Abnormal fatty acid metabolism in spinal muscular atrophy may predispose to perioperative risks. Zolkipli Zarazuela,Sherlock Mary,Biggar William D,Taylor Glenn,Hutchison Jamie S,Peliowski Arie,Alman Benjamin A,Ling Simon C,Tein Ingrid European journal of paediatric neurology : EJPN : official journal of the European Paediatric Neurology Society A 15 year old boy with SMA type II underwent spinal fusion and suffered a mitochondrial Reye-like catabolic crisis 4 days postop with hypoketotic hypoglycemia, lactic acidaemia, hyperammonemia and liver failure, with 90% coagulative necrosis and diffuse macro- and microvesicular steatosis, requiring orthotopic liver transplantation. This crisis responded in part to mitochondrial therapy and anabolic rescue. He made a dramatic sustained neurological recovery, though his post-transplant liver biopsies revealed micro- and macrosteatosis. We hypothesize that a combination of surgical stress-catecholamine induced lipolysis, prolonged general anaesthesia with propofol and sevoflurane, and perioperative fasting on a background of decreased β-oxidation were potential risk factors for the mitochondrial decompensation. 10.1016/j.ejpn.2012.01.004

A randomized controlled trial comparing methohexital and propofol for induction in patients receiving angiotensin axis blockade. Medicine BACKGROUND:Pharmacologic angiotensin axis blockade (AAB) has been associated with profound hypotension following anesthetic induction with propofol. To combat this problem, investigators have attempted to withhold angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) preoperatively, or evaluated the effects of different induction agents in conferring greater hemodynamic stability. To date, methohexital has not been compared with the most commonly used induction agent, propofol. Hence, the primary objective was to study the hypothesis that methohexital confers a better hemodynamic profile than propofol for anesthetic induction, in patients receiving AAB. The secondary objective was to investigate the postinduction levels of serum neurohormones in an attempt to explain the mechanisms involved. METHODS:Forty-five adult, hypertensive patients taking ACEi or ARB and scheduled for elective, noncardiac surgery completed the study. Patients were randomized to receive equi-anesthetic doses of either propofol or methohexital for anesthetic induction. Hemodynamic variables were measured and blood samples were drawn before induction and for 15 minutes afterwards. RESULTS:Methohexital resulted in less hypotension compared with propofol (P = .01), although the degree of refractory hypotension was similar (P = .37). The postinduction systolic blood pressure (P = .03), diastolic blood pressure (P < .001) and heart rate (P = .03) were significantly higher in the methohexital group. A nonsignificant elevation of serum norepinephrine and epinephrine levels was observed in the methohexital group, while serum arginine vasopressin and angiotensin II levels did not differ between groups. CONCLUSION:While methohexital was shown to confer greater hemodynamic stability in patients taking ACEi/ARB, the measured hormone levels could not explain the mechanism for this effect. 10.1097/MD.0000000000014374

Effect of remimazolam induction on hemodynamics in patients undergoing valve replacement surgery: A randomized, double-blind, controlled trial. Liu Tianxiao,Lai Ting,Chen Jing,Lu Yizhi,He Fang,Chen Yanhua,Xie Yubo Pharmacology research & perspectives BACKGROUND:The stability of hemodynamics during anesthesia induction in patients undergoing valve replacement surgery is particularly important. Remimazolam is a new type of benzodiazepine drug, with supposed advantages of rapid induction, rapid recovery, stable hemodynamics, and mild respiratory inhibition. AIM:To evaluate the effect of remimazolam anesthesia induction on hemodynamics in patients undergoing valve replacement surgery. METHODS:This randomized, double-blind, controlled trial enrolled consecutive patients undergoing mitral valve replacement (MVR)/aortic valve replacement (AVR)/double-valve replacement (DVR) surgery on cardiopulmonary bypass (CPB). The study was conducted according to the Consolidated Standards of Reporting Trials statement. Participants were randomly assigned to receive either remimazolam or propofol induction of 30 patients each. All patients, data collectors, and data analyzers were blinded to the group allocation. The primary outcomes were the fluctuations in hemodynamic parameters (the difference of maximum or minimum heart rate to baseline, ▲HR, the difference of maximum or minimum mean arterial pressure to baseline, ▲MAP), the occurrence of cardiovascular events (hypotension, severe bradycardia), and the cumulative norepinephrine doses used per patient, averaged per group during induction. The secondary outcomes were hemodynamic parameters (heart rate, HR, mean arterial pressure, MAP, bispectral index, BIS, plasma lactic acid, Lac, and blood glucose, Glu values). RESULTS:A total of 60 patients with heart valve replacement were included in the final analysis, with 30 patients in each group. The ▲MAP was significantly lower in the remimazolam group than in the propofol group during induction (p < .05). The incidences of hypotension and the cumulative norepinephrine doses used per patient, averaged per group during induction were significantly lower in the remimazolam group than in the propofol group (p < .05). CONCLUSION:Remimazolam may be safe and effective for induction and may as an alternative to propofol during anesthesia induction in patients undergoing valve replacement surgery. 10.1002/prp2.851

[Anesthetic Management with Propofol Alone in a Patient with Hereditary Sensory and Autonomic Neuropathy]. Fujita Yuki,Nakamoto Ai,Inoue Mitsuko,Hayashi Yasue,Shimizu Motoko,Hotta Arisa,Yoshikawa Noriko,Ohira Naoko,Tatekawa Shigeki Masui. The Japanese journal of anesthesiology Hereditary sensory and autonomic neuropathy (HSAN) is a rare peripheral nerve disorder associated with sensory dysfunction (pain, touch, and pressure) and various degrees of autonomic dysfunction. We administered general anesthesia for a 54-year-old woman with HSAN type II undergoing amputation of the left hallux. She had reduced sensation for pain, pressure, and temperature since birth and frequently injured her hands and legs. Before the operation, she did not report pain in the hallux. Only propofol was given for anesthesia without use of analgesia. Intraoperatively, her vital signs were stable. To evaluate the sympathetic nervous response to surgical stimulation, we measured the plasma catecholamine levels before tracheal intubation and just before and during surgery. Plasma catecholamine levels were normal at all time points, indicating no sympathetic responses to surgical stimulation. This case suggests that anesthesia for HSAN II patients can be safely managed with propofol alone.

Different effects of propofol and dexmedetomidine on preload dependency in endotoxemic shock with norepinephrine infusion. Yu Tao,Li Qing,Liu Ling,Guo Fengmei,Longhini Federico,Yang Yi,Qiu Haibo The Journal of surgical research BACKGROUND:To clarify whether propofol (PROP) and dexmedetomidine (DEX) differentially affect preload dependency in an endotoxemic model based on evaluations of the systemic vascular system and cardiac function. METHODS:Animals were prepared under PiCCO monitoring (BL), and endotoxemic shock was induced using an intravenous bolus of lipopolysaccharide (055:B5) in 16 New Zealand ketamine-anesthetized rabbits. After fluid resuscitation and norepinephrine infusion (SD0), the animals were randomized to PROP (n = 8) or DEX (n = 8) sedation at two incremental doses (SD1 and SD2). The mean arterial pressure and the central venous pressure were monitored. Pulse pressure variation (PPV) was assessed to evaluate preload dependency. Global end-diastolic volume, vascular resistance, mean systemic filling pressure, and cardiac function index were assessed at each time point. RESULTS:PPV progressively and significantly increased with increasing infusion rates of PROP (SD1 versus SD0, P < 0.01; SD2 versus SD0, P < 0.001; and SD2 versus SD1, P = 0.024) but not DEX. PPV was higher at SD1 and SD2 in the PROP group than in the DEX group (P < 0.001). PROP increased the heart rate without affecting cardiac contractility or vascular resistance. In contrast, DEX decreased heart contractility and increased vascular resistance at the highest dose. However, neither drug affected mean arterial pressure, central venous pressure, mean systemic filling pressure, global end-diastolic volume, or venous return. CONCLUSIONS:PROP more effectively increased PPV than DEX in an endotoxemic shock model after fluid resuscitation during norepinephrine infusion. DEX, but not PROP, at the highest dose influenced vascular resistance and heart contractility. 10.1016/j.jss.2015.05.029