamics during neurosurgical procedures using laser speckle image analysis

Aneurysmal subarachnoid hemorrhage (aSAH) is a severe medical condition associated with a significant cause of mortality throughout the world. Cisterna magna injection model is accepted widely to mimic clinical aSAH and is performed on small animal models to study aSAH during neurosurgery. Coherent light scattered from the surface of the rat brain is used to infer information about the variations in blood flow during this condition. We obtained speckle images from the exposed cortex during the entire experiment using an external tissue imaging system. Contrast and fractal analyses are carried out for the recorded speckle pattern time series. Correlation analysis based on Hurst exponent for these images is found to be a more sensitive tool in studying aSAH as compared to routinely used laser speckle contrast analysis for assessing the changes in blood flow velocity. Additionally, our studies provide improved blood flow detection sensitivity with image Hurst exponent in combination with computed fractal dimension, during an event of aSAH.     

Fructose augments infection-impaired net hepatic glucose uptake during TPN administration

During chronic total parenteral nutrition (TPN), net hepatic glucose uptake (NHGU) and net hepatic lactate release (NHLR) are markedly reduced (downward arrow approximately 45 and approximately 65%, respectively) with infection. Because small quantities of fructose are known to augment hepatic glucose uptake and lactate release in normal fasted animals, the aim of this work was to determine whether acute fructose infusion with TPN could correct the impairments in NHGU and NHLR during infection. Chronically catheterized conscious dogs received TPN for 5 days via the inferior vena cava at a rate designed to match daily basal energy requirements. On the third day of TPN administration, a sterile (SHAM, n = 12) or Escherichia coli-containing (INF, n = 11) fibrin clot was implanted in the peritoneal cavity. Forty-two hours later, somatostatin was infused with intraportal replacement of insulin (12 +/- 2 vs. 24 +/- 2 microU/ml, SHAM vs. INF, respectively) and glucagon (24 +/- 4 vs. 92 +/- 5 pg/ml) to match concentrations previously observed in sham and infected animals. After a 120-min basal period, animals received either saline (Sham+S, n = 6; Inf+S, n = 6) or intraportal fructose (0.7 mg x kg(-1) x min(-1); Sham+F, n = 6; Inf+F, n = 5) infusion for 180 min. Isoglycemia of 120 mg/dl was maintained with a variable glucose infusion. Combined tracer and arteriovenous difference techniques were used to assess hepatic glucose metabolism. Acute fructose infusion with TPN augmented NHGU by 2.9 +/- 0.4 and 2.5 +/- 0.3 mg x kg(-1) x min(-1) in Sham+F and Inf+F, respectively. The majority of liver glucose uptake was stored as glycogen, and NHLR did not increase substantially. Therefore, despite an infection-induced impairment in NHGU and different hormonal environments, small amounts of fructose enhanced NHGU similarly in sham and infected animals. Glycogen storage, not lactate release, was the preferential fate of the fructose-induced increase in hepatic glucose disposal in animals adapted to TPN.     

Zinc status in plasma of obese individuals during glucose administration

To know whether plasma zinc status is altered under acute hyperglycemic state, the interrelationships among plasma glucose, insulin, and zinc concentrations during oral glucose tolerance test (OGTT) in obese individuals and their lean controls were studied. Plasma glucose and insulin concentrations under fasting as well as those values in response to OGTT were significantly higher in obese individuals than those in lean controls. On the other hand, the obese had lower fasting plasma zinc concentrations compared to lean controls (13.5 vs 18.1 Μmol/L,p < 0.005). Under fasting, plasma zinc concentrations in overall individuals inversely correlated to their body mass index (BMI) (r = -0.516), plasma glucose (r = -0.620), and plasma insulin (r = -0.510). However, there were no significant changes in plasma zinc and copper values during OGTT in both obese individuals and lean controls. This study showed that plasma zinc values had no changes during OGTT in obese individuals. The results also indicated that lower fasting plasma zinc concentrations in obese individuals were not the short-term metabolic result.     

Regional brain glucose utilization during and following chronic naltrexone administration: preliminary observations in rat brain

Experiments were conducted to determine some of the metabolic correlates of tonic opioid activity in the central nervous system under conditions previously examined for changes in monoamine levels. The glucose metabolic rates in seven brain regions were determined by autoradiographic visualization of 14C-deoxyglucose incorporation in female rats after 8 days of chronic exposure to naltrexone pellets and 10 days after pellet removal. Autoradiographs were analyzed on a region-by-region basis to correspond to areas previously dissected and analyzed for changes in monoamine content under similar experimental conditions. Chronic administration of naltrexone resulted in a significant decrease in the metabolic activity of neurons in the striatum. Other brain areas examined under this condition were not significantly affected. Ten days following pellet removal, 14C-deoxy-glucose incorporation was indistinguishable from that determined in placebo treated rats in all brain regions examined. These results indicate that tonic opioid input is an important determinant of metabolic activity in the striatum. In addition, these results indicate that conditions previously shown to alter regional content of monoamines do not necessarily produce concomitant changes in regional glucose utilization.     

Anesthesiology: New Muscle Relaxants

The Council on Scientific Affairs of the California Medical Association presents the following epitomes of progress in anesthesiology. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and clinical importance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, and scholars to stay abreast of progress in medicine, whether in their own field of special interest or another.The epitomes included here were selected by the Advisory Panel to the Section on Anesthesiology of the California Medical Association, and the summaries were prepared under the direction of Dr Jackson and the panel.     

Increased glucose production following neurotensin administration

Neurotensin (NT), a recently isolated extract from bovine hypothalami, has been shown to have a hyperglycemic effect when injected into fed rats. This hyperglycemia has been attributed entirely to glycogenolysis, but no evidence is available regarding the effect of NT on the rate of glucose production and uptake. We have therefore used the primed-constant infusion of 6-³H-glucose technique to evaluate the effect of an intravenous injection of NT (1.2 nmole/kg) on glucose production $\text{in vivo}$ in 48-h starvèd, conscious rats (n=10). NT induced a progressive rise in plasma glucose concentration from the control value of 101 ± 2.3 to 162.2 ± 10.8 mg/dl at 30 min. Glucose production was significantly (p<.05) elevated 35–40% throughout the first 30 minutes after NT, while the rate of disappearance of glucose was slightly, but not significantly, elevated. An average of 38.2 mg/animal of glucose was required to account for the average increase in glucose production above the basal rate during the 30 minutes following NT. This requirement exceeded the total amount of glycogen (27.9 mg.) found in the livers of 48 hour starved rats. We therefore concluded that the rise in blood glucose concentration after NT injection was entirely due to an increased rate of glucose production, and that at least part of the increased glucose production represented an elevated rate of gluconeogenesis.     

Anesthesiology: regional anesthesia in children

The Scientific Board of the California Medical Association presents the following inventory of items of progress in anesthesiology. Each item, in the judgement of a panel of knowledge physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers, or scholars to stay abreast of these items of progress in anesthesiology that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Anesthesiology of the California Medical Association and the summaries were prepared under its direction.     

Hepatic glucose metabolism during intraduodenal glucose infusion: impact of infection

We previously reported that infection decreases hepatic glucose uptake when glucose is given as a constant peripheral glucose infusion (8 mg. kg(-1) x min(-1)). This impairment persisted despite greater hyperinsulinemia in the infected group. In a normal setting, hepatic glucose uptake can be further enhanced if glucose is given gastrointestinally. Thus the aim of this study was to determine whether hepatic glucose uptake is impaired during an infection when glucose is given gastrointestinally. Thirty-six hours before study, a sham (SH, n = 7) or Escherichia coli-containing (2 x 10(9) organisms/kg; INF; n = 7) fibrin clot was placed in the peritoneal cavity of chronically catheterized dogs. After the 36 h, a glucose bolus (150 mg/kg) followed by a continuous infusion (8 mg. kg(-1). min(-1)) of glucose was given intraduodenally to conscious dogs for 240 min. Tracer ([3-(3)H]glucose and [U-(14)C]glucose) and arterial-venous difference techniques were used to assess hepatic and intestinal glucose metabolism. Infection increased hepatic blood flow (35 +/- 5 vs. 47+/-3 ml x g(-1) x min(-1); SH vs. INF) and basal glucose rate of appearance (2.1+/-0.2 vs. 3.3+/-0.1 mg x kg(-1) x min(-1)). Arterial insulin concentrations increased similarly in SH and INF during the last hour of glucose infusion (38+/-8 vs. 46+/-20 microU/ml), and arterial glucagon concentrations fell (62+/-14 to 30+/-3 vs. 624+/-191 to 208+/-97 pg/ml). Net intestinal glucose absorption was decreased in INF, attenuating the increase in blood glucose caused by the glucose load. Despite this, net hepatic glucose uptake (1.6+/-0.8 vs. 2.4+/- 0.9 mg x kg(-1) x min(-1); SH vs. INF) and consequently tracer-determined glycogen synthesis (1.3+/-0.3 vs. 1.0+/-0.3 mg. kg(-1) x min(-1)) were similar between groups. In summary, infection impairs net glucose absorption, but not net hepatic glucose uptake or glycogen deposition, when glucose is given intraduodenally.     

Capnography sensor use is associated with reduction of adverse outcomes during gastrointestinal endoscopic procedures with sedation administration

Background

Evidence to date suggests that capnography monitoring during gastrointestinal endoscopic procedures (GEP) reduces the incidence of hypoxemia, but the association of capnography monitoring with the incidence of other adverse outcomes surrounding these procedures has not been well studied. Our aims were to estimate the incidence of pharmacological rescue events and death at discharge from an inpatient or outpatient hospitalization where GEP was performed with sedation, and to determine if capnography monitoring was associated with reduced incidence of these adverse outcomes.

Methods

This retrospective Premier Database analysis included medical inpatients and all outpatients undergoing GEP with sedation. Patients were grouped as follows: (1) pulse oximetry (SpO₂) only, (2) capnography only, (3) SpO₂ with capnography, and (4) neither SpO₂ nor capnography. Multivariable logistic regression and propensity-score matching were used to compare patients with capnography sensor use to patients with only SpO₂ sensor use. Outcome measures included the incidence of pharmacological rescue events, as defined by administration of naloxone and/or flumazenil, and death.

Results

Two hundred fifty eight thousand and two hundred sixty two inpatients and 3,807,151 outpatients were analyzed. For inpatients, capnography monitoring was associated with a 47% estimated reduction in the odds of death at discharge (OR: 0.53 [95% CI: 0.40–0.70]; P?<?0.0001) and a non-significant 10% estimated reduction in the odds of pharmacological rescue event at discharge (0.91 [0.65–1.3]; P?=?0.5661). For outpatients, capnography monitoring was associated with a 61% estimated reduction in the odds of pharmacological rescue event at discharge (0.39 [0.29, 0.52]; P?<?0.0001) and a non-significant 82% estimated reduction in the odds of death at discharge (0.18 [0.02, 1.99]; P?=?0.16).

Conclusions

In hospital medical inpatients and all outpatients undergoing GEP performed with sedation, capnography monitoring was associated with a reduced likelihood of pharmacological rescue events in outpatients and death in inpatients when assessed at discharge. Despite the limitations of the retrospective data analysis methodology, the use of capnography during these procedures is recommended.