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.

Previous research has shown that a preoperative assessment clinic enhances hospital cost-efficiency. However, the differences in organization of the patient flow have not been analysed. In this descriptive study, we evaluated the consequences of the organization of the patient flow of a preoperative assessment clinic on its performance, by analysing two Dutch university hospitals, which are organized essentially differently.

In the final analysis, the study included 880 patients who visited either academic centre. The performance of the two preoperative assessment clinics was evaluated by measuring patient flow time, various procedure times and the total waiting time. Patients’ age, ASA physical status and any preoperative tests requested by the physician were also recorded.

There was a significant difference in patient flow time between the two preoperative assessment clinics. More time was needed for the preoperative assessment when patients’ ASA class was higher. The patient flow time was longer when electrocardiogram and venepuncture were performed at the general outpatient laboratory than when they were performed at the preoperative assessment clinic due to longer waiting times. More tests were requested when they were performed at the preoperative assessment clinic.

This study shows that the organization of patient flow is an important aspect of the logistic processes of the preoperative assessment clinic. It might influence patient flow times as well as the number of preoperative tests requested. Together with other aspects of logistic performance, patient satisfaction and quality of medical assessment, patient flow logistics can be used to assess the quality of a preoperative assessment clinic.

Vasoactive substances such as histamine, acetylcholine or ATP increase the [Ca2+]i of endothelial cells, which leads to the activation of nitric oxide synthase (eNOS). The NO produced by this enzyme relaxes the underlying smooth muscle. Evidence suggests that eNOS activation is dependent on agonist-induced Ca2+ entry. Recently we have shown that in human endothelial cells (HUVEC), this Ca2+ entry is sensitive to isoflurane. The objective here was to study the mechanism by which volatile anaesthetics can depress the histamine-induced Ca2+ entry into HUVEC cells.

HUVECs on coverslips were loaded with the Ca2+ indicator Fluo-3 and inserted in a gastight, temperature-controlled perfusion chamber. Excitation was at 488 nm and fluorescence signals were monitored with a confocal laser scanning microscope (MRC1024, Biorad). Direct measurement of the Ca2+ influx was with Mn2+ as surrogate for calcium at 360 nm in cells loaded with Fura-2.

Addition of histamine induces a biphasic [Ca2+]i increase consisting of Ca2+ release from internal stores and a Ca2+ influx from the external medium (plateau phase). The plateau phase was dose-dependently inhibited by enflurane and sevoflurane (13.7 resp. 21.9% inhibition by 1 MAC anaesthetic). Direct measurement of the Ca2+ influx using the Mn2+ quench of the Fura-2 fluorescence gave similar results. The inhibition of the anaesthetics was not reduced by inhibition of the cGMP pathway, inactivation of protein kinase C, depolarization of the cells or the presence of specific Ca2+-dependent K+ channel inhibitors. Interestingly, unsaturated fatty acids inhibit the histamine-induced Ca2+ influx in a similar way as the volatile anaesthetics.

Volatile anaesthetics dose-dependently inhibit the histamine-induced Ca2+ influx in HUVECs by a mechanism that may involve unspecific perturbation of the lipid bilayer.

Patent blue (4-[(4-diethylaminophenyl)-(4-diethylazaniumylidencyclohexa-2,5-dienyliden) methyl]-6-hydroxy-3-sulfo-benzolsulfonate, sodium salt) is a contrast dye used for the intraoperative detection of the primary lymphatic nodes draining the area of tumour infiltration. The dye is known to interact with pulse oximeter readings. However, the degree of alteration seems to be moderate and predictable when patent blue is injected into the perimammilar region during breast surgery.

Here we report severe interference with the anaesthetic monitoring when patent blue was injected into the cervix prior to laparoscopy-assisted radical vaginal hysterectomy for cervical cancer.

Injection of patent blue into the cervix induced a rapid (within 14 ± 9 min after the injection) and severe (from ⩾98% to 89 ± 2%) decrease in pulse oximeter readings, accompanied by positive methaemoglobin values of 7.3 ± 2.5% (arterial co-oximetry, Bayer Rapidlab 865 blood gas analyser; Bayer, Fernwald, Germany). Control of these values by a different device (Radiometer ABL co-oximeter blood gas analyser; Radiometer, Willich, Germany) yielded negative methaemoglobin results (<1.7%, mean 0.9 ± 0.6%). The arterial PO2 was normal in all patients throughout the procedure.

Injection of patent blue into the cervix uteri interferes dramatically with pulse oximeter readings. This situation is further complicated by device-dependent arterial co-oximetry methaemoglobin results. For the time being it is recommendable to monitor adequate oxygenation of the patient in the presence of patent blue by regular control of the arterial PO2. Clearly, the unresolved issue of reliable methaemoglobin determination in the presence of patent blue remains a matter of clinical concern for anaesthetists.

Rheumatoid arthritis is a lifelong systemic disease that can affect any joint with a synovium. Managing intubation in patients with rheumatoid disease is a special challenge in these patients especially if specific joints, which play an important role during intubation, are affected. We aimed to investigate if there was a correlation between the activity and duration of the disease and the commonly used predictors of difficult intubation in rheumatoid arthritis.

Sixty-six patients with the diagnosis of rheumatoid arthritis and 60 control patients were included in the study. Patient characteristics were recorded. Body mass index, disease activity scores, Mallampati classification, sternomental distance, thyromental distance, inter-incisor distance and atlanto-occipital joint extension were measured for each patient. Every patient was asked to complete the Stanford Health Assessment Questionnaire (HAQ score). Disease activity score (DAS 28 score) including 28 joints was used to assess the activity of the disease. Correlation between the predictors of difficult intubation and activity was assessed and was compared with the control group.

Mallampati scores were higher (P = 0.000), sternomental distance (P = 0.005) and inter-incisor distance (P = 0.003) were shorter and also occlusal surface–upper teeth angle (P = 0.000) and mouth corner–tragus line angle were smaller in the rheumatoid arthritis group compared with controls (P = 0.000). We did not observe a correlation between the disease activity scores and the Mallampati score (P = 0.619), sternomental distance (P = 0.195), thyromental distance (P = 0.174), inter-incisor distance (P = 0.764), angle I (P = 0.372) and angle II (P = 0.609). There was no correlation between the HAQ score and the Mallampati score (P = 0.872), sternomental distance (P = 0.455), thyromental distance (P = 0.841), inter-incisor distance (P = 0.162), angle I (P = 0.768) and angle II (P = 0.287). There was no correlation between the duration of the disease and the Mallampati score (P = 0.619), sternomental distance (P = 0.505), thyromental distance (P = 0.426), inter-incisor distance (P = 0.813), angle I (P = 0.377) and angle II (P = 0.600).

Tests of disease activity and the duration of the disease were not found to be correlated with the predictors of difficult intubation in this study. Thus, performing the predictive tests for difficult intubation especially in patients with very low scores or short disease is recommended.

Unlike for intensive care unit and home mechanical ventilators, no study has evaluated the user-friendliness of the recently introduced new anaesthesia workstations.

We performed a prospective study to evaluate the user-friendliness of four anaesthesia workstations, which were categorized into two groups: first-generation (Kion) and second-generation (Avance, Felix and Primus). Twenty users (12 nurse-anaesthetists and 8 anaesthesiologists) from three different anaesthesia departments at the same univeristy hospital participated in the study. The user-friendliness scale evaluated 10 criteria, including two design and monitoring criteria, four maintenance criteria and four ventilation use criteria. Each criterion was evaluated from 0 (poor) to 10 (excellent).

The mean score obtained for the first-generation workstation was lower than those obtained for the three second-generation workstations (P < 0.05). No significant differences in the overall user-friendliness score was observed for the three second-generation workstations. The first-generation workstation obtained a significantly lower score than the three second-generation workstations for the design criteria (P < 0.01). For the screen criteria, the highest score was obtained by Felix, which has the largest screen and associated characters. For the main maintenance criteria, Kion and Felix obtained the lowest scores. No significant differences between the four anaesthesia workstations were found for only three of the user-friendliness criteria (self-test, alarms and settings).

Anaesthesia machines have benefited from considerable advances in design and technology. This novel user-friendliness scale revealed that the most recent workstations were more appreciated by users than the first-generation of anaesthesia workstations. This user-friendliness scale may help the anaesthetic staff to ‘consensually’ choose the future workstation for their anaesthesia department.

Functional endoscopic sinus surgery can be performed under either local or general anaesthesia. The objective of this study was to investigate the haemodynamic effects of perioperatively administered dexmedetomidine, a new generation α-2-agonist, in patients for functional endoscopic sinus surgery.

Sixty-two patients who were planned to undergo functional endoscopic sinus surgery under local anaesthesia were included in the study. Following meperidine premedication, both groups were monitored in a standard manner with electrocardiogram, non-invasive blood pressure and percentages of peripheral saturation of oxygen. Saline intravenous infusion was started in the placebo group, and dexmedetomidine bolus intravenous infusion (an initial loading dose of 1 μg kg−1 given for a 10-min period followed by 0.7 μg kg−1 h−1) was administered to the treatment group. Maintenance dose infusion was stopped 15 min before the end of the surgical procedure.

Systolic, diastolic and mean arterial pressures, and heart rate markedly decreased in the dexmedetomidine group. However, dexmedetomidine had no effect on serum nitric oxide levels, measured by a nitric oxide/ozone chemiluminescence method. No significant difference was found in oxygen saturation levels of the two groups. Postoperative nausea and vomiting rates were significantly lower in the dexmedetomidine group. No adverse effects were observed with this α-2-agonist. Dexmedetomidine provided appropriate levels of sedation.

These results suggest that dexmedetomidine provides analgesia, adequate sedation and surgical comfort without adverse effects for patients undergoing functional endoscopic sinus surgery under local anaesthesia.

Combined spinal epidural analgesia is effective for fast relief of severe labour pain but has been associated with worrisome decreases in fetal heart rate. Since the reasons for this phenomenon remain elusive, some anaesthesiologists may abstain from using this technique. We postulated that factors unrelated to the neuraxial technique could play a role in the decrease in fetal heart rate. To our knowledge, no prospective study has previously looked into this possibility.

We collected prospective data on 223 consecutive patients who received combined spinal epidural analgesia (123) or epidural analgesia (100). Maternal blood pressure, analogue pain scores, exogenous infusion of oxytocin, cervical dilatation, maternal age, parity and ethnicity were collected and correlated with the occurrence of decreases in fetal heart rate post combined spinal epidural.

Univariate analysis showed a correlation between the incidence of fetal bradycardia and higher maternal pain scores, older maternal age, and combined spinal epidural analgesia. Multivariate analysis revealed that only pain scores and maternal age were independent predictors of fetal bradycardia post neuraxial blockade.

Maternal pain scores and older maternal age are factors unrelated to the neuraxial technique that are independent predictors of fetal bradycardia after neuraxial analgesia for labour.

To determine whether magnesium sulphate could induce controlled hypotension, reduce choroidal blood flow, provide a ‘dry’ operative field and could be compared with sodium nitroprusside in the recently raised issue of the use of hypotensive anaesthesia in eye surgery, i.e. for choroidal tumour surgery as the choroid is the most fragile and vascular structure in the eye.

Forty adult patients undergoing choroidal melanoma resection and anaesthetized with 2.5 mg kg−1 propofol, followed by a constant infusion of 120 μg kg−1 min−1, and remifentanil 1 μg kg−1, followed by a continuous infusion of 0.25 μg kg−1 min−1, were randomly assigned to two groups to receive either magnesium sulphate or sodium nitroprusside.

Controlled hypotension was achieved at the target systolic pressure of 80 mmHg within 107 ± 16 and 69 ± 4.4 s for magnesium sulphate and sodium nitroprusside, respectively. Choroidal blood flow decreased by 24 ± 0.3% and 22 ± 3.3% for magnesium sulphate and sodium nitroprusside, respectively. Controlled hypotension was sustained in both groups throughout surgery, and the surgical field rating decreased in a range of 80% in both groups. Sodium nitroprusside decreased pH and increased PaCO2. There were no postoperative complications in any of the groups.

Magnesium sulphate controlled hypotension, reduced intraoperative pressure and provided good surgical conditions for choroidal melanoma resection with no need for additional use of a potent hypotensive agent in adults.

Anaesthetic requirements differ among inbred mouse strains. We tested the genetic influence on induction and arousal times to inhalational anaesthetics in two of these strains.

Five male C57BL/6J (B6) and five male C3H/HeJ (C3) mice were each exposed to five different concentrations of nitrous oxide (N2O) at five different levels of halothane. Time to sleep and arousal were assessed. Data were analysed by repeated measures of analysis of variance.

Halothane, N2O and genetic strain, all were significant independent factors on the time to sleep, while only N2O was a significant independent factor on the time to arousal (P = 0.004). B6 mice took significantly longer to fall asleep compared to the C3 mice controlling for halothane and N2O concentrations (F-ratio = 36, P < 0.0001). The effect of N2O on time to arousal was only significant for the B6 strain (F-ratio = 10, P = 0.005), and not for the C3 strain (F-ratio = 0.8, P = 0.38).

Genetics influences the time to sleep for anaesthetic agents in mice.

The measurement of α-glutathione-S-transferase enzyme is one of the most sensitive indicators of hepatocellular function. Variation in the glutathione-S-transferase P1 gene clusters has been intensively investigated and polymorphism has been described. The aim of the study was to assess whether an association exists between glutathione-S-transferase P1 gene polymorphism and serum α-glutathione-S-transferase concentrations for the first postoperative day in patients who underwent anaesthesia with sevoflurane.

In all, 54 unrelated patients were enrolled in this study. Anaesthesia was induced with thiopental and fentanyl. Vecuronium was used for neuromuscular relaxation before endotracheal intubation. Anaesthesia was maintained with sevoflurane in a gas mixture containing 50% nitrous oxide in oxygen. Peripheral venous blood samples to determine serum α-glutathione-S-transferase concentrations were collected before induction (T1), at the end of anaesthesia (T2) and at 24-h postoperatively (T3). Enzyme-linked immunosorbent assay (ELISA) immunoassay was used to measure α-glutathione-S-transferase levels. Genomic DNA was isolated from serum samples using a genomic DNA purification kit. In order to detect the variants of glutathione-S-transferase P1, polymerase chain reaction – restriction fragment length polymorphism analysis was employed.

Early postoperative serum α-glutathione-S-transferase levels for all patients were significantly increased when compared with preanaesthetic and 24-h postoperatively (P < 0.05). Serum α-glutathione-S-transferase concentrations, in individuals with glutathione-S-transferase P1 Ile105Val genotypes (heterozygote gene), remained elevated at 24 h (P < 0.05), whereas levels in individuals with glutathione-S-transferase P1 Ile105Ile (wild gene) decreased (P > 0.05).

Although α-glutathione-S-transferase levels were elevated in all patients after sevoflurane anaesthesia, levels remained high at 24 h in patients with glutathione-S-transferase P1 Ile105Val genotypes compared to controls.

Radical prostatectomy is at high risk for intraoperative and postoperative bleeding due to surgical trauma, release of urokinase and tissue type plasminogen activator. We conducted this prospective, observational multi-centre study to assess the degree of systemic fibrinolysis or hypercoagulation in the perioperative period. We studied serial changes in standard laboratory values and in thrombelastographic (TEG®; Haemoscope Corporation, Skokie, IL, USA) parameters including lysis at 30 and 60 min (LY-30, LY-60), alpha-angle (α) and maximum amplitude.

In all, 49 patients undergoing radical retropubic prostatectomy in five Italian University Hospitals were included. Blood samples were taken before surgery (T1), at the removal of the prostate (T2), 4 h after surgery (T3) and then 1 day after surgery (T4). Native blood samples were analysed using a thrombelastograph Haemoscope 5000 (Haemoscope Corporation).

We did not see any relevant activation of fibrinolysis during any stage. Intraoperatively, we showed even more activated blood coagulation with consumption of fibrinogen and a reduced TEG® percentage clot lysis. Only at the first postoperative sample point we saw a trend towards a more fibrinolytic state indicated by increasing partial thromboplastin time, LY-30 and LY-60 values, and a peak of the fibrin degradation product D-dimers. This is consistent with a normal reaction to the hypercoagulable state before and is unlikely to be due to an intraoperative tissue type plasminogen activator release. We found no evidence of an uncontrolled activation of fibrinolysis on the day after surgery. On the contrary, α-values which indicate the rate of clot formation and which increase during hypercoagulation showed the tendency to rise slightly compared with the preoperative value.

Neither standard coagulation parameters nor TEG® values showed any significant activation of fibrinolysis or of hypercoagulation in the preoperative period. Nevertheless, hypercoagulation seems to have a substantial clinical impact as it has been shown that cardiovascular complications and pulmonary embolism were the most common causes of death after retropubic prostatectomy.

The influence of the combined application of cisplatin and sevoflurane on a variety of cell types of healthy mice or mice bearing Ehrlich ascites tumour has been investigated in an in vivo study.

The alkaline comet assay method was carried out on peripheral blood leucocytes, brain, liver, kidney and tumour cells of healthy mice or mice bearing Ehrlich ascites tumour. Groups of mice were treated intraperitoneally with cisplatin, exposed to sevoflurane or by combined treatment of sevoflurane after treatment with cisplatin for 3 consecutive days.

The in vivo exposure to sevoflurane induced genotoxicity to all assayed cells. A strong synergistic genotoxic effect to peripheral blood leucocytes, liver and kidney cells was found in mice receiving both cisplatin and sevoflurane. In contrast, a decrease of the comet tail lengths of brain cells in the combined treatments was found as compared to cisplatin alone in both healthy (P < 0.001) and Ehrlich ascites tumour-bearing mice (P < 0.05), respectively. In addition, Ehrlich ascites tumour cells of mice treated with combined treatments showed a decrease in tail lengths (P < 0.001). These findings indicate an antagonistic effect of combined treatments.

Treatment of mice with cisplatin and sevoflurane induced genotoxic effect in peripheral blood leucocytes, liver, kidney, brain and Ehrlich ascites tumour cells; synergistic effect of combined treatments was expressed in all cells but brain and Ehrlich ascites tumour cells.

To investigate the effect of urinary flow rate on the urinary bladder temperature, we compared the accuracy and precision of urinary bladder temperature with oesophageal temperature at both high and low urine flow rates.

Twenty-four patients ASA physical status I or II who were undergoing tympanoplasty were randomly assigned to two groups with different intravenous fluid volumes: high (10 mL kg−1 h−1, n = 12) and low (3 mL kg−1 h−1, n = 12). General anaesthesia was induced with propofol and maintained with sevoflurane (1.5–2.5%) in nitrous oxide and oxygen. Urinary bladder temperature was measured using a Foley urinary catheter; distal oesophageal temperature was measured using a stethoscope thermocouple. These temperatures were measured every 5 min during surgery and the accuracy and precision of urinary bladder temperature with oesophageal temperature were determined using regression and Bland and Altman analyses.

The correlation coefficient for oesophageal and urinary bladder temperature was 0.90 in the high urinary volume group and 0.75 in the low urinary volume group. The offset (oesophageal–urinary bladder) was −0.13 ± 0.32°C and −0.46 ± 0.45°C, respectively.

Urinary bladder temperature appears to be more accurate at high urinary flow rates than at low urinary flow rates for clinical use.

Adrenomedullin is a potent vasodilatory peptide. The mechanisms of adrenomedullin-induced responses are via guanine nucleotide guanosine 5′-triphosphate-binding protein (G-protein)-coupled receptor activation and are similar to those of calcitonin gene-related peptide (CGRP). Previously, we reported that sevoflurane and isoflurane inhibit CGRP-induced haemodynamic responses. The effects of volatile anaesthetics on adrenomedullin-induced haemodynamic responses, however, are unclear. We hypothesized that the volatile anaesthetic isoflurane inhibits adrenomedullin-induced haemodynamic responses. We studied the effects of isoflurane on adrenomedullin-induced haemodynamic responses in pithed rats, which enables us to evaluate the direct cardiovascular effects of drugs without interference from centrally mediated circulatory reflexes.

Male Wistar rats were pithed by inserting a stainless-steel rod into the spinal cord. Following median sternotomy, a flow probe was placed around the ascending aorta to measure aortic blood flow. Mean arterial pressure and cardiac output were maintained at approximately 100 mmHg and 50 mL min−1, respectively, with continuous infusion of norepinephrine. After 30 min inhalation of isoflurane (1%, or 2%) in oxygen, or only oxygen, adrenomedullin (1, 3, 10 or 30 μg kg−1) was administered intravenously.

Adrenomedullin administration induced a transient increase followed by a persistent decrease in mean arterial pressure and cardiac output. Isoflurane (2%) significantly inhibited the initial increase in mean arterial pressure and the later decrease in mean arterial pressure and systemic vascular resistance.

Isoflurane inhibits adrenomedullin-induced vasodilation and positive inotropic effect in pithed rats. Isoflurane might inhibit the adrenomedullin receptor-mediated response, which is a common pathway for both actions.

In emergency trauma situations, manual in-line stabilization of the cervical spine is recommended to reduce cervical spine movement during intubation. The aim of this study was to compare the effect of manual in-line stabilization during different intubation techniques on three-dimensional cervical spine movements and times to intubation.

Forty-eight subjects without any history of trauma, inflammatory or degenerative disorder of the cervical spine were randomly grouped, regardless of gender or age. All underwent elective surgery under general anaesthesia. Under manual in-line stabilization, laryngeal intubation with Macintosh laryngoscope, intubating laryngeal mask airway, fibre-endoscopic oral intubation and fibre-endoscopic nasal intubation was performed. During the intubation process, cervical three-dimensional motion was detected by an ultrasound real-time motion analysis system and intubation times were measured.

Cervical spine range in the extension/flexion direction of orolaryngeal intubation with Macintosh (17.57 ± 8.23°) showed significantly more movement than using the intubating laryngeal mask airway (4.60 ± 1.51°) and fibreoptic procedures. Intubating laryngeal mask airway was significantly different than the fibreoptic intubation techniques. There was also a significant difference between oral (3.61 ± 2.25°) nasal and (5.88 ± 3.11°) fibreoptic intubation. Times to intubation all differed significantly (P < 0.05) for the Macintosh laryngoscope (27.25 ± 8.56 s) and for the intubating laryngeal mask airway (16.5 ± 9.76 s). Fibreendoscopic laryngoscopic oral (52.91 ± 56.27 s) and nasal (82.32 ± 54.06 s) intubation resulted in further prolongation of the times to intubation.

The intubating laryngeal mask airway with manual in-line stabilization is a potentially useful adjunct to intubation of patients with potential cervical spine injury, if there are no contraindications to these methods. These results predict that fibreoptic procedures may be a safe instrument for airway management in patients with potential cervical spine injuries; however, the main disadvantages are the longer intubation times.

The line joining the two iliac crests is classically regarded as the anatomical landmark determining the inter-vertebral space L4–L5 for the spinal punctures. Its variability has been reported but never related to predictive clinical anatomic factors identifying patients groups in which there is increased risk of miscalculation of the spinal level.

Two sagittal pelvic anatomical angles, called ‘pelvic incidence’ and ‘pelvic lordosis’ were measured on lateral X-rays of the pelvis of 132 normal individuals and 49 spondylolysis patients. The values were compared with the sagittal projection of the intercrestal line on the disco-vertebral lumbar structures.

A strict relation was observed between this projection of the intercrestal line and the sagittal pelvic anatomical angles. The greater the pelvic incidence, the higher the intercrestal line was projected, all the more in patients with spondylolysis with a listhesis or a disc narrowing.

The relation between the pelvic sagittal angles and the intercrestal line projection explains the variability described for this anatomical landmark. It implies precautions minimizing neurological risk in the case of a puncture carried out more cranially than expected, particularly for high values of pelvic incidence occurring in spinal pathologies such as spondylolysis, in the elderly or in the obese patients. In these cases, we recommend the use of spinal imaging during the procedure to assist selection of the desired insertion level.

Pumpless arteriovenous extracorporeal lung assist is increasingly used as a rescue therapy in acute respiratory distress syndrome. Arteriovenous extracorporeal lung assist is highly efficient in eliminating carbon dioxide and allows the application of ventilator techniques that prioritize lung protection and aim to reduce ventilator-induced lung injury and remote organ dysfunction.

Retrospective data analysis performed in a 12-bed university hospital ICU. In all, 22 patients with acute respiratory distress syndrome refractory to standard care were included. Arteriovenous extracorporeal lung assist as central part of a multimodal treatment concept was combined with tidal volume (VT) reduction below 4 mL kg−1 predicted body weight, a positive end-expiratory pressure titrated to optimize oxygenation and continuous axial rotation.

Hypercapnia was reversed within 24 h in survivors (39 mmHg (35–42) (median and interquartile range) vs. 65 mmHg (54–72), P < 0.05) and non-survivors (5.2 kPa (5.5–6.0) vs. 10 kPa (6.9–13.9), P < 0.05). Oxygenation was significantly improved in survivors after 24 h (PaO2/FiO2 ratio 20.7 kPa (17.4–22.7) vs. 11.7 kPa (7.3–20.8), P < 0.05). All patients required norepinephrine infusion and volume resuscitation. The overall complication rate was 23%, predominantly due to reversible lower limb ischaemia. One patient (5%) was permanently disabled due to amputation of a seriously injured lower leg 9 days after initiation of arteriovenous extracorporeal lung assist therapy; however, the patient survived without neurological deficits despite an initial oxygenation index of 4.4 kPa. The overall mortality rate was 27%.

A multimodal treatment concept with arteriovenous extracorporeal lung assist as its central part provides reversal of hypercapnia and stabilization of oxygenation. In an attempt to maximize lung protection and potentially reduce ventilator-induced lung injury, a further VT reduction below 4 mL kg−1predicted body weight combined with a high mean airway pressure and continuous axial rotation is safely possible.

Patients with impaired renal function are at risk of developing renal dysfunction after abdominal aortic surgery. This study investigated the safety profile of a recent medium-molecular-weight hydroxyethyl starch (HES) preparation with a low molar substitution (HES 130/0.4) in this sensitive patient group.

Sixty-five patients were randomly allocated to receive either 6% hydroxyethyl starch (Voluven®; n = 32) or 3% gelatin (Plasmion®; n = 33) for perioperative volume substitution. At baseline, renal function was impaired in all study patients as indicated by a measured creatinine clearance < 80 mL min−1. The main renal safety parameter was the peak increase in serum creatinine up to day 6 after surgery.

Both treatment groups were compared for non-inferiority (pre-defined non-inferiority range hydroxyethyl starch < gelatin + 17.68 μmol L−1 or 0.2 mg dL−1). Other renal safety parameters included minimum postoperative creatinine clearance, incidence of oliguria and adverse events of the renal system. Baseline characteristics, surgical procedures and the mean total infusion volume were comparable. Non-inferiority of hydroxyethyl starch vs. gelatin could be shown by means of the appropriate non-parametric one-sided 95% CI for the difference hydroxyethyl starch − gelatin [−∞, 11 μmol L−1]. Oliguria was encountered in three patients of the hydroxyethyl starch and four of the gelatin treatment group. One patient receiving gelatin required dialysis secondary to surgical complications. Two patients of each treatment group died.

As we found no drug-related adverse effects of hydroxyethyl starch on renal function, we conclude that the choice of the colloid had no impact on renal safety parameters and outcome in patients with decreased renal function undergoing elective abdominal aortic surgery.