Earlier operating time for certain surgical procedures, screening for proper support at home, and implementation of clinical pathways to deal aggressively with problems such as pain, nausea and vomiting should decrease the incidence of unanticipated admission.

Tracheal resection and reconstructionPurpose: To review the literature on tracheal and carinal resection and reconstruction, and to report the general approach to these patients, as well as the general guidelines for the safe administration of anesthesia. The airway management is extensively reviewed. Source: Articles obtained from a Medline search (1960 to October 1997; keywords: tracheal surgery, carinal surgery, airway management). Textbook literature including the bibliographies were also consulted. Principal Findings: Benign or malignant tracheal and carinal pathology causing obstruction can be managed in several ways but resection and reconstruction are the treatment of choice for most patients with tracheal stenosis or tumour. Surgery of the trachea is a special endeavour where the airway is shared by the surgeon and the anesthesiologist. The principal anesthetic consideration is ventilation and oxygenation in the face of an open airway. Ventilation can be managed in different ways, including manual oxygen jet ventilation, high frequency jet ventilation, distal tracheal intubation, spontaneous ventilation, and cardiopulmonary bypass. Conclusion: The management of anesthesia for tracheal surgery presents many challenges to the anesthesiologist. Knowledge of the various techniques for airway management is crucial. Meticulous planning and communication between the anesthesia and surgical teams are mandatory for the safe and successful outcome of surgery for patients undergoing this procedure.Objectif: Passer en revue la documentation concernant la r&ection trach~ale et car~nale ainsi que leur reconstruction, et indiquer la conduite ~ tenir dans ce cas avec les patients, aussi bien que les directives g~n&ales pour I'administration s&uritaire de I'anesth&ie. La gestion des voies respiratoires a fait I'objet d'un examen pouss& Sources : Des articles provenant d'une recherche dans Medline (1960 ~ octobre 1997; mots-cl&: chirurgie de la trach&, chirurgie de la car~ne, gestion des voies respiratoires). Des monographies incluant les bibliographies ont aussi ~t~ consult&s. Constatations principales : La pathologie trach~ale et car~nale b~nigne ou maligne causant de I'obstruction peut &re trait~e de diff&entes mani&es, mais la r&ection et la reconstruction sont le traitement de choix pour la plupart des patients atteints de st~nose trachfiale ou de tumeur. C'est une intervention sp&iale off I'acc~s aux voies respiratoires est partag~ par le chirurgien et I'anesth&iologiste. La consideration anesth&ique principale est la ventilation et I'oxyg~nation en pr&ence de voies a&iennes ouvertes. La ventilation jet manuelle avec de I'oxyg~ne, la ventilation jet ~ haute fr~quence, rintubation trach~ale distale, la ventilation spontan& et la circulation extracorporelle sont des variantes possibles de la ventilation dans cecas. Conclusion 9 La gestion de I'anesth&ie Iors d'intervention ~. la trach& repr&ente de nombreux d~fis pour ranesth&iologiste. La connaissance des diverses techniques de gestion des voies respiratoires est pr...

P Pu ur rp po os se e: : To examine the feasibility of immediate extubation after off-pump coronary artery bypass grafting (OPCAB) using opioid based analgesia or high thoracic epidural analgesia (TEA) and compare postoperative analgesia with continuous TEA vs patient-controlled analgesia (PCA).M Me et th ho od ds s: : One hundred consecutive patients undergoing OPCAB were included in this prospective audit. After induction of anesthesia using fentanyl 2 to 5 µg·kg -1 , propofol 1 to 2 mg·kg -1 and endotracheal intubation facilitated by rocuronium, anesthesia was maintained using sevoflurane titrated according to bispectral index monitoring. Perioperative analgesia was provided by TEA (n = 63) at the T3/T4 interspace or T4/T5 interspace using bupivacaine 0.125% 8 to 14 mL·hr -1 and repetitive boluses of bupivacaine 0.25% during surgery. In patients who were fully anticoagulated or refused TEA, perioperative analgesia was achieved by iv fentanyl boluses (up to 15 µg·kg -1 ) and remifentanil 0.1 to 0.2 µg·kg -1 ·min -1 , followed by morphine PCA after surgery (n = 37). Maintenance of body temperature was achieved by a heated operating room and forced-air warming blankets.R Re es su ul lt ts s: : Ninety-five patients were extubated within 25 min after surgery (PCA, n = 33; TEA, n = 62). Five patients were not extubated immediately because their core temperature was lower than 35°C. One patient was re-intubated because of agitation (TEA group); one was re-intubated because of severe pain and morphine-induced respiratory depression (PCA group). Pain scores were low after surgery, with pain scores in the TEA group being significantly lower immediately, at six hours, 24 hr and 48 hr after surgery (P < 0.05).C Co on nc cl lu us si io on n: : Immediate extubation is possible after OPCAB using either opioid-based analgesia or TEA. TEA provides significantly lower pain scores after surgery in comparison to morphine PCA. Objectif : Vérifier la faisabilité de l'extubation immédiatement après un pontage aortocoronarien à coeur battant (PACCB) en utilisant une analgésie avec opioïdes ou une analgésie péridurale thoracique (APT), et comparer l'analgésie postopératoire avec APT continue ou analgésie auto-contrôlée (AAC). Méthode : Cent patients consécutifs devant subir un PACCB ont été inclus dans un audit prospectif. Après l'induction de l'anesthésie avec

The syncytiotrophoblast of the placenta is the site of exchange of nutrients and minerals between the mother and fetus. We have recently demonstrated that PTH influences, in vitro, phosphate transport through the placenta brush border membranes (BBM) and increases cAMP accumulation in placental tissue. To demonstrate the site of binding of PTH in the cytoplasmic membrane, we have purified two polar membranes: the first located on the apical side, the BBM, and the second, on the fetal side, the basal plasma membrane (BPM). BBM were enriched 24-fold in alkaline phosphatase (marker for BBM), and the BPM was enriched 37-fold in binding of [3H] dihydroalprenolol (marker for BPM) compared to homogenate. Both placental membranes contain binding sites (maximum binding = 0.550 +/- 0.032 and 0.298 +/- 0.065 pmol/mg protein for BBM and BPM, respectively) with similar affinities (Kd = 2.05 +/- 0.23 and 1.78 +/- 0.19 nM, respectively) for 125I-[Nle8,Nle18,Tyr34] bovine (b) PTH-(1-34) amide. The three bovine preparations [bPTH-(1-34), its analog [Nle8,Nle18,Try34]bPTH-(1-34) amide, and the antagonist bPTH-(3-34)] were equipotent in binding to both placental membranes. In contrast, human PTH-(1-84) was more effective in displacing the bovine radioligand in BBM. Thyrocalcitonin and insulin, two non-PTH peptides, did not significantly displace the radioligand in BBM and BPM. Adenylate cyclase activity, located exclusively in BPM, was stimulated by PTH. Since the enzyme is absent from BBM, it is probable that the binding of the hormone to this membrane activates another system of messengers.