Journal of Cellular & Molecular Anesthesia

Remote ischemic preconditioning for noncardiac surgeries: is the final word "ready" yet?                                                                                         

Aim and Background: Remote Ischemic Preconditioning introduces brief episodes of ischemia and reperfusion which reduces long term ischemia in orthopaedic surgery. The aim of this study was to evaluate hemodynamic and respiratory effects of remote ischemic preconditioning in lower extremity orthopaedic surgeries.

Methods: In this clinical trial 40 patients scheduled for lower extremity surgery with pneumatic tourniquet were randomly allocated to remote ischemic preconditioning (RIP group, n=20) and control group (n=19). Patients in RIP group received three “5 minutes” cycles of ischemia, alternating with 5 minutes of reperfusion before extended use of tourniquet. Hemodynamic variables prior to inflation of tourniquet, every 30 minutes during the surgery and 10 minutes after tourniquet deflation and also arterial blood gas sample prior to and after surgery were recorded and compared between groups.

Results: During operation blood pressure dropped in the RIP group and variations in heart rate, respiratory rate and pulse oximeter measurements after surgical tourniquet release were not significantly different between two groups. Changes in blood gas parameters were significantly less pronounced in the RIP group.

Conclusion: Remote ischemic preconditioning may not attenuate most of the adverse effects of surgical tourniquet deflation including variations in heart rate, respiratory rate and arterial oxygen saturation as well as blood pressure drops. However, RIP may reduce increases in systolic blood pressure and acidosis following tourniquet application.

Key Words: Remote Ischemic Preconditioning; Orthopedic, surgery, blood pressure, tourniquet, oxygenation

Background: Liver ischemic insults are important sources of liver injuries leading to production of reactive oxygen species (ROS) and mediating liver cell injury. Glutathione mediated mechanisms are among the most important defense mechanisms of the liver; N-acetylcysteine (NAC) provides cysteine for glutathione defense mechanisms. Patients undergoing cardiac surgery are at increased risk of liver ischemia. This study was performed to assess the role of NAC in prevention of liver ischemia.Materials and Methods: In a double blind, randomized clinical trial, 90 patients entered the study in two groups (45 in each). Patients in the NAC group received 150 mg/Kg NAC after induction of anesthesia and the other group, the same volume of placebo. Serum levels of aspartate aminotransferase (AST), Alanine aminotransferase (ALT) and bilirubin were checked before and after the surgery. ANOVA was used for data analysis and p value less than 0.05 was considered statistically significant.Results: No difference between the two groups regarding basic variables; however, the postoperative values of AST and ALT were lower in the NAC group with statistically significant difference. Also, postoperative levels of total bilirubin were lower in the NAC group compared with the control group; a statistically significant difference.Conclusion: Patients undergoing CABG are advised to receive prophylactic 150 mg/Kg NAC to improve their postoperative levels of AST, ALT and bilirubin.

Keywords: glutathione antioxidant mechanism, N-acetylcysteine; Aspartate aminotransferase (AST), Alanine aminotransferase (ALT), bilirubin, liver ischemia.

Erratum: The correct affiliation of corresponding author of this manuscript has been edited as follows:

"Akbar Dorgalaleh: Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran."

Hypercoagulable states are a group of conditions associated with an enhanced tendency toward blood clotting. Although usual clinical manifestations of hypercoagulable states are thrombotic events such as deep venous thrombosis, hematoma can also occurs as a result of hypercoagulability in some patients. Several inherited or acquired conditions may lead to hypercoagulable states. Some of them include myeloproliferative syndromes, over activity of coagulation factors and methyltetrahydrofolateee reductase (MTHFR) polymorphisms. MTHFR is required for converting

the amino acid   homocysteine to methionine. Another significant role of an aptly functioning MTHFR enzyme is nucleic acid biosynthesis. Therefore MTHFR polymorphisms are expected to be associated with hypersegmentation of neutrophils because of a defect in DNA metabolism. Neutrophil hypersegmentation is one of the most sensitive haematological features of cobalamin or folate deficiency with normal serum vitamin B12-folic acid and iron levels. Hypersegmentation of neutrophils and hematoma which  both of them suspected to be  due to gene variations of MTHFR. Here we report a 37 years old female who simultaneously affected by hereditary hypersegmentation and extensive hematoma. Laboratory analysis revealed normal serum vitamin B12, folic acid and iron levels. Routine and specific coagulation tests were normal in except of factor VIIIc that was high. Results of complete blood cell count (CBC) test were normal. Although this is just an idea, but simultaneous presentations of these two conditions can have a common origin.

During the past two decades, a variety of serum or cerebrospinal fluid (CSF) biochemical markers in daily clinical practice have been recommended to diagnose and monitor diverse diseases or pathologic situations. It will be essential to develop a panel of biomarkers, to be suitable for evaluation of treatment efficacy, representing distinct phases of injury and recovery and consider the temporal profile of those. Among the possible and different biochemical markers, S100b appeared to fulfill many of optimized criteria of an ideal marker. S100b, a cytosolic low molecular weight dimeric calciumbinding protein from chromosome 21, synthesized in glial cells throughout the CNS, an homodimeric diffusible, belongs to a family of closely related protein, predominantly expressed by astrocytes and Schwann cells and a classic immunohistochemical marker for these cells, is implicated in brain development and neurophysiology. Of the 3 isoforms of S-100, the BB subunit (S100B) is present in high concentrations in central and peripheral glial and Schwann cells, Langerhans and anterior pituitary cells, fat, muscle, and bone marrow tissues. The biomarker has shown to be a sensitive marker of clinical and subclinical cerebral damage, such as stroke, traumatic brain injury, and spinal cord injury. Increasing evidence suggests that the biomarker plays a double function as an intracellular regulator and an extracellular signal of the CNS. S100b is found in the cytoplasm in a soluble form and also is associated with intracellular membranes, centrosomes, microtubules, and type III intermediate filaments. Their genomic organization now is known, and many of their target proteins have been identified, although the mechanisms of regulating S100b secretion are not completely understood and appear to be related to many factors, such as the proinflammatory cytokines, tumor necrosis factor alpha (TNF-a), interleukin (IL)-1b, and metabolic stress.

Contrast induced angioedema is a rapidly progressive state involving a number of organ systems including the upper airway tract; which is usually a type I anaphylactic reaction also known as immediate hypersensitivity reaction. Prompt preservation of the respiratory tract is the cornerstone of this situation. The use of fiberoptic bronchoscope for tracheal intubation though very helpful, has some special considerations due to the anatomic distortions created by edema.

This manuscript describes a patient with contrast induced angioedema managed successfully. Serum levels of IgE were highly increased during the first hours after the event; while serum levels of complement were normal. However, rapid airway management and prophylactic intubation saved the patient and prevented the possible aftermath of airway obstruction.

Keywords: airway management; type I anaphylactic reaction, angioedema; fiberoptic bronchoscope.

Conflict of interest: none of the authors has any conflict of interest.

Wolfram syndrome was first described by physician D J Wolfram and Wagener in 1938. This autosomal recessive syndrome is also referred to as DIDMOAD syndrome which stands for Diabetes Insipidus, Insulin Dependent Diabetes Mellitus, Optic Atrophy and Deafness

One of the most important features of interdisciplinary research is "team working"; leading to multidisciplinary, interdisciplinary, and transdisciplinary approaches in medical education. These approaches are applicable in research, education and service provision. There are a number of fields in anesthesiology that cope with the models that use disciplines; including novel anesthetic agents, pain clinics and pain management, pediatric anesthesia and a number of other distinct fields. Undoubtedly, other aspects of medical sciences are much involved in these areas.