Huei-Ming Yeh

Is a pre-operative brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide measurement an independent predictor of adverse cardiovascular outcomes within 30 days of noncardiac surgery? A systematic review and meta-analysis of observational studies.

OBJECTIVES We conducted a systematic review and meta-analysis to determine if pre-operative brain natriuretic peptide (BNP) (i.e., BNP or N-terminal pro-B-type natriuretic peptide [NT-proBNP]) is an independent predictor of 30-day adverse cardiovascular outcomes after noncardiac surgery. BACKGROUND Pre-operative clinical cardiac risk indices have only modest predictive power. BNP predicts adverse cardiovascular outcomes in a variety of nonsurgical settings and may similarly predict these outcomes in the perioperative setting. METHODS We employed 5 search strategies (e.g., searching bibliographic databases), and we included all studies that assessed the independent prognostic value of pre-operative BNP measurement as a predictor of cardiovascular complications after noncardiac surgery. We determined study eligibility and conducted data abstraction independently and in duplicate. We calculated a pooled odds ratio using a random effects model. RESULTS Nine studies met eligibility criteria, and included a total of 3,281 patients, among whom 314 experienced 1 or more perioperative cardiovascular complications. The average proportion of patients with elevated BNP was 24.8% (95% confidence interval [CI]: 20.1 to 30.4%; I(2) = 89%). All studies showed a statistically significant association between an elevated pre-operative BNP level and various cardiovascular outcomes (e.g., a composite of cardiac death and nonfatal myocardial infarction; atrial fibrillation). Data pooled from 7 studies demonstrated an odds ratio (OR) of 19.3 (95% CI: 8.5 to 43.7; I(2) = 58%). The pre-operative BNP measurement was an independent predictor of perioperative cardiovascular events among studies that only considered the outcomes of death, cardiovascular death, or myocardial infarction (OR: 44.2, 95% CI: 7.6 to 257.0, I(2) = 51.6%), and those that included other outcomes (OR: 14.7, 95% CI: 5.7 to 38.2, I(2) = 62.2%); the p value for interaction was 0.28. CONCLUSIONS These results suggest that an elevated pre-operative BNP or NT-proBNP measurement is a powerful, independent predictor of cardiovascular events in the first 30 days after noncardiac surgery.

Preoperative plasma N‐terminal pro‐brain natriuretic peptide as a marker of cardiac risk in patients undergoing elective non‐cardiac surgery

Plasma N‐terminal pro‐brain natriuretic peptide (NTproBNP) is a sensitive marker for heart failure. This study tested whether the preoperative plasma level of NTproBNP could predict cardiac complications in patients undergoing non‐cardiac surgery.

Intravenous lidocaine and ephedrine, but not propofol, suppress fentanyl-induced cough

PurposeThe aim of this study was to evaluate the effectiveness of lidocaine, propofol and ephedrine in suppressing fentanyl-induced cough.MethodsOne hundred and eighteen patients were randomly assigned into four groups and the following medications were given intravenously: patients in Group I (n = 31) received normal saline 2 mL, Group II (n = 29) received lidocaine 2 mg · kg−1, Group III (n = 30) received propofol 0.6 mg · kg−1 and Group IV (n = 28) received ephedrine 5 mg. At one minute after the study medication, fentanyl 2.5 μg · kg−1 was given intravenously within two seconds. The occurrence of cough and vital sign profiles were recorded within two minutes after fentanyl bolus by an anesthesiologist blinded to study design.ResultsSixty-five percent of patients in the placebo group had cough, whereas the frequency was significantly decreased in Groups II(14%) and IV (21%). Although a numerically lower frequency of cough was noted in Group III (37%), it was not statistically different from that of the placebo group. SpO2 decreased significantly in patients of Group III compared to placebo; one patient experienced hypoxemia necessitating mask ventilation. Patients in Group III showed a decrease in heart rate and systolic blood pressure (2 beats · min−1 and 8 mmHg vs baseline). Patients in Group IV showed an increase in both measurements (5 beats · min−1 and 8 mmHg vs baseline). No truncal rigidity was observed throughout the study.ConclusionsIntravenous lidocaine 2 mg · kg−1 or ephedrine 5 mg, but not propofol 0.6 mg · kg−1, was effective in preventing fentanyl-induced cough. The results provide a convenient method to decrease fentanyl-induced cough.RésuméObjectifÉvaluer l’efficacité de la lidocaïne, du propofol et de l’éphédrine dans la suppression de la toux induite par le fentanyl.MéthodeCent dix-huit patients ont été répartis au hasard en quatre groupes et ont reçu: Groupe l (n = 31), 2 mL de solution saline; Groupe II (n = 29), 2mg · kg−1de lidocaïne; Groupe III (n = 30), 0,6 mg · kg−1 de propofol et Groupe IV (n = 28), 5 mg d’éphédrine. À une minute après la médication expérimentale, 2,5 μg · kg−1 de fentanyl iv ont été administrés en moins de deux secondes. L’occurrence de toux et les profils des signes vitaux ont été enregistrés par un anesthésiologiste impartial pendant les deux minutes qui ont suivi l’administration de bolus de fentanyl.RésultatsSoixante-cinq pour cent des patients du groupe placebo ont eu de la toux, tandis que la fréquence a significativement diminué dans les Groupes II (14 %) et IV (21 %). Même si une fréquence de toux numériquement plus basse a été notée dans le Groupe III, elle n’était pas statistiquement différente de celle du groupe placebo. La SpO2 a diminué significativement chez les patients du Groupe III comparé au groupe placebo; un patient a présenté de l’hypoxémie nécessitant une ventilation au masque. Les patients du Groupe III ont subi une baisse de la fréquence cardiaque et de la tension artérielle systolique (2 battements · min−1 et 8 mmHg vs les mesures de base). Ceux du Groupe IV ont présenté une augmentation de ces deux paramètres (5 battements · min−1 et 8 mmHg vs les mesures de base). Aucune rigidité tronculaire n’a été observée pendant l’étude.ConclusionL’administration iv de 2 mg · kg−1 de lidocaïne ou de 5 mg d’éphédrine, mais non de 0,6 mg · kg−1 de propofol, a été efficace pour prévenir la toux induite par le fentanyl. Les résultats offrent une méthode pratique de diminuer la toux induite par le fentanyl.

Functional genomic study on atrial fibrillation using cDNA microarray and two-dimensional protein electrophoresis techniques and identification of the myosin regulatory light chain isoform reprogramming in atrial fibrillation.

Introduction: Functional and structural changes of atrial tissue occur during the natural course of atrial fibrillation (AF), and these changes may contribute to further AF. We investigated the changes in AF tissue using cDNA microarray and two‐dimensional protein electrophoresis techniques.

The addition of morphine prolongs fentanyl-bupivacaine spinal analgesia for the relief of labor pain.

The combination intrathecal fentanyl (25 μg) and bupivacaine (2.5 mg) provides effective labor analgesia for approximately 90 minutes. The purpose of this prospective, randomized, double-blinded investigation was to determine if the addition of morphine (150 μg) to the intrathecal combination of fen

Usefulness of intravenous propofol anesthesia for radiofrequency catheter ablation in patients with tachyarrhythmias: infeasibility for pediatric patients with ectopic atrial tachycardia.

General anesthesia is sometimes required during radiofrequency catheter ablation (RFCA) of various tachyarrhythmias because of an anticipated prolonged procedure and the need to ensure stability during critical ablation. In this study, we examine the feasibility of using propofol anesthesia for RFCA procedure. There were 150 patients (78 male, 72 female; mean age 30 years, range 4–96 years) in the study. Electro physiologic study was performed before and during propofol infusion in the initial 20 patients and was performed only during propofol infusion in the remaining 130 patients. In the initial 20 patients, propofol infusion increased the sinus rate and facilitated AV nodal conduction. The accessory pathway effective refractory period, as well as the sinus node recovery time, atrial effective refractory period, and ventricular effective refractory period were not significantly changed. There were 152 tachyarrhythmias in 150 patients (24 atrial flutter, 31 AV nodal reentrant tachycardia, 68 AV reciprocating tachycardia, 12 ventricular tachycardia, and 17 atrial tachycardia). Most (148/152) tachycardias remained inducible after anesthesia and RFCA was performed uneventfully. However, in four of the seven pediatric patients with ectopic atrial tachycardia, the tachycardia terminated after propofol infusion and could not be induced by isoproterenol infusion. Consequently, RFCA could not be performed. Intravenous propofol anesthesia is feasible during RFCA for most tachyarrhythmias except for ectopic atrial tachycardia in children

A randomised double-blind controlled study evaluating the hypothermic effect of 150 μg morphine during spinal anaesthesia for Caesarean section

We studied the hypothermic effect of adding 150 μg morphine during spinal anaesthesia in 60 parturients scheduled for elective caesarean section. All the parturients received intrathecal injection of a solution containing 150 μg morphine or normal saline in addition to 10–12 mg hyperbaric bupivacaine 0.5%. In both groups, a significant decrease in body temperature was noted. There was no difference in the area under the curve for temperature against time for the two groups; however, the maximum decrease in temperature from baseline was significantly larger after morphine than after saline injection (mean (SD) 1.11 (0.61) °C vs 0.76 (0.39) °C, respectively; p = 0.01) and the time to nadir temperature was significantly longer (59.5 (17.6) min vs 50.4 (15.9) min, respectively; p = 0.047). The lowest temperature observed in the morphine group was 34.3 °C. We conclude that intrathecal injection of 150 μg morphine intensified the intra‐operative hypothermic effect of bupivacaine spinal anaesthesia for caesarean section.

The 27-bp Tandem Repeat Polymorphism in Intron 4 of the Endothelial Nitric Oxide Synthase Gene Is Not Associated with Coronary Artery Disease in a Hospital-Based Taiwanese Population

We studied whether the 27 base pair (bp) tandem repeat polymorphism in intron 4 of the endothelial nitric oxide synthase (eNOS) gene was associated with coronary artery disease (CAD) in a hospital-based Taiwanese population. We included 219 consecutive patients who underwent coronary angiography at our institution. Two alleles, containing 4 (eNOS4a) and 5 repeats (eNOS4b), were identified after polymerase chain reaction amplifying intron 4 of the eNOS gene. The genotype frequencies for eNOS4b/b, eNOS4a/b and eNOS4a/a were 77.9, 21.5 and 0.6% in CAD subjects, and 80, 20 and 0% in control subjects (Fisher’s exact test, p = 0.90), respectively. The odds ratio (OR) for CAD in patients with at least one eNOSa allele was 1.2 (0.5–2.9) after adjustment for classical CAD risk factors. The eNOS4a allele was not associated with the severity of CAD (Fisher’s exact test, p = 0.90) and the occurrence of acute myocardial infarction (AMI) or unstable angina (adjusted OR 0.6, 0.3–1.6) in patients with CAD. In conclusion, the 27-bp repeat polymorphism of the eNOS gene was not associated with CAD and the occurrence of AMI or unstable angina in a hospital-based Taiwanese population.

Characterization of Muscarinic Receptor Subtypes in Canine Left Ventricular Membranes

The pharmacological characteristics of muscarinic receptor (mAChR) subtypes in canine left ventricular membranes (LVM) were determined using [3H] quinuclidinyl benzilate ([3H]QNB) and [3H]N-methyl scopolamine ([3H]NMS) as ligands. Binding of [3H]QNB and [3H]NMS was saturable with respect to the radioligand concentrations. Analysis of binding isotherms by Scatchard plot showed that [3H]QNB and [3H]NMS bound to an apparently homogeneous population of mAChRs in LVM, with KD values of 390 +/- 100 and 285 +/- 34 pM and Bmax values of 240 +/- 20 and 133 +/- 9 fmol/mg protein, (n = 6), respectively. The Hill coefficients for [3H]QNB and [3H]NMS binding were 0.95 +/- 0.02 and 0.99 +/- 0.01, respectively. Based on the competitive inhibition of [3H]ligand binding, atropine and NMS as well as the selective M1 antagonist PZ revealed no selectivity for these mAChRs. PZ competed with [3H]QNB or [3H]NMS for a single binding site with a Ki value of 0.23 +/- 0.03 microM and 0.62 +/- 0.10 microM, (n = 6), respectively, which is close to the values of M2 or M3 receptors. The data indicate that the M1 receptor subtype did not exist in canine LVM. Competition of [3H]ligand binding with selective M2 antagonists, AF-DX 116 and methoctramine and the selective M3 antagonists, 4-DAMP and hexahydrosiladifenidol, gave a best fit for a two-binding site model. The inhibition of carbachol-mediated phosphoinositide hydrolysis by PZ, AF-DX 116 and 4-DAMP, generated an affinity profile for this response also dissimilar to that described for the classical cardiac M2 response. Although no other muscarinic receptor mRNA has been detected in this tissue, these data suggest the presence of a second population of muscarinic sites, which may signify an M2 receptor diversity.

Suspected malignant hyperthermia during sevoflurane anesthesia.

Malignant hyperthermia is a rare anesthetic-related disorder. We present a case with unusual presentation. A boy aged 3 years and 9 months who was scheduled for Hotzs operation presented normally before the operation. Anesthesia was induced by atropine, thiopental and sevoflurane. Trachea intubation was facilitated by succinylcholine. Jaw stiffness was first noted although trachea was intubated without difficulty. The following tachycardia, hypercapnia and hyperthermia led to the diagnosis of malignant hyperthermia. Symptoms were relieved dramatically after the discontinuation of sevoflurane. Molecular genetic testing identified a novel ryanodine receptor (RYR1) mutation in exon 39, which confirmed malignant hyperthermia susceptibility in this patient.