Diabetes mellitus is the most common metabolic disease and its incidence is increasing. New classifications have been recently proposed based upon a better knowledge of pathogenesis, mechanisms of glucose transport and insulin resistance. The perioperative care of diabetic patients is less dependent on blood-glucose control, which needs to be exceptionally tight, and is usually easily obtained thanks to pharmacological improvements, human insulins and analogues, technical progress with blood-glucose monitoring at the bedside and infusion with constant flow rates. More important is the influence of end-organ pathology, often clinically silent, which must be carefully assessed during the preoperative evaluation. The organ impairments concern especially the heart, but also all those organs that were modified by abnormal glycosylated proteins. The pre-existing pathology has many consequences on anaesthesia management; the anaesthetic technique depends essentially on their existence. A better long-term control of diabetes both for Type 1 and Type 2 by insulins, and the new oral anti-diabetic drugs reduce the incidence of the end-organ pathology and the risk linked to organ failures in the perioperative period.

Background and objective Increased glutamate concentration in the cerebrospinal fluid has been reported in severely head–injured patients, suggesting that an excessive release of glutamate may be involved in the process of neuronal damage. Ischaemic damage after subdural haematoma has been reported to be reduced by glutamate (N-methyl-D-aspartate: NMDA) receptor antagonists such as dizocilpine and CGS 19755; even though these drugs were given 20–30 min after insult. Excessive release of excitatory amino acids may produce the neural damage after subdural haematoma and NMDA receptor antagonists may become valuable therapeutic drugs. This study compared the effects of ketamine and dizocilpine, on intracranial pressure and histopathological changes after acute subdural haematoma produced by an injection of autologous blood (150 μL) in rats.

Methods The control (n =9), ketamine (n =9) and dizocilpine (n =9) groups, respectively, received saline, ketamine (total dose: 210 mgkg−1) or dizocilpine (total dose: 1.0 mgkg−1) from 0.5 to 8 h after acute subdural haematoma. A silicone group (n =9) had the same volume of silicone injected subdurally.

Results The volume of ischaemic damage in the silicone group (1.3±1.2mm3) was significantly smaller than in the control group (11.9±3.8mm3). Ketamine and dizocilpine did not increase intracranial pressure. Dizocilpine significantly decreased the volume of ischaemic damage (6.1±3.8mm3). Ketamine failed to significantly decrease damage (7.8±5.0mm3).

Conclusions These results suggest that the factors elicited by the clotted blood contribute to the ischaemic damage after subdural haematoma, and that the glutamate receptor antagonist dizocilpine reduces the damage, while ketamine shows only a trend reduction of the damage.

Background and objective The aim of the study was to test the peripheral analgesic action of neostigmine. Intraplantar administration of neostigmine was studied in carrageenan-injected rats.

Methods After assessing baseline values (T0) for paw circumference and the paw withdrawal threshold on both hind paws, the right hind paw was injected with 0.2mL of 1% carrageenan and the left hind paw with 0.2mL of saline (0.9% NaCl). Two hours later (T1), both hindpaws were tested for inflammation (paw circumference) and for hyperalgesia (paw withdrawal threshold) and subsequently 20 mg of neostigmine was injected in the right hind paw. The paw withdrawal threshold was tested again 10 (T2), 20 (T3) and 60 min (T4) and paw circumference 60 min (T4) after neostigmine injection.

Results Carrageenan injection in the right hindpaw was associated with a decrease in the paw withdrawal threshold reflecting mechanical hyperalgesia (P < 0.001) and an increase in paw circumference reflecting oedema (P < 0.001) in the right hind paw when compared with the left side from T1 to T4. Neostigmine had no effect on paw circumference and the paw withdrawal threshold at measuring points T2, T3 and T4 when compared with T1 in the right hindpaw. Conclusion Our results support the lack of peripheral analgesic effect of neostigmine.

Background and Objective To investigate the response to general anaesthetics of different sodium channel subtypes, we examined the effects of pentobarbital, a close thiopental analogue, on single sodium channels from human ventricular muscle and compared them with existing data from human brain channels.

Methods Sodium channels from preparations of human ventricular muscle were incorporated into planar lipid bilayers in the presence of batrachotoxin, a sodium channel activator. Single channel currents were recorded in symmetrical 100mmolL−1 and 500mmolL−1 NaCl before and after the addition of the anaesthetic pentobarbital (0.34–1.34mmolL−1).

Results The blocking effect of pentobarbital on the fractional open time had an IC50 of 690 μmol L−1 in 500 mmolL−1 NaCl, whereas it had a significantly lower IC50 of 400 μmol L−1 in 100 mmolL−1 NaCl. Pentobarbital caused a significant shift of steady-state activation to hyperpolarized potentials (fmax = −42 mV, IC50=2 mmolL−1). This effect was independent of NaCl concentration.

Conclusion Despite pharmacological and electrophysiological differences between human cardiac and human brain sodium channels their responses to pentobarbital are similar. The finding of channel block being dependent on the electrolyte concentration is novel for sodium channels.

Background and objective Factors which lead to prolonged stay in the day–care unit and unplanned admission after day-case surgery are poorly understood.

Methods Data sets of 3152 day-case patients were collected with a computerized online record keeping system (NarkoData). Predictors of prolonged postoperative stay including unanticipated admission were identified using univariate analysis. Charts of patients, who needed admission, were reviewed.

Results 13.2% of day–case patients had a postoperative stay ≤3 h, 55.3% 3–6 h and 26.2%≥6h. The rate of unanticipated admission was 5.4%. Intraoperative haemoglobin concentration and blood loss were the best predictors of a prolonged postoperative stay. Other significant predictors were female gender, advanced age, longer duration of surgery, larger volume of infusions, intubation, spinal anaesthesia, intraoperative use of opioids and non–depolarizing muscle relaxants, high pain score, nausea and vomiting and prolonged preoperative waiting time. Chart review of patients admitted to hospital confirmed the validity of the statistically significant predictors.

Conclusions In day-case surgery, the predictors of prolonged stay in the day-care unit and unplanned Hospital admission are mainly related to the surgical procedure.

Background and objective The incidence and clinical impact of perioperative myocardial infarction during coronary artery bypass graft surgery vary greatly depending upon the diagnostic criteria applied. Fatal perioperative myocardial infarction has a less arguable diagnosis and clinical impact. The aim of this paper is to find out the risk factors for fatal myocardial infarction after coronary surgery.

Methods Data from 1561 consecutive patients, who underwent coronary revascularization during a 10-month period, have been retrospectively analysed. After an univariate analysis for pre- and intraoperative risk factors, a multivariate model (logistic regression analysis) was settled.

Results Preoperative use of subcutaneous/intravenous heparin, a heparin sensitivity index <1.3 and need for a thromboendarterectomy of the left anterior descending coronary artery are independent risk factors for fatal myocardial infarction. The relative risk for fatal myocardial infarction was about 2 in the case of preoperative heparin use or heparin sensitivity index <1.3 and 5.5 in the case of thromboendarterectomy of the left anterior descending coronary artery.

Conclusions In patients undergoing coronary artery bypass surgery, preoperative anticoagulation management with heparin may represent a risk factor for fatal myocardial infarction. Patterns of heparin resistance, whether or not due to heparin pretreatment, seem to be closely related to fatal myocardial infarction.

Von Hippel-Lindau disease is a rare autosomal dominant disease with incomplete penetrance and variable expression and is characterized by diffuse haemangioblastomas of the central nervous system and viscera. The majority of the central nervous system lesions are located in the cerebellum. This report describes the successful management with epidural anaesthesia of a woman with a term gestation, von Hippel-Lindau disease and cerebellar haemangioblastoma.

Mitochondrial myopathies are rare complex multisystem disorders, which can present several potential anaesthetic problems. A 49-year-old man with mitochondrial myopathy was anaesthetized successfully for cataract extraction using propofol and alfentanil infusions. Vecuronium sensitivity was apparent, with a prolonged duration of action, despite dosage reduction