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BACKGROUND: Neurological outcome after cardiac arrest (CA) is difficult to predict in the acute phase. In this pilot study, we assessed blood levels of tau protein as a prognostic marker for the neurological outcome after 6 months in patients treated with hypothermia after resuscitation from CA. METHODS: 22 unconscious patients resuscitated after CA were treated with mild hypothermia (32-34°C) for 26 h. Blood samples were collected at 2, 6, 12, 24, 48, and 96 h after CA, and the concentration of tau protein was analyzed. Neurological outcome was assessed with the Glasgow-Pittsburgh cerebral performance category (CPC) scale at intensive care unit (ICU) discharge and after 6 months. The higher of the two CPC scores was used. RESULTS: At ICU discharge, 21/22 patients were alive, of whom 10 had a good (CPC 1-2) outcome. After 6 months, 15/22 patients were alive, of whom 14 had a good outcome. Tau protein levels were higher among those with a poor outcome at 48 h and 96 h. At 96 h sampling, tau concentration predicted a poor outcome (CPC 3-5) with a sensitivity of 71% and a specificity of 93%. CONCLUSIONS: Although in a pilot study, a late increase in plasma tau protein seems to be associated with a worse outcome after hypothermia treatment after CA, although more studies are needed.

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Emergency patients need special considerations and the number and severity of complications from general anaesthesia can be higher than during scheduled procedures. Guidelines are therefore needed. The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine appointed a working group to develop guidelines based on literature searches to assess evidence, and a consensus meeting was held. Consensus opinion was used in the many topics where high-grade evidence was unavailable. The recommendations include the following: anaesthesia for emergency patients should be given by, or under very close supervision by, experienced anaesthesiologists. Problems with the airway and the circulation must be anticipated. The risk of aspiration must be judged for each patient. Pre-operative gastric emptying is rarely indicated. For pre-oxygenation, either tidal volume breathing for 3 min or eight deep breaths over 60 s and oxygen flow 10 l/min should be used. Pre-oxygenation in the obese patients should be performed in the head-up position. The use of cricoid pressure is not considered mandatory, but can be used on individual judgement. The hypnotic drug has a minor influence on intubation conditions, and should be chosen on other grounds. Ketamine should be considered in haemodynamically compromised patients. Opioids may be used to reduce the stress response following intubation. For optimal intubation conditions, succinylcholine 1-1.5 mg/kg is preferred. Outside the operation room, rapid sequence intubation is also considered the safest method. For all patients, precautions to avoid aspiration and other complications must also be considered at the end of anaesthesia.

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BACKGROUND: Induced mild hypothermia (32-34 degrees C) has proven to reduce ischemic brain injury and improve outcome after a cardiac arrest (CA). The aim of this investigation was to study the occurrence of increased intracranial pressure (ICP) and neurochemical metabolic changes indicating cerebral ischemia, after CA and cardiopulmonary resuscitation (CPR), when induced hypothermia was applied. METHODS: ICP, brain chemistry and brain temperature were monitored during induced hypothermia and re-warming in four adult unconscious patients with restoration of spontaneous circulation after CA and CPR. RESULTS: ICP was occasionally above 20 mmHg. Neurochemical changes indicating cerebral ischemia (increased lactate/pyruvate ratio) and excitoxicity (increased glutamate) were found after CA, and signs of ischemia were also observed during the re-warming phase. A biphasic increase in glycerol was seen, which may have been a result of both membrane degradation and overspill from the general circulation. CONCLUSIONS: Intracerebral microdialysis and ICP monitoring may be used in selected patients not requiring anticoagulants and PCI to obtain information regarding the common disturbances of intracranial dynamics after CA. The results of this study underline the importance of inducing hypothermia quickly after CA and emphasize the need for developing tools for guidance of the re-warming.

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Systemically administered mexiletine, an antiarrhythmic, has been shown to also possess analgesic properties in some conditions of neuropathic pain. It has been suggested that the analgesic effect of mexiletine may be derived from the action of one of its optical isomers, (+)(S)-mexiletine. In the present study, we have compared the effects of systemic (-)-(R)- and (+)-(S)-mexiletine, on chronic mechanical allodynia-like behaviour in spinally injured rats, a model of central neuropathic pain in which racemic mexiletine has been shown to be active. I.p. racemic mexiletine as well as (-)-(R)- and (+)(S)-mexiletine at 25 mg/kg all produced significant, but brief, alleviation of mechanical allodynia in a similar fashion as assessed with von-Frey hair elicited vocalization in the spinally injured rats. A slight increase in motor impairment was observed in all three groups which reached statistical significance for the racemic mexiletine and (+)-(S)-mexiletine. Our results suggest that both isomers of mexiletine contribute to the antiallodynic effect in this model of central pain.

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A two-electrode voltage clamp was used to examine the effects of the local anaesthetics (LAs) lidocaine, tetracaine and bupivacaine, and the meta-isomer of lidocaine (LL33), on the gamma-aminobutyric acid (GABA)-gated Cl- channel in the crayfish stretch receptor neurone. The voltage-induced current changes were recorded while exposing the neurone to GABA in saline containing different LAs. All LAs enhanced the voltage-induced Cl- current equivalent to a shift of the conductance vs GABA curve towards lower concentrations. The mechanism of the facilitation of GABA-induced conductance was found to be mainly a block of the GABA uptake in the stretch receptor neurone. Tetracaine, and to a lesser extent LL33, also seem to affect directly the GABA/receptor Cl-/channel complex resulting in an increased conductance of the channel.

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A method for assessment of the kidney size in infants and children is described based on measurement of the renal parenchymal area determined planimetrically, using for reference the height of the column of the upper three lumbar vertebrae or the body weight. The kidney size is expressed in standard deviation in the appropriate nomograms.

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