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CO measurements and serum lactate levels add little information to the decision-making process for blood transfusions, as neither CO nor serum lactate levels correlate with HB levels in an otherwise asymptomatic population of preterm infants. In infants where the indication for blood transfusion is made based on traditionally accepted clinical criteria, serum lactate is an additional laboratory indicator of impaired oxygenation, as it correlates significantly with oxygen delivery. A significant lower oxygen delivery in patients in whom blood transfusion is indicated and an increase in oxygen induced by transfusion demonstrate the value of these criteria in identifying preterm infants who benefit from transfusion.

BackgroundIn many studies investigating measures to attenuate the hemodynamic and humoral stress response during induction of anaesthesia, primary attention was paid to the period of endotracheal intubation since it has been shown that even short-lasting sympathetic cardiovascular stimulation may have detrimental effects on patients with coronary artery disease. The aim of this analysis was, however, to identify the influencing factors on high catecholamine levels before induction of anaesthesia.MethodsVarious potential risk factors that could impact the humoral stress response before induction of anaesthesia were recorded in 84 males undergoing coronary aortic bypass surgery, and were entered into a stepwise linear regression analysis. The plasma level of norepinephrine measured immediately after radial artery canulation was chosen as a surrogate marker for the humoral stress response, and it was used as the dependent variable in the regression model. Accordingly, the mean arterial blood pressure, heart rate and the calculated pressure-rate product were taken as parameters of the hemodynamic situation.ResultsStepwise regression analysis revealed that the oral administration of low-dose clonidine (mean dose 1.75 μg·kg-1) on the morning of surgery was the only significant predictor (p = 0.004) of the high variation in preoperative norepinephrine plasma levels. This intervention decreased norepinephrine levels by more than 40% compared to no clonidine administration, from 1.26 to 0.75 nmol·l-1. There was no evidence for dose-responsiveness of clonidine. All other potential predictors were removed from the model as insignificant (p > 0.05). The use of beta-blocker, ace-inhibitors, ejection fraction, and body mass index were significant determinants for the hemodynamic situation (heart rate, mean arterial pressure, pressure rate product) of the patient during the pre-induction period.ConclusionThe oral administration of clonidine is the only significant predictor for the observed variation of norepinephrine levels during the preoperative period. Lack of significant dose responsiveness suggests that even a low dose of the drug can attenuate the preoperative stress response and thus is recommended in cardiovascular high risk patients.

The half-lives of endogenous and exogenous (biosynthetic monomeric) GH were compared in the morning and evening in healthy young men (n = 10). In group A, a bolus of GHRH was injected either at 0800 or at 2000 h, whereas in group B hGH was injected iv after suppression of endogenous GH by somatostatin. GH was sampled every 10 min and the t1/2 for GH was determined by deconvolution analysis (two compartments). The GH elimination half-life was shorter in the morning: for endogenous GH, t1/2 was 23 +/- 1.1 min (mean +/- SE) in the morning compared to 26 +/- 1.7 min in the evening (P < 0.02). T1/2 correlated negatively with estradiol (r = -0.78; P < 0.01) and positively with sex hormone-binding globulin (r = 0.71; P < 0.03). The half-life of exogenous 22-kilodalton GH was shorter compared to endogenous GH (P < 0.002), and diurnal variation was even more pronounced: t1/2 was 14 +/- 1.0 min in the morning and 19 +/- 1.0 min in the evening (P < 0.01). These effects were not due to differences in GH distribution volumes. The half-life of exogenous GH was significantly affected by weight (r = -0.8; P < 0.01) and height (r = 0.67; P < 0.05). We conclude that in young males, the rate of GH disappearance from the circulation depends on both diurnal mechanisms as well as the source or structural composition of the hormone. Body size and sex steroids contribute to the variability of GH clearance in healthy man.

Neuromuscular blockade can be relatively easily measured in the clinical setting. Consequently, closed-loop control can be exercised by measuring the neuromuscular activity, calculating the dose of drug necessary to achieve a predefined degree of neuromuscular blockade and finally directing an infusion pump. Recently introduced short-acting blocking agents like mivacurium provide benefits for the clinical routine due to a small onset time and half life. In order to provide a stable blockade for different groups of patients a fast and highly adaptable control unit is needed. Furthermore its development should not imply costly investigations for determining a pharmacological model. The fulfilling of these requirements yield a self-adapting model-based predictive control system. The application of artificial neural networks allows an appropriate adjustment of specific parameters without the knowledge of inner pharmacodynamic processes. In a clinical study the EMG module within a Datex AS/3 monitor was used to measure the blockade and a Grasepy 3500 infusion pump for i.v. administration of mivacurium to 35 patients (ASA I-III). The performance of the novel system (mean of the T1 error: -0.32 +/- 1.7) compares favourably with closed-loop controllers demonstrated in the past. These promising results and the easy adaption to other blocking agents encourage to apply this technology even for delivering hypnotic drugs.

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A closed-loop system for control of a mivacurium infusion could be established. The system proofed to be reliable for a closed-loop infusion of mivacurium in order to maintain a predefined degree of neuromuscular blockade of 95% during routine surgery. The performance of the described controller is comparable to all recent attempts and could therefore be useful for scientific studies. It should be further validated and established for other muscle relaxants, as well.