Anesthesiology Special book rEvIEwS - The IHE Website

Volume 36 • E 20
IHE April - May 2010
also in this issue
international
hospital
1975 2010
Equipment & solutions
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Anesthesiology Special
Paracetamol as a perioperative anesthetic
Anesthesiology in cosmetic surgery
• Validation of blood pressure monitors
• Continuous StO 2 monitoring in goal-oriented ICU resuscitation
• Novel radiolabelled probes for imaging tumour angiogenesis
• Internal radionuclide dosimetry
Ultrasound imaging
with elastography
Page 32
Combined PET-MRI
Page 33
Celebrating
Urology work station
Page 34
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It’s only ten years
ago when they were
first pronounced
but already they
seem to have faded
away into history.
As part of the
apparently irresistible human reflex not
to let an anniversary pass without taking
the opportunity to summarize the
past or to predict the future, the Millennium
Development Goals (MDG) were
solemnly adopted in 2000 by no fewer
than 189 different countries, specifying
eight global objectives that should
be attained by 2015. Laudable as these
objectives were, there were few details as
to how exactly the objectives were to be
reached, or, even more crucially, where
the necessary investment and resources
would come from. Of the eight MDG
objectives, three were health-related,
namely to reduce child mortality, to
improve maternal health and to combat
HIV/AIDS, malaria and other diseases,
all of which are, of course, easier to say
than do. Since 2000 there have been so
many non health-related crises such
as 9/11, wars, global recession, credit
crunches, etc., not to mention numerous
natural disasters such as tsunamis and
earthquakes, that it is easy to overlook
the particular MDG health goals and the
progress being made to attain them.
Luckily the assiduous statisticians at the
World Health Organization (WHO)
don’t get distracted and regularly produce
their progress report on how
close we are to achieving the MDG
goals (www.who.int/topics/millenium_
development_goals). The latest WHO
progress report has just been published
and, although there is some good news,
there is little room for complacency.
The percentage of underweight children
is estimated to have declined from
25% to 16% in 2010, and annual deaths
of children under five years of age has
fallen to 8.8 million, but it is estimated
that 104 million children throughout the
world are still under-nourished. Almost
inevitably, however, the global results
mask inequalities between countries
and regions. For example, few developing
countries (some of which have been
held back by conflict, poor governance,
or humanitarian and economic crises)
Editor’s LEttEr 3 Apr/May 2010
Progress report on the Millenium
development Goals: must do better
are on track to reach the MDG objectives
for a reduction in maternal mortality
although there has been progress in
other countries. In the field of infectious
diseases, the picture is also varied. While
there has been a welcome decline in new
HIV infections and TB mortality in non-
HIV infected patients has dropped by
approximately one third, the challenge
of malaria remains particularly tough:
there are still nearly a million malaria
deaths per year and access to appropriate
medication is still inadequate. With five
years still to run till the 2015 deadline, a
huge amount of progress still remains to
be achieved.
Comments
on this article?
please feel free to post them at
www.ihe-online.com/comment/MDG
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Contents
FRONT COVER PRODUCTS
[32] Ultrasound imaging
with elastography
FEATURES
[6 - 11] PATiENT MONiTORiNg
[33] Combined PEt- Mri [34] Urology Work
station
[6 - 7] Validation of blood pressure monitors.
The ESH- IP: a success story and its future
[8 - 11] Continuous StO 2 monitoring in goal-directed
shock and ICU resuscitation
[14 - 21] ANESThESiOlOgy SPECiAl
[14] scientific literature review — anesthesiology
[16 - 17] Paracetamol: a major role in peri-operative anesthesiology
[18 - 21] Anesthesiology in cosmetic surgery
[21] Book reviews:
• Pediatric Anesthesiology review
• Anesthesia student survival guide
[22 - 26] NUClEAR MEDiCiNE
[22 - 23] internal radionuclide dosimetry
[24 - 26] Novel radiolabelled probes for imaging tumor angiogenesis
[28 - 29] ENDOSCOPy
[28 - 29] Enteroscopy: yesterday, today and tomorrow
REgUlARS
[3] Editor’s letter
[12 - 13] News in brief
[27] scientific literature review — hospital management
[30 - 34] Product news
[34] Calendar of upcoming events
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Apr/May 2010
Blood pressure measurement and
protocols for device validation
Blood pressure measurement is widely used
across the healthcare system, by clinicians of
almost all specialties, nurses, medical assistants
and even patients themselves. People with high
blood pressure generally have their blood pressure
measured in the office or clinic and because
of the phenomenon of “white coat hypertension”,
such measurements are often falsely elevated,
so 24-hour ambulatory blood pressure
monitoring and/or self-monitoring by patients
at home is often recommended [1]. In all cases,
the accuracy of the blood pressure monitor is
therefore an important prerequisite for the reliable
assessment of the level of blood pressure so
as to enable the accurate diagnosis of high blood
pressure and to enable reliable decision making
and long-term drug treatment [1].
In 1987 the US Association for the Advancement
of Medical Instrumentation (AAMI) published
the first protocol for formal validation of
all blood pressure monitors against the mercury
standard [2]. This was followed in 1990 by the
British Hypertension Society (BHS) protocol
[3] and revised versions of these protocols were
published in 1993. In 2002, the European Society
of Hypertension Working Group on Blood
Pressure Monitoring published the International
Protocol (ESH-IP) for the validation of blood
pressure monitors [4]. The ESH-IP was developed
on the evidence of a large number of validation
studies performed using the AAMI and
BHS protocols. The purpose of developing the
ESH-IP protocol was to simplify the validation
procedure and reduce the sample size required
without losing the evaluation accuracy of the
previous more complicated, cumbersome and
costly protocols. In the rapidly expanding market
6 BLood PrEssUrE MoNitoriNG
EsH-iP for the validation of blood
pressure monitors:
a success story and its future
the validation of blood pressure monitors is an important prerequisite for the accurate
measurement of blood pressure. in the last decade the European society of
Hypertension international Protocol (EsH-iP) has expanded the device validation
procedure worldwide by three to four-fold compared to the period before its original
publication in 2002 and is now the preferred validation protocol. in keeping
with improvements in device technology, the international Protocol was revised, in
2010 and imposes stricter requirements for device accuracy.
by dr G.s. stergiou, dr N Karpettas, dr N Atkins and dr E. o’Brien
of blood pressure monitors for home, ambulatory
and office measurements, it was anticipated
that such a simplified protocol would facilitate
greater use of the validation procedure by more
centers throughout the world, thereby facilitating
independent validation of greater numbers
of devices.
Application of the ESH-IP for device
validation (2002-2009)
A systematic review of the use of the ESH-IP
for validating blood pressure measuring devices
was recently performed [5]. The review covered
the number of reported validation studies
(compared to the use of other protocols), the
main study results, the performance in following
the protocol’s requirements and criteria, the
problems in data reporting, the issues within
the protocol that might need modification or
clarification, and the impact of applying more
stringent validation criteria. This analysis, which
relies on data from 104 validation studies conducted
using the protocol between 2002 (ESH-
IP publication) and 2009, forms the basis for the
recommendations in the revised ESH-IP [5].
According to the systematic review, within 8
years after the publication of the ESH-IP there
were 48 studies reported using the BHS protocol,
38 using the AAMI and 104 using the ESH-
IP [5]. In particular, between January 2007 and
June 2009, 29 studies have been reported using
the BHS and/or the AAMI protocols compared
to 67 using the ESH-IP [5]. Thus, it appears
that the ESH-IP has succeeded in expanding
the validation procedure worldwide by three
to four-fold compared to the period before its
publication [5] and now is the preferred validation
protocol. A total of 26 different research
groups performed ESH-IP studies and evaluated
devices from 32 different manufacturers [5].
Whether a blood pressure monitor is designed for use by a healthcare professional or by the patient himself,
it is vital that the monitor be validated. The European Society of Hypertension
International Protocol (ESH-IP) is now the most widely used protocol for BP monitor validation.
The 2010 revision to the protocol tightens the validation criteria

ESH-IP validations have been conducted in 18
countries, the vast majority of them in Europe
(70%), with some in the USA, in China and
elsewhere [5]. Of these studies, 80% validated
oscillometric devices, 80% upper arm devices
(the rest being wrist devices); 65% of devices
were designed for self-home monitoring, 20%
were professional devices for office/clinic use
and 15% were for ambulatory blood pressure
measurement [5].
Interestingly, the proportion of the reported
validation studies that fulfilled the ESH-IP criteria
is impressively high (85%) [5]. This success
might reflect improved accuracy of devices
due to advancement in technology. However,
other reasons are possible, such as a publication
bias whereby negative studies are not published,
and that the ESH-IP criteria are too easy
to fulfil and need to be made more stringent.
There were also problems in conducting and
reporting some of the ESH-IP validation studies
that make the interpretation of the results rather
questionable. A total of 21 different types of violations
of the ESH-IP were detected, appearing
33 times and involving 23 studies [5]. Twenty
per cent of the violations were regarded as major
(affecting the protocol integrity, requirements
and stringency of criteria), whereas the rest
were minor with negligible impact [5]. Some of
the studies did not provide a complete report of
recruited and excluded subjects and others did
not report the cuff sizes used, particularly for
observer measurements. These findings suggest
that a more standardized report of the validation
study results is necessary.
With the aim of determining which of the ESH-
IP validation criteria were easily passed by the
currently available accurate devices and which
were only marginally passed, several ‘arbitrarily
chosen’ changes in all the validation criteria
of the protocol were tested [5]. The impact of
applying these arbitrary criteria on the evaluation
of devices that had passed the ESH-IP in
published validation studies was also investigated
and helped to decide on which criteria to
tighten in the revision of the ESH-IP.
ESH-IP revision 2010
On the basis of these analyses a revised version
of the protocol was published in February
2010 [6]. There are several changes in the
revised protocol, regarding participants’ age,
blood pressure limits for inclusion, distribution
of observer blood pressure measurements and
validation results reporting [6]. However, the
most challenging change is the tightening of
the validation criteria for the pass level. It has
been estimated that about one third of validations
that passed the ESH-IP 2002 will not satisfy
the criteria of the revised ESH-2010 (Stergiou
G, et al. unpublished data 2010). Thus, the
application of the revised ESH-IP is expected
to more than double the validation fail rate.
Indeed it appears that time has come to increase
the level of minimal accuracy requirements for
device approval. First, 85% of the devices tested
so far using the ESH-IP have been successful
[5], implying an improvement in current technology
of blood pressure monitors (although
as mentioned above a publication bias cannot
be excluded). Second, a recent analysis of successful
ESH-IP validation studies showed a
trend towards an improvement in accuracy of
the electronic devices in the period between
2002-2010, as assessed by their performance in
passing several validation criteria (Stergiou G,
et al. unpublished data 2010).
Conclusions
Eight years after its publication, the ESH-IP
has proven to be successful in achieving its
goals. The large number of published studies,
devices tested, and investigators involved
indicate that the protocol has succeeded in
expanding the validation procedure worldwide
by three to four-fold compared with the
period before its initial publication. However,
there is a need to tighten the accuracy criteria
so as to encourage the manufacture of better
devices and there is also a need to improve the
validation methodology by standardizing the
reporting of validation studies. These issues
have been successfully addressed in the 2010
revision of the ESH-IP.
References
1. O’Brien E, Asmar R, Beilin L, Imai Y, Mallion JM,
Mancia G, et al. European Society of Hypertension
recommendations for conventional, ambulatory
and home blood pressure measurement. J Hypertens
2003;21:821-48.
2. Association for the Advancement of Medical
Instrumentation. The national standard of electronic
or automated sphygmomanometers. Arlington,
VA: AAMI;1987.
3. O’Brien E, Petrie J, Littler W, De Swiet M, Padfield
P, O’Malley K, et al. The British Hypertension
Society protocol for the evaluation of automated
and semi-automated blood pressure measuring
devices with special reference to ambulatory systems.
J Hypertens 1990;8:607-19.
4. O’Brien E, Pickering T, Asmar R, Myers M, Parati
G, Staessen J, et al. European Society of Hypertension
International Protocol for validation of blood
pressure measuring devices in adults. Blood Press
Monit 2002;7:3-17.
5. Stergiou G, Karpettas N, Atkins N, O’Brien E. European
Society of Hypertension International Protocol
for the validation of blood pressure monitors:
a critical review of its application and rationale for
revision. Blood Press Monit 2010;15:39-48.
6. O’Brien E, Atkins N, Stergiou G, Karpettas N, Parati
G, Asmar R, et al. European Society of Hypertension
International Protocol revision 2010 for the
7 Apr/May 2010
validation of blood pressure measuring devices in
adults. Blood Press Monit 2010;15:23-38.
The authors
George S. Stergiou 1 * MD, FRCP,
Associate Professor of Medicine & Hypertension
Nikos Karpettas 1 MD, Clinical Research Fellow
Neil Atkins 2 PhD, Statistician
Eoin O’Brien 3 Professor of Molecular Pharmacology
1 Hypertension Center, Third University Department
of Medicine, Sotiria Hospital, Athens,
Greece.
2 dabl Ltd, 34 Main Street, Blackrock, Co. Dublin,
Ireland.
3 Conway Institute of Biomolecular & Biomedical
Research, University College Dublin, Ireland.
* Corresponding author:
George S. Stergiou, MD
Hypertension Center
Third University Department of Medicine
Sotiria Hospital
152 Mesogion Avenue
Athens 11527, Greece
Tel: +30 210 7763117
E-mail: gstergi@med.uoa.gr
Comments on this article?
Feel free to post them at
www.ihe-online.com/comment/ESH-IP
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Apr/May 2010
Near-infrared Spectroscopy (NIRS) has
emerged as a new monitoring tool that is a reliable,
noninvasive means of continuously measuring
tissue perfusion. In this review we summarize
our experience with the value of StO 2
monitoring in a number of settings including
a) ICU shock resuscitation, b) predicting outcomes
in the emergency department, c) ICU
sepsis resuscitation.
ICU traumatic shock resuscitation
In the 1980s, William Shoemaker wrote a
series of papers addressing the use of physiological
monitoring to predict outcome and
assist in clinical decision making [1-3]. He
identified two key variables, oxygen delivery
(DO 2 ) and oxygen consumption (VO 2 ),
as predictors of survival and popularised
“supranormal oxygen delivery” as a resuscitation
strategy. He proposed that unrecognised
flow-dependent oxygen consumption
contributed to the devel opment of multiple
organ failure (MOF) and believed that this
deficit could be corrected by maximising
DO 2 [2, 3]. Although, it is now recognised
that resuscitation to achieve supranormal
indices is not beneficial in all patients, the
use of physiological parameters to guide
resuscitation and predict outcomes is central
to all ICU resuscitation.
The introduction of new technology into
intensive care units, including continuous
venous oximetry and continuous cardiac
output monitoring with PA catheters [4] permitted
wide spread use of oxygen transport
variables to guide resuscitation. In an effort
to further refine the logic for traumatic shock
resuscitation, surgical intensivists employed
computerised clinical decision support to
prospectively collect data on responders and
nonresponders and optimise resuscitation
strategies. Computerised protocols also provided
the opportunity to test the utility of
various monitors in shock resuscitation, such
8 PAtiENt MoNitoriNG
Continuous sto 2 monitoring in goaldirected
shock and iCU resuscitation
throughout the years, iCU technology has allowed physicians to obtain reliable
physiological parameters to guide goal-oriented iCU resuscitation. A number of
studies have validated the use of tissue hemoglobin oxygen saturation (sto 2 ) as a
reliable index of tissue perfusion. sto 2 monitoring offers a continuous assessment
of the adequacy of ongoing shock resuscitation and aids in early identification of
high-risk patients in septic and hemorrhagic shock.
by dr rachel J. santora and dr Frederick A. Moore
as the tissue hemoglobin oxygen saturation
(StO 2 ) monitor. Prospective studies utilising
protocol-driven shock resuscitation demonstrated
that changes in skeletal muscle StO 2
showed a strong correlation with changes in
DO 2 , blood base deficit (BD, and lactate. This
observation that the StO 2 as an index of perfusion
that tracks DO 2 during active resuscitation
led laboratory investigators to explore the
role of StO 2 monitors in large animal models
of hemorrhagic shock [5].
In these studies, hemodynamic and NIR
spectroscopic measurements were used to
identify early predictors of irreversible shock.
Measurements of hind-limb StO 2 in each
group diverged within 30 minutes of shock,
such that by the end of the 90 minute period,
the StO 2 value for unresuscitatable remained
low despite resuscitation. Animals destined
to survive shock and resuscitation did not
exhibit an irreversible decline in StO 2 . These
findings demonstrate that skeletal StO 2 is a
reliable, noninvasive means for early differentiation
between resuscitatable and nonresuscitatable
animals. Similarly, studies utilising
noninvasive StO 2 to guide fluid resuscitation
after traumatic shock showed StO 2 as
a reliable assessment tool to determine the
adequacy of shock resuscitation in response
to colloids [6].
Taken together these clinical and research
data suggest that StO 2 (derived from a noninvasive
monitor) could provide information
about the effectiveness of resuscitation
equivalent to that of a invasive PA catheter or
serial blood draws to measure base deficit or
lactate levels.
Predicting outcomes in MOF
Post injury Multiple Organ Failure is well
recognized as a significant cause of mortality
following traumatic injury. In an effort to
identify critically ill patients at risk, a number
of studies focused on identifying early predictors
of postinjury MOF [7,8]. Through a
series of studies, investigators determined
base deficit as the earliest independent predictor
of postinjury MOF [9], an observation
that was validated by a number of clinical
studies [10].
With this in mind, Cohn et al decided to perform
a study using StO 2 monitoring in the
The use of modern oxygenation monitors to determine StO 2 levels can identify life-threatening conditions before
there are any visible clinical signs.

emergency room to determine if it could predict
MOF [11]. The group performed a prospective
observational study involving seven
US trauma centers evaluating the efficacy of
thenar StO 2 as an early predictor of MOF in
major torso trauma patients compared to the
accepted standard (base deficit). StO 2 monitors
were placed upon arrival and MOF and death
were the primary outcomes. They determined
that 1) StO 2 was equal to base deficit analysis
for predicting MOF development and 2) StO 2
out-performed both base deficit and systolic
blood pressure as an early predictor of death
[11]. Subset analysis comparing StO 2 levels to
lactate levels also validated StO 2 as an early predictor
of death when compared to conventional
parameters[12].
Figure 1
(A)
(B)
24h Sepsis Protocol
24 Hour Sepsis Protocol- First 12 Hours
From these observations, we conclude that
StO 2 obtained within the first hour after ED
admission is an equally reliable predictor of
adverse outcomes as the more conventionally
used parameters of lactate and base deficit in a
continuous, noninvasive fashion.
ICU sepsis resuscitation and the role
of the StO 2 monitor
In recent years, it has been recognized that
severe sepsis and septic shock are the leading
cause of ICU mortality [13-16]. Recent efforts
have been directed at updating the surviving
sepsis campaign guidelines and improving
early delivery [16]. To assist with consistent
implementation of these interventions, surgical
intensivists at the Methodist Hospital in
Physiologic Parameters Interventions
Hour MAP CVP HR StO 2 [Hb] LR Hextend PRBCs
1 103 10 150 58 10.1 1000
2 93 11 158 57 1000
3 77 15 99 51
4 77 10 151 61 9.0 1000 1 unit
5 73 8 140 69 500
6 71 9 141 66 7.9 500 1 unit
7 67 11 134 67 250
8 67 8 140 68 9.4 250
9 69 9 134 71 250
10 70 12 117 71
11 69 11 109 72
12 71 12 106 69 9.6
Figure 1 A & B: Case Report
StO 2 tracings over the first 36 hours of postoperative ICU admission, where the first 24 hours represents
ongoing resuscitation with our sepsis protocol (A). Physiologic Parameters and Interventions corresponding
with the StO 2 tracings above (B); Hour, hour on sepsis resuscitation protocol; MAP, mean arterial pressure;
CVP, central venous pressure; HR, heart rate; StO 2 , skeletal muscle tissue hemoglobin saturation; [Hb],
hemoglobin concentration; LR, lactated ringers; PRBCs, packed red blood cells.
9 Apr/May 2010
Houston, TX, USA have developed a computerized
clinical decision support application.
To facilitate early identification of sepsis and
facilitate implantation of this support application,
a three step screening process was
developed to collect physiologic parameters
that characterize the systemic inflammatory
response syndrome (SIRS) and to compile a
SIRS score. If the SIRS score exceeds 4, efforts
are focused on ascertaining presence of an
infection. For patients that are identified as
having sepsis, the computerized clinical decision
support application is utilized to implement
our sepsis protocol and provide a tool
for ongoing assessment.
Our current sepsis protocol is composed of two
distinct phases. Phase one is for management
of simple sepsis; it dictates that the patient get
appropriate cultures, antibiotics, a fluid challenge
and repeat laboratory determinations.
Phase two of our protocol is for septic shock,
which is much more complex and is a data
driven protocol that insures the appropriate
use of fluid resuscitation, inotropes, vasopressors
and testing for adrenal insufficiency. In
this setting, we have been using StO 2 data and
have found it to provide valuable information
regarding the adequacy of resuscitation.
The following case presentation emphasizes the
ability of StO 2 monitoring to detect life-threatening
clinical deterioration before derangement
of other physiologic parameters.
Case Report: A 38 year old man who initially
presented with pancreatitic necrosis and retroperitoneal
abscesses managed with IV antibiotics
and percutaneous drainage, was transferred
to our institution after developing severe sepsis
from methicillin resistant staphylococcus
aureus (MRSA) bacteremia. Upon arrival in
our ICU, we implemented our sepsis protocol
and he responded to our sepsis resuscitation.
Despite improved percutaneous drainage
for source control, he continued to have SIRS,
characterized by spiking temperatures and
tachycardia. He remained ventilator dependent
and required ongoing dialysis. Based on
repeat CT scans, the left IR drain was upsized
to a chest tube in the ICU for improved source
control. As his SIRS resolved, he was weaned
from the ventilator and his renal failure also
resolved. The patient was transferred to the
floor with tachycardia and purulent drainage
material from the left chest tube. Repeat CT
showed resolution of the upper retroperitoneal
abscesses, however lower retroperitoneal
abscesses extending into his scrotum were now
present. After operative drainage and debridement
of these retroperitoneal fluid collections
through a bilateral groin retroperitoneal exploration,
he was readmitted to the intensive care
unit for worsening sepsis and was placed on
phase II of our sepsis protocol.

Apr/May 2010
Figure 1 illustrates the StO 2 tracings over the
first 36 hours, where the first 24 hours represents
ongoing resuscitation with our sepsis
protocol. The patient initially dropped his
StO 2 as he became septic, and it rose up to the
70 range over the first 4 hours with ongoing
resuscitation. There was some variability over
the next several hours and then the StO 2 value
increased and plateaued and remained constant
until the completion of this sepsis protocol.
Following sepsis resuscitation, the StO 2
monitor was left in place. That evening the
patient remained persistently tachycardic, his
urine output decreased and his hemoglobin
Figure 1
(A)
(B)
24h Sepsis Protocol
10
concentration decreased from 9.6 to 7.9. During
this time he received three 500ml boluses
of isotonic crystalloid. Initially the decrease in
hemoglobin was attributed to hemodilution;
due to his persistent tachycardia, he was given
2 units of packed red blood cells. At 6 am the
next morning the ICU resident examined the
patient, noted the patient to be persistently
tachycardic but with a good MAP and adequate
urine output. His dressings were noted
to be nonsanguinous, however, at 8 am, during
ICU team rounds the dressing was soaked
with blood. The patient returned to operating
room for immediate exploration and was
24 Hour Sepsis Protocol- First 12 Hours
Physiologic Parameters Interventions
PAtiENt MoNitoriNG
Hour MAP CVP HR StO 2 [Hb] LR Hextend PRBCs
1 103 10 150 58 10.1 1000
2 93 11 158 57 1000
3 77 15 99 51
4 77 10 151 61 9.0 1000 1 unit
5 73 8 140 69 500
6 71 9 141 66 7.9 500 1 unit
7 67 11 134 67 250
8 67 8 140 68 9.4 250
9 69 9 134 71 250
10 70 12 117 71
11 69 11 109 72
12 71 12 106 69 9.6
Figure 1 A & B: Case Report
StO 2 tracings over the first 36 hours of postoperative ICU admission, where the first 24 hours represents ongoing
resuscitation with our sepsis protocol (A). Physiologic Parameters and Interventions corresponding with the
StO 2 tracings above (B); Hour, hour on sepsis resuscitation protocol; MAP, mean arterial pressure; CVP, central
venous pressure; HR, heart rate; StO 2 , skeletal muscle tissue hemoglobin saturation; [Hb], hemoglobin
concentration; LR, lactated ringers; PRBCs, packed red blood cells.
found to have a small arterial bleeder that was
ligated. Postoperative mesenteric angiography
confirmed that there was no pseudoaneurysm
or sources of ongoing bleeding. After
reviewing the StO 2 tracing, at approximately 8
pm prior to this event, there was a presumptuous
drop in StO 2 from 70 down to 35. With
ongoing fluid resuscitation and blood transfusions
the StO 2 value and went back up to 70
[Figure 2].
However, in the early morning hours, the StO 2
number began to drift downwards prior to
recognition of the patient’s ongoing bleeding.
Comparison of the StO 2 tracings with other
physiologic parameters shows that the StO 2
monitor provides more precise information
regarding the adequacy of resuscitation at specific
points in time. This case is an example of
how the StO 2 can provide additional information
that could help a clinician identify a life
threatening complication long before it is clinically
recognized.
Conclusion
In our ongoing experience with ICU resuscitation,
NIRS or StO 2 monitoring offers a continuous,
non-invasive index of tissue perfusion.
Early clinical trials utilizing StO 2 monitors during
active shock resuscitation validated changes
in skeletal muscle StO 2 as an index of perfusion
that was equivalent to serial measurements of
base deficit and lactate levels. In the setting of
ICU sepsis we have observed that StO 2 responds
to interventions, and may be useful in titrating
vasopressors to avoid excessive vasocontrictors
and for monitoring for significant clinical deteriorations.
We concluded with a case presentation
in which StO 2 identified life threatening
postoperative bleeding nearly 12 hours before
it became clinically evident to the clinicians.
Competing interests
Dr. Frederick Moore is a member of the Hutchinson
Technology Inc. Trauma and Critical
Care Advisory Board.
References
1. Shoemaker WC, Appel P, Bland R. Use of physiologic
monitoring to predict outcome and to assist
in clinical decisions in critically ill postoperative
patients. Am J Surg 1983, 146(1):43-50.
2. Shoemaker WC, Appel PL, Kram HB, Waxman K,
Lee TS. Prospective trial of supranormal values
survivors as therapeutic goals in high risk surgical
patients. Chest 1988, 94: 1176-1183
3. Shoemaker WC. Invasive and Noninvasive Hemodynamic
Monitoring of High-Risk Patients to
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and Pain, 1999, 18(1):63-70.
4. Nelson L. Continous Venous Oximetry in Surgical
Patients. Ann Surg 1986, 203(3): 329-33.
5. Taylor JH, Mulier KE, Myers DE, Beilman GJ.
Use of Near Infrared Spectroscopy in Early

Determination of Irreversible Hemorrhagic
Shock. J Trauma 2005, 58: 1119-1125.
6. Crookes BA, Cohn SM, Burton EA, Nelson J,
Proctor KG. Noninvasive muscle oxygenation to
guide fluid resuscitation after shock. Surgery 2004,
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7. Davis J, Shckford SR, Mackersie RC, Hoyt DB.
Base Deficit as a Guide to Volume Resuscitation. J
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8. Davis JW, Parks S, Kaups K, Gladen HE, O’Donnell-
Nicol. Admission Base Deficit Predicts Transfusion
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9. Sauaia A, Moore FA, Moore EE, Haenal JB, Read
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10. Sauaia A, Moore FA, Moore EE, Norris JM, Lezotte
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11. Cohn SM, Nathens AB, Moore FA, Rhee P, Puyana
JC, Moore EE, Beilman GJ, and the StO2
in Trauma Patients Trail Investigators. Tissue
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of Organ Dysfunction During Traumatic Shock
Resuscitation. J Trauma 2007, 62:44-55.
12. Moore FA. Tissue oxygen saturation predicts
the development of organ failure during traumatic
shock resuscitation. In: Faist E, ed. International
Proceedings of the 7th World Congress
on Trauma, Shock, Inflammation and Sepsis.
Munich, Germany, 13-17 March 2007. Bologna,
Italy: Medimond; 2007:111–114.
13. Dellinger RP, Carlet JM, Masur H, Gerlach H,
Calandra T, Cohen J, Gea-Banacloche J, Keh D,
Marshall JC, Parker MM, Ramsay G, Zimmerman
JL, Vincent JL, Levy MM; Surviving Sepsis
Campaign Management Guidelines Committee.
Surviving Sepsis Campaign guidelines for managment
of severe sepsis and shock. Crit Care Med
2004, 32(3):858-73.
14. Hollenberg SM, Ahrens TS, Annane D, Astiz
ME, Chalfin DB, Dasta JF, Heard SO, Martin C,
Napolitano LM, Susla GM, Totaro R, Vincent JL,
Zanotti-Cavazzoni S. Practice Parameters for
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Barie PS, Hitt J, Kuti JL, Septimus E,
Lawler N, Schilling L, Dorman T; Core Sepsis
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for Sepsis Care in the ICU. Jt Comm J Qual
and Patient Saf. 2007, 33(9):559-68.
16. Dellinger RP, Levy MM, Carlet JM, Bion J,
Parker MM, Jaeschke R, Reinhart K, Angus DC,
Brun-Buisson C, Beale R, Calandra T, Dhainaut
JF, Gerlach H, Harvey M, Marini JJ, Marshall J,
Ranieri M, Ramsay G, Sevransky J, Thompson
BT, Townsend S, Vender JS, Zimmerman JL, Vincent
JL; International Surviving Sepsis Campaign
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Critical-Care Nurses; American College of Chest
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Physicians; Canadian Critical Care Society;
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The authors
Rachel J. Santora 1 & Frederick A. Moore 1,2
1 Department of Surgery,
The Methodist Hospital,
Houston, TX, USA
&
2 Department of Surgery,
Weill Cornell Medical College,
New York, NY, USA
Corresponding author:
Rachel J. Santora MD
The Methodist Hospital
Department of Surgery
6550 Fannin Street, SM 1661
Houston, TX 77030,
USA
E-mail: rjsantora@tmhs.org
Apr/May 2010
Comments on this article?
Feel free to post them at
www.ihe-online.com/comment/ST02
A New Vital Sign for the 21 st Century
The InSpectra StO2 Tissue
Oxygenation Monitor provides
continuous, real-time information
for perfusion status monitoring;
a new hemodynamic parameter
that assists clinicians in the early
detection of inadequate tissue
perfusion (hypoperfusion).
How the InSpectra StO2 System
can provide critical value to
clinicians
• Identifies critically ill patients by
detecting hypoperfusion early.
• Tracks patient status, regardless
of cause of hypoperfusion
(e.g., hypovolemia, early sepsis,
cardiogenic shock).
• Responds to interventions
real-time, assisting with
fluid management.
• A noninvasive, easy-to-use
alternative for monitoring
hypoperfusion.
• Helps guide interventions
by monitoring resuscitation
progress.
Interested in knowing more?
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The InSpectra StO2 Tissue Oxygenation Monitor is a noninvasive monitoring system that measures an approximated value
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InSpectra is a registered trademark of Hutchinson Technology Inc. in the United States of America, the European
Community, Canada, China and Japan.
© 2010 Hutchinson Technology Inc. 5024835 A 01/10 All Rights Reserved. 0086
www.ihe-online.com & search 45562

Apr/May 2010
Whole body MRI is highly
accurate in the early detection
of breast cancer metastases
Whole body magnetic resonance imaging
(MRI) should be the imaging modality of
choice for the detection of breast cancer metastases,
as it is highly accurate and can detect bone
metastases while a patient is still asymptomatic,
according to a study presented at the American
Roentgen Ray Society (ARRS) 2010 Annual
Meeting in San Diego, CA, USA. Breast cancer
cells commonly spread to the bones, lungs, liver
or brain; metastatic breast cancer tumours may
be found before or at the same time as the primary
tumour, or months and even years later.
The study, performed at Deenanath Mangeshkar
Hospital and Research Center in Pune,
India, included 99 patients with known breast
cancer who were evaluated for metastases
using whole body MRI. Of the 99 patients, MRI
accurately revealed that 47 patients were positive
for metastases while 52 were negative. Of
those patients who were positive for metastases,
whole body MRI frequently detected bone
metastases earlier when the patient was still
asymptomatic. Whole body MRI is an effective
tool for the detection of metastases and unlike
other procedures commonly used in this role,
it emits no radiation.
http://womensimagingonline.arrs.org/
High-pressure jobs increase younger
women’s heart disease risk
A large study of female nurses, published
recently in Occupational and Environmental
Medicine, suggests that high pressure jobs
increase the risk of ischemic heart disease in
women. Previous research has indicated a link
12 NEWs iN BriEF
between a demanding job and heart disease
risk, but the findings have been largely confined
to men.
This research assessed the impact of work pressure
and degree of personal influence in the
workplace on the heart health of 12,116 nurses,
who were taking part in the Danish Nurse
Cohort Study. The nurses were all aged between
45 and 64 in 1993, when they were quizzed
about their daily work pressures and personal
influence, after which their health was tracked
for 15 years, using hospital records.
By 2008, 580 nurses had been admitted to hospital
with ischemic heart disease, which included
369 cases of angina and 138 heart attacks.
Nurses who indicated that their work pressures
were a little too high were 25% more
likely to have ischemic heart disease as those
who said their work pressures were manageable
and appropriate; those who felt work
pressures were much too high were almost
50% more likely to have ischemic heart disease.
After taking account of risk factors for
heart disease, such as smoking and lifestyle,
the risk fell to 35%, but still remained significant.
Poor job control in the workplace
did not influence heart disease risk, while
the amount of physical activity at work,
which is known to affect health, had a small
although significant impact. When the findings
were analysed by age, only the nurses
under the age of 51 were at significant risk of
heart disease.
In a separate analysis, the researchers looked
at the impact of work pressures on the same
group, but for just five years up to 1998. Nurses
who felt themselves to be moderately pressurised
at work were 60% more likely to have
ischemic heart disease while those who said
they faced excessive pressures at work were
almost twice as likely to have it. These findings
held true even after taking account of other
risk factors.
http://www.bma.org.uk/
On-site pathology improves the
inadequacy rate of ultrasound-guided
thyroid biopsies
Having a pathologist on-site during ultrasound-guided
thyroid biopsies can decrease
the number of repeat biopsies that are often
performed due to an inadequate sample from
the first procedure, according to a study presented
at the ARRS 2010 Annual Meeting in
San Diego, CA, USA.
Requests for ultrasound-guided biopsies for
the diagnosis of thyroid nodules have increased
rapidly in recent years, putting a strain on radiology
departments everywhere, according to
Wui K. Chong, MD, lead author of the study.
Unfortunately, there are a number of inadequate
biopsies (where the pathologist deems there is
an insufficient amount of information to make
a diagnosis) that ultimately must be repeated.
Repeat biopsy is unpleasant and inconvenient
for the patient and is obviously wasteful. Having
a pathologist on-site to review the specimen
can cut down on the number of patients
returning for repeat biopsy, thus making more
efficient use of resources.
The study compared 200 biopsies that were
performed with a pathologist on-site and 200
that were not. It was found that all other factors
being equal, 13.5 percent of biopsies performed
without a pathologist on-site were inadequate,
compared to only 5 percent that were performed
with a pathologist on-site. The authors
thus recommend that radiologists performing
large numbers of thyroid biopsies use on-site
pathology as it may reduce the need for repeat
biopsy by up to 60 percent.
http://womensimagingonline.arrs.org/
Study finds everolimus-eluting
stent safer, more effective than
paclitaxel-eluting stent
Results from the SPIRIT IV clinical trial, which
were first presented at the Transcatheter Cardiovascular
Therapeutics (TCT) 2009 scientific
symposium, were published recently in the
New England Journal of Medicine.
Data from the trial, a large-scale multi-centre
study of nearly 4,000 patients in the US, showed
that everolimus-eluting stents demonstrated
enhanced safety and efficacy in the treatment
of de novo native coronary artery lesions when
compared to paclitaxel-eluting stents. The trial,
which was powered for superiority for clinical
endpoints without angiographic follow up, also
examined the differences in performance of the
two stents in patients with diabetes.
The primary endpoint of the trial was targetlesion
failure (TLF) at one year, a composite
measure of cardiac death, target-vessel heart
attack or ischemia-driven target-lesion revascularization
(TLR). Major secondary endpoints

of the trial were ischemia-driven TLR at one
year, and the composite rate of cardiac death or
target-vessel heart attack at one year.
For everolimus-eluting stents, TLF at one
year was 4.2 percent, and for paclitaxeleluting
stents, TLF was 6.8 percent, a significant
38 percent reduction. At one-year,
ischemia-driven TLR was 2.5 percent for
everolimus-eluting stents and 4.6 percent for
paclitaxel-eluting stents, a significant 45 percent
reduction. The composite rates of cardiac
death or target-vessel myocardial infarction
through one year were not statistically
different with the two stents (2.2 percent
for everolimus-eluting stents and 3.2 percent
for paclitaxel-eluting stents). The oneyear
rates of myocardial infarction and stent
thrombosis, however, were also lower with
everolimus-eluting stents than with paclitaxel-eluting
stents (1.9 percent vs. 3.1 percent
for myocardial infarction and 0.17 percent
vs. 0.85 percent stent thrombosis). The
results were consistent regardless of lesion
length, vessel size and the number of lesions
treated. However, in the diabetic-patient subgroup,
the study found a comparable rate of
TLF with both stents, whereas in patients
without diabetes, everolimus-eluting stents
reduced TLF by 53 percent compared to
paclitaxel-eluting stents.
http://tinyurl.com/37sfo7s
Outcomes of early vs. late
tracheotomy for mechanically
ventilated ICU patients
Adult ICU patients who received tracheotomy
6 to 8 days vs. 13 to 15 days after mechanical
ventilation did not have a significant reduction
in the risk of ventilator-associated pneumonia,
according to a study published in a recent issue
of JAMA.
Tracheotomy replaces endotracheal intubation
in patients who are expected to require prolonged
mechanical ventilation. Advantages of
tracheotomy include prevention of ventilatorassociated
pneumonia (VAP), earlier weaning
from respiratory support and reduction in
sedative use. There is considerable variability
in the time considered optimal for performing
tracheotomy.
Pier Paolo Terragni, M.D., of the Uni¬versita di
Torino, Turin, Italy, and colleagues inestigated
NEWs iN BriEF Apr/May 2010
whether tracheotomy performed earlier (6-8
days) vs. later (13-15 days) after laryngeal (larynx)
intubation would reduce the incidence of
VAP and increase the number of ventilatorfree
and intensive care unit (ICU)-free days.
The randomized controlled trial, performed
in 12 Ital¬ian ICUs from June 2004 to June
2008, enrolled 600 adult patients without lung
infection who had been ventilated for 24 hours.
Patients who had worsening of respiratory conditions,
unchanged or worse sequential organ
failure assessment score, and no pneumonia
48 hours after inclusion were randomized to
early tracheotomy (n = 209; 145 received tracheotomy)
or late tracheotomy (n = 210; 119
received tracheotomy).
The researchers found that 30 patients (14 percent)
had VAP in the early tracheotomy group
and 44 patients (21 percent) had VAP in the
late tracheotomy group. The numbers of ventilator-free
and ICU-free days and the incidences
of successful weaning and ICU discharge were
significantly greater in patients randomized to
the early tracheotomy group compared with
patients randomized to the late tracheotomy
group; there were no differences between the
groups in survival at 28 days.
The data show that in intubated and mechanically
ventilated adult ICU patients with a
high mortality rate, early tracheotomy did not
result in a significant reduction in incidence
of VAP compared with late tracheotomy.
Although the number of ICU-free and ventilator-free
days were higher in the early tracheotomy
group than in the late tracheotomy
group, long-term outcome did not differ. Considering
that anticipation for tracheotomy of
1 week increased the number of patients who
received a tracheotomy, and more than onethird
of the patients experienced an adverse
event related to tracheotomy, these data suggest
that a tracheotomy should not be performed
earlier than after 13 to 15 days of
endotracheal intubation.
www.jamamedia.org
Harm caused by nicotine withdrawal
during intensive care
Nicotine withdrawal can cause dangerous
agitation in intensive care patients. Researchers
writing in BioMed Central’s open access
journal Critical Care found that, compared
to non-smokers, agitated smokers were more
likely to accidentally remove tubes and catheters,
require supplemental sedative, analgesic
or anti-psychotic medications, or need physical
restraints.
Damien du Cheyron, from Caen University
Hospital, France, worked with a team of
researchers to study the effects of nicotine
withdrawal in 44 smokers and 100 non-smokers
in the hospital’s intensive care unit, finding
that agitation was twice as common in smokers
than controls. He said that agitation was
13
significantly more common in smokers than
in non-smokers. These results suggest the need
to be aware of nicotine withdrawal syndrome
in critically ill patients, and support the need
for improved strategies to prevent agitation or
treat it earlier”.
None of the smokers in the study were
allowed nicotine replacement therapy (NRT)
during the study period. According to du
Cheyron, NRT remains a controversial topic
in intensive care and has been associated with
mortality. Due to the serious consequences
of withdrawal-induced agitation, including
sedation and physical restraint, the authors
suggest that the use of nicotine replacement
therapy should be tested by a well-designed,
randomized controlled clinical trial in the
ICU setting.
http://tinyurl.com/37ko8d5
www.ihe-online.com & search 45344

Anesthesiology special
Selection of peer-reviewed literature
on anesthesiology
the number of peer-reviewed papers
covering the vast field of anesthesiology
is huge, to such an extent that it is
frequently difficult for healthcare professionals
to keep up with the literature.
As a special service to our readers,
iHE presents a selection of key literature
abstracts from the clinical and scientific
literature chosen by our editorial
board as being particularly worthy
of attention.
An anesthesiologist’s perspective on
inhaled anesthesia decision-making.
The practice of anesthesiology requires complex
monitoring, detailed knowledge of pharmacology,
and the ability to make quick decisions
about patient management. In the United
States, most general anesthesia involves inhaled
agents. The minimum alveolar concentration
(MAC) of inhaled anesthetic agents, which
anesthesiologists use in dosing these drugs,
can be affected by age, a variety of medications
and other patient-specific factors. MAC can be
thought of as a measure of drug potency. Both
MAC and solubility in blood and tissues differ
among inhaled anesthetic agents. Agents with
low solubility have a rapid onset and offset of
effect and may allow for faster recovery. The
choice among inhaled anesthetic agents may
depend on their solubility, as well as the propensity
to cause airway irritation and coughing,
drug cost and characteristics such as patient
age, obesity and duration of surgery. Anesthesia
care providers’ experience and habits may also
influence drug choice. Emergence delirium
(i.e., agitation) can occur with all three inhaled
anesthetic agents in common use (isoflurane,
desflurane, and sevoflurane). Other potential
issues such as hepatotoxicity and nephrotoxicity
are of minimal concern with these agents.
Using low flow rates of fresh gas is one strategy
for minimising inhaled anesthesia costs, but it
is not always feasible.
Prielipp RC. Am J Health Syst Pharm. 2010 Apr
15;67(8 Suppl 4):S13-20.
Risk in anesthesia.
Modern anesthesia is still associated with a risk
of serious complications. This article focusses
on frequency, causes, and prevention of the
most important anesthetic complications. The
article is based on literature identified through
a non-systematic search in Pub-Med, and the
author’s research and experience in this field.
The risk of death associated with anesthesia is
closely related to patient age and physical status.
In otherwise healthy patients (ASA 1), the
risk of such deaths is approximately 1:250 000.
Medication errors occur in approximately 1:1
000 anesthetic procedures. The risk of awareness
during general anesthesia is approximately
1:650. Neural injury from epidural and spinal
anesthesia is rare, especially in obstetrics. Anaphylaxis
caused by muscle relaxant drugs is
more common in Norway than in many other
industrialised countries. Pulmonary aspiration
occurs in approximately 1:7 000 anesthetic
procedures, but with low morbidity in
healthy patients. The incidence of anesthetic
accidents is higher in infants than older children,
and requires special competence. Serious
anesthetic complications are most often related
to the cardiovascular and respiratory system.
The complications are often multicausal, and
human errors and organisational factors contribute
in 50-70 % of the cases. Optimisation
of the patient’s preoperative health is important
to improve safety. The focus of the anesthesiology
department should be education and
guidelines. Systems and routines for improved
safety must also take into account that
human and organisational factors may cause
anesthetic accidents.
Fasting S. Tidsskr Nor Laegeforen. 2010 Mar
11;130(5):498-502.
General anesthesia occurs frequently
in elderly patients during
propofol-based sedation and spinal
anesthesia.
This study tested the hypothesis that sedation
in elderly patients is often electrophysiologically
equivalent to general anesthesia (GA). Forty elderly
patients (>or=65 yrs of age) undergoing hip
fracture repair with spinal anesthesia and propofol-based
sedation were observed. In the routine
practice group (RP; n = 15), propofol sedation
was administered as usual. In the targeted sedation
group (TS; n = 25), sedation was titrated to
an observer’s assessment of alertness/sedation.
Both patient groups underwent processed electroencephalographic
monitoring using bispectral
index (BIS) intraoperatively. BIS levels were compared
between groups to determine amount of
surgical time spent in GA (BIS

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Apr/May 2010
The introduction onto the market of a ready-touse
intravenous paracetamol formulation has
created a new future for a drug that is in fact
more than 100 years old. The new formulation
has stimulated interest on the part of anesthesiologists
to use paracetamol in the peri-operative
setting. The most popular over-the-counter
pain relieving and antipyretic drug has become
a major protagonist in operating rooms. However,
physicians still have many questions and
concerns about its use, its mechanism of action
and its safety profile.
Is paracetamol a NSAID? — a look
at its mechanism of action
Paracetamol, also known as acetaminophen,
was first synthesised in 1878 but had only limited
use until the 1950s, when it was identified
as the active metabolite of two well-known
antipyretic drugs, acetanilide and phenacetin,
which were themselves withdrawn from the
market for their nephrotoxicity.
Despite its widespread use, the detailed mechanism
of action of paracetamol is still poorly
understood; questions remain open as to
whether it acts peripherally and/or centrally, as
16 ANEstHEsioLoGy
Paracetamol : the otC pain reliever
becomes a protagonist in operating theatres
the new intravenous formulation of paracetamol has transformed the most popular
over-the-counter (otC) pain reliever into a valuable analgesic option for pain
management in the peri-operative setting. However, more than 100 years after its
original introduction into clinical practice, there are still many questions about the
drug’s mechanism of action, its analgesic efficacy and safety.
by Prof. Flaminia Coluzzi, dr Giada Nardecchia and dr Consalvo Mattia
Figure 1. The effect of hydroperoxide concentration
on the action of paracetomol.
well as which analgesic pathway is principally
affected by its administration.
A commonly posed question is whether paracetamol
inhibits cyclooxygenase (COX)
like nonsteroidal anti-inflammatory drugs
(NSAIDs) or whether its analgesic activity
is due to modulation of other endogenous
pathways. In 1972, Flower and Vane showed
that the anti-pyretic effect of paracetamol
was related to the inhibition of prostaglandin
synthetase in the brain. Recent investigations
showed that paracetamol has no direct affinity
for the active site of COX, but rather acts as a
reducing agent — by reducing the active oxidised
form of the enzyme to an inactive form,
it blocks the activity of COX. Because COX is
sensitive to the local oxidation environment,
which is influenced by a high organic peroxide
concentration such as is found in peripheral
sites of inflammation and in platelets, paracetamol
is a weak inhibitor of prostaglandin
synthesis. In the central nervous system and
in the endothelial cells, however, where the
concentration of hydroperoxides is low, paracetamol
selectively inhibits the enzyme [Figure
1]. This explains why paracetamol is not associated
with the gastric side-effects and inhibition
of platelet activity traditionally observed with
NSAIDs. However, paracetamol does not have
the anti-inflammatory efficacy of NSAIDs, but
only analgesic and antipyretic activity.
The hypothesis that paracetamol could selectively
inhibit a particular isoform of the COX
enzyme, namely COX-3, which is highly
expressed in the brain and in the heart, has
been recently ruled out. COX-3 is just a variant
of COX-1, with a significantly lower potency
(about 1/5th) in generating prostaglandins.
Other possible mechanisms of the analgesic
action have been postulated:
a) Paracetamol interacts with the endogenous
opioid pathways, but it does not bind to opioid
receptors.
b) Paracetamol is associated with changes in
the serotoninergic system, the endogenous
descending pain inhibitory pathway, known
as the “analgesic system”.
c) Paracetamol inhibits substance P-mediated
hyperalgesia, by interaction with the nitric
oxide pathway.
d) Paracetamol can indirectly activate cannabinoid
receptors (CB1) by increasing brain levels
of endogenous cannabinoids. One of the
metabolites of paracetamol, namely AM404,
acts as an inhibitor of cellular re-uptake of
anandamide, which is the first recognised
endocannabinoid.
Hepatotoxicity: myth or reality?
Paracetamol is a safe drug when used at the
recommended therapeutic doses. However,
overdose can lead to serious and even fatal liver
injury. This potential hepatotoxicity could still
represent a perceived barrier to its use by some
physicians. Paracetamol is responsible for up to
40% of cases of acute liver failure in the United
States and the United Kingdom.
Damage to the liver following paracetamol
ingestion is not due to the drug itself, but to a
toxic metabolite, namely N-acetyl-p-benzoquinine
imine (NAPQI). Once absorbed, approximately
90% of the paracetamol is metabolised
by conjugation and sulphation, 5% is eliminated
unchanged, and the remaining 5% is oxidised to
form NAPQI. This is quickly combined in the
liver with the endogenous antioxidant, glutathione,
to form non-toxic conjugates, which are
eliminated in the urine. After an overdose, when
glutathione stores in the liver become depleted,
free NAPQI begins to accumulate and causes
life-threatening liver injury.
Excluding suicide attempts, unintentional overdoses
constitute at least half of all paracetamolrelated
hepatotoxicity cases. The median dose
ingested in subjects who developed acute liver
failure was 24 g, i.e. six times the maximum 4g
daily dosage. Risk factors include excessive dosing
(repeated dosing in excess of package labelling
specified doses, or use of multiple paracetamol-containing
products), increased P450
activation, simultaneous use or abuse of alcohol
and narcotics, very young age, and comorbidities
including liver disease and depression.
The recommended dose for intravenous paracetamol
injection in adults is 1 g every 6 hours. Recent
studies evaluated the efficacy and safety of higher
doses. Serum hepatic aminotransferase activity
remained in the normal ranges, even when up to

8 g/day of paracetamol was used for three days
in healthy young adults. Similarly, in alcoholic
patients treated with 4 g/day for three consecutive
days, no increases in serum transaminases
or other measures of liver injury were observed.
The perception that paracetamol should be
avoided in patients with chronic liver disease arose
from the awareness of the association between
massive paracetamol overdose and acute liver
failure. However, the literature supports the use of
paracetamol in patients with liver disease.
Optimal formulation and dose
Different routes of administration have been
extensively studied for the peri-operative use of
paracetamol. With oral administration, a large
variability is observed in individual plasma paracetamol
levels. Intravenous administration is the
route of choice when oral administration is not
possible or when rapid analgesia is required, such
as in the post-operative setting.
What is the right dose for adequate analgesia?
The minimum plasma paracetamol level required
for analgesia and anti-pyresis is thought to be
10-20 mg/L. However, recent studies have shown
that it is the concentration in of the drug in the
effect compartment, rather than in plasma, that
relates more consistently to the analgesic effect.
It is therefore important to administer the right
dose at the right time in order to reach an adequate
concentration in the central nervous system
— the ready-to-use intravenous formulation
shows the best pharmacokinetic profile for postoperative
pain management. This formulation
penetrates readily into the cerebrospinal fluid and
provides rapid and predictable analgesia in the
post-operative setting.
Paracetamol in adults
In adults, the standard dose of paracetamol is 1g
every 6 hours administered as an intravenous
infusion every 15 minutes. Several studies have
demonstrated that the efficacy of 2g of intravenous
paracetamol is significantly superior
to 1g. In healthy subjects, the administration
of a 2g starting dose and 5g during the first 24
hours does not change the pharmacokinetics
of paracetamol, and the
peak plasma concentration
did not rise above the
toxic threshold. When a
single intravenous dose
of 3g of paracetamol
was administered, no
serious adverse events
were observed, but the
opioid-sparing effect was
similar to that reported
after conventional doses
of paracetamol. In conclusion,
even though no
hepatotoxicity has been
reported, the administration
of paracetamol at doses higher than 4g daily
is not recommended, since it does not improve
the drug’s analgesic efficacy.
Paracetamol in children
Rectal administration is preferred in children,
even though absorption is slower and more
variable compared with intravenous administration.
Plasma concentrations after administering
1g paracetamol are 1.2µg/mL for the
rectal route versus 2.7 µg/mL for the oral route.
In children, the analgesic efficacy of rectal
paracetamol increases in a linear manner as the
dose is increased from 0 to 60 mg/kg. However,
rectal doses greater than 30 mg/kg are not recommended.
In pediatric surgical patients, the
recommended dose of intravenous paracetamol
is 15 mg/kg. Precautions must be taken when
using paracetamol in neonates and infants, as
they have an increased risk of forming the reactive
intermediate metabolite that causes hepatocellular
damage, particularly after multiple
doses. Neonates and infants have an immature
glucuronide conjugation system, and the sulphation
metabolic pathway is the main route
of metabolism for paracetamol.
Opioid sparing
The opioid-sparing effect of paracetamol,
when used in combination with opioid receptor
agonist for multimodal analgesia, is still
controversial. After major surgery, the use of
paracetamol significantly reduced morphine
use by approximately 20%, compared to 40%
with NSAIDs, and 25% with COX-2 inhibitors.
However, it did not change the incidence
of morphine-related adverse events during the
post-operative period. A meta-analysis proved
that adding an NSAID may increase the analgesic
efficacy of paracetamol, but their combination
does not provide a better analgesic effect
than NSAID alone.
Paracetamol in combination with
other drugs
Paracetamol is also available in fixed combinations
with other molecules, such as codeine, tramadol
and oxycodone, for oral administration
17 Apr/May 2010
only. These formulations have proved effective
for post-operative pain management, especially
in day-surgery, where analgesia must be provided
at home. Combining drugs from different
classes with different modes of action may offer
the opportunity to optimise efficacy and tolerability,
by using lower doses of each drug to reach
a similar degree of pain relief. After orthopedic
surgery, a paracetamol/tramadol combination
(325 mg/37.5 mg) showed an analgesic efficacy
significantly superior to placebo and comparable
to that obtained with codeine/paracetamol,
with better tolerability and a lower incidence
of constipation.
Conclusion
In conclusion, paracetamol is a safe and effective
centrally-acting analgesic for acute and
chronic pain management. The multiple interactions
with different endogenous systems
(cyclooxygenase, opioid, serotoninergic, nitric
oxide, and endocannabinoid pathways) make
it difficult to identify the exact mechanism of
action of the molecule. Its role in the peri-operative
setting has been widely demonstrated.
Advantages compared to traditional NSAIDs
are the lack of gastrointestinal side effects and
low interaction with platelet aggregation.
References
1. Mattia C, Coluzzi F. What anesthesiologists should know
about paracetamol (acetaminophen). Minerva Anestesiol
2009; 75: 644-53
2. Oscier CD, Milner QJ. Peri-operative use of paracetamol.
Anaesthesia 2009; 64: 65-72
3. Bertolini A, Ferrari A, Ottani A, Guerzoni S, Tacchi R,
Leone S. Paracetamol: new vistas of an old drug. CNS
Drug Reviews 2006; 12: 250-75
4. Elia N, Lysakowski C, Tramer MR. Does multimodal
analgesia with acetaminophen, nonsteroidal antiinflammatory
drugs, or selective cyclooxygenase-2 inhibitors
and patient-controlled analgesia morphine offer advantages
over morphine alone? Anesthesiology 2005; 103:
1296-304
5. Remy C, Marret E, Bonnet F. Effects of acetaminophen
on morphine side-effects and consumption after major
surgery: meta-analysis of randomized controller trials.
Br J Anesth 2005; 94: 505-13
6. Mattia C, Coluzzi F, Sarzi Puttini P, Viganò R. Paracetamol/Tramadol
association: the easy solution for mildmoderate
pain. Minerva Med 2008; 99: 369-90
The authors
Flaminia COLUZZI, M.D, Giada NARDEC-
CHIA, M.D. and Consalvo MATTIA, M.D.
I.C.O.T. – Polo Pontino
Department of Anesthesiology, Intensive Care
Medicine and Pain Therapy
Sapienza University of Rome, Rome, Italy
Corresponding author:
Prof. Flaminia COLUZZI
Research Associate Professor
Via India, 7 – 00196 Rome, Italy
E-mail: flaminia.coluzzi@uniroma1.it

Apr/May 2010
The American Board of Plastic Surgeons
(ABPS) recently reported that more than 11
million cosmetic procedures were performed
last year in the United States [1]. Many expect
this number to rise as plastic surgery procedures
become more advanced and less invasive.
Largely because of meticulous preoperative
screening and technological advances
in outpatient anesthesia for elective cosmetic
surgery, morbidity and mortality resulting
from outpatient anesthesia are rare [2].
Pre-hospital care
Patients should be medically optimized
before receiving any type of anesthetic. In
preparing for surgery, the American Society
of Anesthesiologists has developed a Physical
Status Score (ASA PS) that places patients
into one of six categories. Class I (completely
healthy) or Class II (mild controlled illness or
disease with no interference to the patient’s
daily life) patients are generally deemed suitable
for cosmetic surgery, while a Class III
patient would most likely need additional
assessment before being cleared for such
procedures. In addition to a thorough history
and physical exam, laboratory screenings
are often required. Commonly ordered tests
include hemoglobin and hematocrit, electrolytes,
blood glucose, urinalysis, an electrocardiogram
(EKG) and a pregnancy test for
women within child-bearing age.
Prior to surgery, the American Society of
Anesthesiologists Task Force on Preoperative
Fasting recommended a minimum fasting
period for clear liquids of two hours and
a minimum of six hours for milk or a light
meal. They further recommended a fasting
period of eight hours for patients who
have ingested any meal containing fried or
fatty foods [3]. Since it is easiest and safest
to adopt a single “nothing by mouth” rule
prior to elective surgery, eight hours is the
18 ANEstHEsioLoGy
Anesthesia for cosmetic surgery
the number of patients undergoing cosmetic surgery is steadily increasing as the
surgical procedures themselves become more advanced and less invasive. However,
just as patients undergoing cosmetic surgery are generally well informed
regarding the nature of the procedure and the reputation of their surgeon, they
frequently overlook the importance of the anesthetic technique needed to effectively
perform the procedure. An overall successful procedure involves not only a
plastic surgeon skilled in cosmetic surgery but also an anesthesiologist proficient
in cosmetic anesthesia. this article reviews the principal aspects to be considered
in the anesthesiology of cosmetic surgery.
by dr Peter J. taub and dr Laurence Hausman
most appropriate since it covers all foods
and liquids.
It is common for patients to feel anxiety and
apprehension before surgery. A preoperative benzodiazepine,
such as alprazolam or lorazepam, is
suitable because in addition to inducing somnolence,
this class of drug is also associated with
anxiolysis. In fact, many plastic surgeons treat
preoperative anxiety prophylactically.
Pre-operative care
Prior to the induction of anesthesia, an intravenous
line is inserted for administration
of medications. The American Society of
Anesthesiology (ASA) has outlined a standard
for which monitoring devices should be
used during outpatient general anesthesia.
These include a continuous electrocardiogram
(EKG), a cycling blood pressure cuff,
a pulse oximeter for oxygen saturation measurements,
an end tidal carbon dioxide monitor,
and a temperature probe. A constant stable
blood pressure in the low-normal range
for the duration of the cosmetic procedure is
desirable to minimize blood loss and bleeding
into the tissues that could contribute to
prolonged postoperative ecchymosis and
edema. Compression boots should be placed
prior to the induction of general anesthesia
to prevent the incidence of deep venous
thrombosis [4]. A bladder catheter is recommended
for cases longer than four hours
to safely manage fluid resuscitation and
to keep the bladder decompressed during
abdominal procedures.
Although there are currently more cosmetic surgical and nonsurgical procedures performed in the
United States than in Europe, the inevitable tendency is that the Europe follows the practices carried out
in the United States. The statistics above show the dramatic increase in procedures carried out
over the decade prior to 2008 (latest data available).
It can be seen that breast augmentation and lipoplasty remain the most common cosmetic surgical procedures.
For each surgical procedure it is estimated that there are four non-surgical procedures or minimally invasive
procedures. These include Botulinum Toxin A ( so-called Botox), soft tissue peelers, chemical peel,
microdermabrasion and laser hair removal.

The temperature of the operating
room is a vital consideration when
planning a surgical procedure.
Due to the vasodilatory nature
and the direct inhibition of the
hypothalamus caused by many
anesthetic agents, all patients are
susceptible to hypothermia during
surgery. Consequences of this can
be platelet dysfunction and bleeding,
enzymatic inactivity, cardiac
dysfunction, or postoperative
shivering [5]. Hence, the ambient
temperature of the operating
room should be kept at a temperature
that minimizes body heat loss
and a warming blanket be used for
longer procedures.
It is believed that a patient’s state
on induction (i.e. when the patient
loses consciousness) mirrors that
of emergence (i.e. when the patient
regains consciousness). Accordingly,
a smooth induction with
minimal hypertension and tachycardia
is desirable for cosmetic
anesthesia. Prior to induction,
the anesthesiologist should consider
giving several medications.
Midazolam, a short-acting benzodiazepine,
can produce sedativehypnotic
effects or can even induce
anesthesia at very high doses. It is
also characterized by its ability to
cause amnesia, hypnosis, and the
relaxation of muscles with relative
celerity. As far as cardiac sensitivity
is concerned, the use of midazolam
is associated with decreases
in mean arterial pressure (MAP),
cardiac output (CO), stroke volume
(SV), and systemic vascular
resistance (TPR). Consequently,
midazolam is contraindicated in
patients with acute pulmonary
insufficiency or severe chronic
obstructive pulmonary disease.
Postoperative nausea and vomiting
(PONV) is a major concern
with any anesthetic procedure.
Preoperative antiemetics should
be used to prevent PONV following
the use of numerous anesthetic
agents, including narcotics and
nitrous oxide. Many anesthesiologists
avoid narcotics altogether to
minimize the incidence of PONV.
Alternative analgesics include local
anesthetics, ketamine, and ketorolac.
Other anesthesiologists advocate
the use of narcotics for heavy
pain cases and use a variety of
available antiemetics to minimize
PONV. Granisitron and Ondansetron
are serotonin antagonists that
reduce the autonomic neuro-activity
in the vomiting center of the
brain. Dexamethasone, a steroid,
and Scopalamine, a tropane alkaloid,
may both be used to resolve
dizziness and nausea. Additionally,
metochlopromide and Amend,
a newer antiemetic, are increasingly
being used. Combination
therapy using several antiemetics
is advisable for patients that have
a high risk of PONV, including
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General anesthesia
General anesthesia is defined as
the controlled state of unconsciousness
accompanied by a loss
of protective airway reflexes [6].
With this type of anesthesia, the
patient may require respiratory
or cardiovascular support. The
insertion of an endotracheal tube
or laryngeal mask airway (LMA)
that sits just above the vocal cords
OMNI II
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19 Apr/May 2010
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after induction will allow control
of ventilation. For procedures that
do not involve frequent head turning,
the LMA provides a safe alternative
to the ETT since it does not
risk vocal cord injury and has less
of an incidence of postoperative
laryngeal irritation and “bucking
on the tube” [7]. However, since
the LMA does not occlude the trachea,
a traditional ETT should be
used for patients at high risk for
aspiration.
General anesthesia can be divided
into three phases: induction
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Apr/May 2010 20 ANEstHEsioLoGy
(loss of consciousness); maintenance (i.e.
when unconsciousness is maintained during
the procedure), and emergence (regaining
of consciousness).
Drugs for anesthesia induction
Various drugs can be used for the induction of
general anesthesia. One commonly used agent
is propofol, a short-acting intravenous drug
used in adult and pediatric patients. It may
also be utilized during the procedure for the
maintenance of anesthesia. Side effects include
hypotension and apnea, as well as pain on injection,
which can be ameliorated by pretreatment
with intravenous lidocaine [8]. Propofol is
often used for cosmetic procedures because it
is associated with reduced PONV and can even
be used as an antiemetic. Thiopental, another
induction agent, is a barbituate that affects fine
motor skills and is notorious for producing a
heavy “hangover” effect and significant PONV
[9]. Midazolam and ketamine can also be used
for induction, although they are associated
with a longer recovery time postoperatively.
Ketamine, a phencyclidine derivitive, is an
anesthetic agent approved for human and veterinary
use, whose popularity in the outpatient
arena has increased over the past several years.
Its effects include analgesia and sedation with
minimal to no respiratory depression. However,
hallucinations, hypertension, increased intracranial
pressure and salivation have limited its
appeal. It has been used successfully with propofol
and midazolam for cosmetic procedures
since it may be used without the need for
endotracheal intubation, supplemental oxygen,
or narcotics [10, 11].
Drugs for anesthesia maintenance
The choice of drugs used to maintain anesthesia
is also important to minimize PONV and
allow for a rapid recovery process. Nitrous
oxide is commonly used as an inhalational
agent to maintain anesthesia. Its use reduces
the need for higher concentrations of the
volatile inhalational agents for maintenance
of anesthesia. It is, however, associated with
PONV and should be limited to concentrations
under fifty percent, especially in patients
with evident coronary disease [12].
Isoflurane is one of a number of volatile inhalation
agents commonly used for maintenance
of anesthesia. Desflurane is a shorter acting
member of this class of drugs and may be
more suitable for cosmetic surgery. However,
desflurane often causes postoperative respiratory
irritation and coughing largely due to its
pungent smell. Sevoflurane is better tolerated
than desflurane since it lacks a characteristic
odor. As a result of the lower solubility of
these newer volatile agents, cognitive functions
return to baseline more rapidly when
compared to inhaled isoflurane.
Continuous intravenous anesthetics are commonly
employed in cosmetic surgery. Propofol,
remifentanil, dexmetatomidine and ketamine
are among the most commonly used. Remifentanil
may be used just prior to induction to
suppress the autonomic responses to intubation
and during maintenance to suppress
other autonomic responses to surgical stimuli.
Because it is also a short acting narcotic, it is
ideal for the end of the procedure since it is a
potent cough suppressant. However, like all narcotics
it can cause PONV [13]. Ketamine, like
Propofol, can be used for both induction and
maintenance, though it is often associated with
an increase in blood pressure and salivation, as
well as bad hallucinations. Fortunately, it is not
associated with PONV.
...Patients about to undergo
cosmetic surgery should
be medically optimized
before receiving any type of
anesthetic. A Physical Status
Score (ASA PS) developed by
the the American Society of
Anesthesiologists can help to
determine whether the patient is
suitable for cosmetic surgery...
Emergence
The ideal emergence from anesthesia following
cosmetic surgery should not increase blood
pressure or heart rate, lead to “bucking” from
irritation of the endotracheal tube, or have
any respiratory complications [14]. While the
concentration of inhalational and intravenous
anesthetics are lowered to allow the patient
to regain consciousness, additional medications
are administered to restore muscle activity
and allow the patient to breathe spontaneously
to permit extubation. Maneuvers that are
particularly stimulating, such as nasogastric
decompression or suctioning, are done while
the patient is still deeply sedated to prevent
hypertension and gagging. Patients should be
reminded as they emerge from anesthesia that
they may have blurred vision due to the ointment
and should be prevented from attempting
to rub their eyes.
Monitored anesthetic care
Most patients associate surgery with general
anesthesia but other forms of anesthesia exist
along the spectrum of choices for intraoperative
sedation/analgesia and are effectively utilized
for such procedures. Monitored anesthesia care
(MAC) may be offered to patients undergoing
compatible procedures. In this technique,
a combination of local anesthetic and intravenous
analgesic and sedative drugs produces a
“minimally depressed level of consciousness
that retains the patient’s ability to maintain an
airway independently and continuously and to
respond to physical stimuli and verbal commands”
[15, 16]. This anesthetic technique is
often referred to as “conscious sedation” and
the patient will be sedated so as to not feel any
pain or have any keen sense of environmental
awareness. However, unlike in general anesthesia
where unconsciousness is induced and
spontaneous respiration is depressed, patients
will continue to breathe on their own.
Monitored anesthetic care has been shown to be
effective and safe in large study populations [17,
18 , 19]. Typically, a combination of two or more
medication types is used to achieve the desired
level of sedation and analgesia. Commonly used
agents include rapid acting opioids, such as fentanyl,
and sedatives, such as midazolam, and
propofol [20, 21].
Postoperative care
Anesthetic care does not end once the patient
is restored to consciousness. Patients must be
closely monitored postoperatively for signs
and symptoms of hypoxia, hypertension, pain,
PONV and even unconsciousness. A patient
may be discharged once an assessment of
home readiness test is conducted to ensure
that their vital signs are stable, to make sure
they are environmentally aware, and to make
sure they can walk without falling or becoming
excessively dizzy [22]. Patients are also
evaluated for pain, PONV, and bleeding at
the surgical site. Most delays in discharge are
due to pain, PONV, hypotension and dizziness
upon ambulating [23]. All patients require
analgesia postoperatively and some may
require stronger medications than acetaminophen
or NSAID type drugs as part of their
postoperative regimen.
Patients undergoing cosmetic surgery are
generally well informed regarding the nature
of the procedure and the reputation of their
surgeon, but overlook the importance of the
anesthetic technique needed to effectively
perform the procedure. A successful procedure
involves both a plastic surgeon skilled
in cosmetic surgery and an anesthesiologist
proficient in cosmetic anesthesia.
References
1. “2000/2005/2006 National Plastic Surgery Statistics.”
American Society of Plastic Surgeons (ASPS)
www.plasticsurgery.org/
2. “Overall risk of ambulatory anesthesia morbidity
and mortality” In: Miller’s Anesthesia 6th Edition.
Churchill Livingstone, 2004, p. 2234.

3. Practice guidelines for preoperative fasting and
the use of pharmacologic agents to reduce the risk
of pulmonary aspiration: Application to healthy
patients undergoing elective procedures. Anesthesiology.
1999; 90, 896-905.
4. Okuda Y et al. Surg Endosc. 2002; 5: 781-4.
5. Rundgren M et al. Anesth Analg. 2008 Nov;107(5):
1465-8.
6. Nique, TA. “Ambulatory Office General Anesthesia.”
In: Anesthesia for Facial Plastic Surgery. New
York: Thieme Medical Publishers, 1993.
7. Cork RC et al. Anesth Analg. 1994; 79: 719-27.
8. Maleck, Mattinger, Piper, Rohm, Papsdorf and
Boldt “Dolasetron reduces pain on injection of
propofol.” Anasthesiol, Intensivmed, Notfallmed,
Schmerzther. [German].2004; 37: 528-31.
9. “Thiopental produces hangover-like effect” In:
Miller’s Anesthesia 5th Edition. Churchill Livingstone,
2000, p. 2224.
10. Friedberg BL. Dermatol Surg 1999; 25:569.
11. Friedberg BK. Aesthetic Plast Surg 1999; 23:70.
12. Moffitt EA et al. Can Anaesth Soc J. 1983; 30:
5-9.
13. Egan TD et al. Anesthesiology. 1993; 79(5):881-
92
14. Koga K et al. Anaesthesia 1998; 53(6): 540-4.
15. “MAC” In: Miller’s Anesthesia 5th Edition.
Churchill Livingstone, 2000, p. 2230.
16. Task Force on Sedation and Analgesia by Non-
Anesthesiologists. Practice guidelines for sedation
and analgesia by non-anesthesiologists:
An updated report by the American Society of
Anesthesiologists Task Force of Sedation and
BooK rEViEWs
Pediatric Anesthesiology Review
Clinical Cases for Self-assessment
by Holzman R, Mancuso Th J, Sethna N F, DiNardo J A
1st Edition, 340 p., Softcover, Publ. by Springer, 2010
Based on a program of study developed in
the Department of Anesthesiology and the
Department of Perioperative and Pain Medicine
at the Children’s Hospital Boston, this
book provides essential medical information
for the subspecialty of pediatric anesthesiology.
Illustrating the broad spectrum of the
pediatric anesthesiologist’s practice, the book
utilizes an interactive question and answer
dialogue which imitates the simplicity of conversation
and affords the reader high-yield
benefits. The case-based approach encourages readers to collaborate
with colleagues, improve their oral presentation skills, and prepare for
challenging situations by explaining various anesthesia care plans and
why specific data are required before and during the care of the pediatric
patient. The book is written by a panel of specialists recognized
internationally for their efforts in their respective areas.
SpRingeR
new York, USA
www.ihe-online.com & search 45565
Analgesia by Non-Anesthesiologists. Anesthesiology
2002; 4,1004.
17. Bitar G et al. Plast Reconstr Surg 2003;
111, 150.
18. Kryger ZB et al. Plast Reconstr Surg 2004;
113, 1807.
19. Marcus JR et al. Plast Reconstr Surg
1999;104(5):1338-1345.
20. Cinella G et al. Plast Reconstr Surg. 2007; 119(7):
2263-2270.
21. Yoon HD et al. Plast Reconstr Surg 2002;
109, 956.
22. “Assessment of home readiness” In: Miller’s
Anesthesia 5th Edition. Churchill Livingstone,
2000, p. 2232.
23. “Delays in discharge” In: Miller’s Anesthesia
5th Edition. Churchill Livingstone, 2000,
p. 2232.
The authors
Peter J. Taub MD, FACS, FAAP
and
Laurence Hausman, MD
Division of Plastic and Reconstructive Surgery
and
Department of Anesthesiology
Mount Sinai Medical Center
New York, New York, USA
Comments on this article?
Feel free to post them at
www.ihe-online.com/comment/anesthesia
21
Anesthesia Student Survival Guide
A Case-Based Approach
Ed by Ehrenfeld J M, Urman R D & Segal S
1st Edition, 515 p. Softcover, Publ. by Springer, 2010
Apr/May 2010
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diagrams, tables, and algorithms, the pocket-sized
guide contains essential material. The editors, who
are academic faculty at Harvard Medical School,
summarize the essential content with 32 informative
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Pharmacology, basic skills, common procedures and anesthesia subspecialties
are covered, too, with just the right amount of detail for an introductory
text. The unique book also offers a section containing career advice and
insider tips on how to receive good evaluations from supervising physicians.
The book combines astute clinical instruction, basic science explanation
and practical tips from physicians that have been there before.
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Apr/May 2010
The energy absorbed per unit mass of tissue, the
absorbed dose, mediates the biologic responses
of radionuclide therapy. Specifically for radionuclide
therapy the energy absorbed, E, in a
particular mass of tissue is defined as:
Ε = number of radionuclide disintegrations in
a particular volume X energy emitted per
disintegration of the radionuclide X fraction
of emitted energy that is absorbed by
a particular (target) mass [1].
Nevertheless, to state that the absorbed dose
alone would predict the radiobiologic response
of tissue is an oversimplification that would
certainly lead to hypo- or hyper- estimation of
radiation-induced effects.
Currently, nuclear medicine dosimetry is based
on the measurement of the biokinetics of the
radionuclide by serial gamma camera scans,
followed by calculations comprising three steps.
Firstly, the percentage of administered activity
of the radiopharmaceutical must be determined
for the accumulating organs for several
scan times. Secondly, these biokinetic data must
be integrated to obtain the percentage of the
number of decays in the source organs, i.e the
residence times. Thirdly, the radiation absorbed
doses of critical organs must be determined.
The significance of patient
specific dosimetry
In order to understand the limitations, problems,
challenges and research directions of Patient Specific
Dosimetry (PSD), it is useful to consider its
standard clinical practice and compare it with
external beam therapy. Currently, in almost all
PSD treatments the administered activity is fixed;
the clinician empirically modifies it according
to patient characteristics including age, size and
clinical findings [2]. However, clinical studies
have shown that this approach leads to errors in
the order of 30%-100% or even higher. The main
reason for such errors is that the absorbed dose is
not only a function of the administered dose, but
is highly correlated to a number of other factors
22 NUCLEAr MEdiCiNE
internal radionuclide dosimetry
the development of patient – specific treatment planning systems is of outmost
importance in the evolvement of radionuclide dosimetry, because the quantification
of the activity in different organs from planar data is hampered by inaccurate
attenuation and scatter correction as well as by background and organ overlay.
Quantitative three-dimensional nuclear medical imaging can be utilized towards
this direction, allowing a more individualized approach.
by dr i. tsougos, dr P. Georgoulias and dr K. theodorou
that are patient-specific, including both anatomical
and functional variations. It is obvious that no
radiation oncologist or medical physicist would
suggest the same protocol in all patients with a
given type of cancer [3]; Variations in beam type,
energy, beam exposure time, geometry, etc are
decided individually for different patients.
Moreover the radioisotope type defines the particles
emitted by the used radionuclide. The emitted
particles can be alpha, beta particles, gamma
rays or a combination. The type of the emitted
particles and their energy is known. However, the
interaction between the particles and tissue is a
statistical process and accurate calculations are
not straightforward. Radiopharmaceutical kinetics
gives information about a) where the radionuclide
is concentrated, b) in what percentage (at
least theoretically), c) how fast it accumulates in
target organs (both tumors and normal organs)
and d) for how long it remains in these areas [4].
Patient anatomy provides accurate information
about tumor(s) and organs size, as well as possible
non homogeneous areas. Finally, the disease type
plays a critical role in the selection of radiopharmaceuticals
and can affect their kinetic properties.
Patient Specific Dosimetry aims to personalize
the above-mentioned parameters and overcome
the limitations of the standard procedures [5],
resulting in an accurate dose calculation model
that addresses all those issues.
Equation-based dosimetry software
The system that defined medical internal dosimetry
for many years is the system developed in
1988 by the Medical Internal Radiation Dose
(MIRD) Committee of the Society of Nuclear
Medicine [6]. The equation for absorbed dose
in the MIRD system is as follows:
In this equation, r k represents a target region and
r h represents a source region. The cumulated
activity is given in the term Ã. Hence all other
terms of the basic equation are lumped in the S
factor, that is:
The use of the ‘S factor’ approach greatly facilitated
dose calculations. The S values were initially
calculated based on idealized models of human
anatomy defined as a collection of appropriately
placed distinct organ volumes with mass and
composition that were selected to reflect a typical
or standard human anatomy. These calculations
were performed with very limited computational
power, with the result that there had to
be several simplifying assumptions.
Phantom-based dosimetry software
The MIRD methodology has been utilized by
several groups who develop software in which
the S factors were implemented. The software
known as MABDOSE [7] allows the user to
place spherically shaped tumors within the
simplified anatomic model originally described
by the MIRD Committee. The most widely
used software was the MIRDOSE software
which has had versions 1, 2, 3 and 3.1 [8]. The
code automated, with great success the calculation
of internal dose for a large number
(>200) of radiopharmaceuticals in 10 different
anthropomorphic models, until it was replaced
by a newer code called OLINDA/EXM (Organ
Level INternal Dose Assessment with EXponential
Modelling) [9].
Image-based dosimetry software
Imaging plays a critical role since the image
provides personalized anatomical as well as
functional information [5]. The most evident
information that (tomographic) imaging provides
is the location, the size and the volume
of the organs and the tumor. While anatomical
imaging has obvious importance, the functional
imaging techniques SPECT and PET provide
complementary information about tracers
kinetics and the functionality of tumors
Furthermore the use of 3D imaging modalities,
such as PET/CT and SPECT/CT has allowed
the use of both tomographic functional data and
anatomical data in the development of patientspecific
nuclear medicine dosimetrical systems.
This is made possible by the increase in computer
processing power and the implementation of
point-kernel or Monte Carlo calculation methodologies
for the estimation of absorbed fractions.

In order to achieve 3D image based dosimetry,
there are two requisites. The first is a 3D anatomic
imaging study, in order to define the anatomy
and provide tissue density information (e.g CT or
MRI), in conjunction with a 3D imaging of the
radioactivity distribution (e.g. PET or SPECT).
The second requisite is appropriate software that
implements the absorbed fraction calculation
(point kernel or Monte Carlo) in order to estimate
the spatial distribution of the absorbed dose.
Based on the above approach several groups
have sought to contribute to the development
of such software, including the following: the
3D-Internal Dosimetry (3D-ID) code [10], the
RTDS code [11] the DOSE3D code [12] and
the SIMDOS code [13].
Monte Carlo and dose kernel-based
dosimetry software
Monte Carlo (MC)
MC is a widely used tool for the simulation, study
and modeling of several processes that limit accuracy
of tomographic and planar images [14]. In
dosimetry the role of MC is to provide additional
tools and methods that will improve image quantification,
thus increasing the accuracy of functional
planar, SPECT or PET images. The main
steps include i) scanner and source simulation ii)
study of scatter distributions, attenuation effects,
collimator penetration etc and iii) incorporation
of all this information in reconstruction probability
matrix. Especially in attenuation correction,
MC can be used to correlate CT X-ray attenuation
coefficients to gamma ray photons attenuation,
resulting in improved quantification.
In addition, MC allows the introduction of
advanced phantoms, including patient imaging
data. This leads to advanced correction techniques
optimized for human studies and specific
scanners; When scanner geometry is accurately
modeled, it is possible to assess the effects
of patient size and injected dose on the system’s
count rate e.g. NECR estimation in PET [15].
Anthropomorphic phantoms and MC simulations
are increasingly being used for modeling
heart and respiratory motion. The latter can
severely affect image quantification, especially
in the case of CT attenuation correction [16].
Dose kernels
These are defined as the absorbed dose per decay
at a point r distant from the source. A common
strategy is the MC simulation of a point source in
a homogeneous media, after which the absorbed
dose is calculated using convolution methods [17].
This method assumes a uniform patient body,
although recently CT values were used to define
different regions and dose kernels were calculated
by MC for other materials [18]. Dose is determined
by convolving those kernels with the activity of the
nuclear medicine image in 3D space.
The main drawback of the method is the difficulty
of incorporating tissue inhomogeneity,
even though it is known from anatomical
images. The dose kernel can only be generated
assuming an infinite, homogeneous medium.
In the paper by Loudos et al a method is analytically
described in order to have an accurate
dose estimation that takes into account the CT
information [18]. In that sense the structure of
each patient has to be taken into account. This
information can be obtained by analyzing the
CT image, which provides accurate information
about anatomy and tissue density, provided
that image values in the CT image are scaled as
Hounsfield units. However it has to be taken
into account that the conversion of Hounsfield
units to attenuation coefficients that correspond
to different materials is a complicated
and challenging problem.
Conclusion
Internal radionuclide dosimetry still stands
at an early stage of development, although
it has evolved greatly with the development
of the MIRD models and advanced calculational
techniques. The physics of absorbed
dose estimation is improving through active
research in the fields of patient-specific
dosimetry supported by the application
of 3D quantitative imaging. The availability
of faster and more powerful computers,
improved and accurate Monte Carlo methods
and imaging devices that support both
anatomy and radioactivity tomography (PET/
CT) will push internal dosimetry into a new
era of individualized therapy.
Nevertheless, it has to be noted that the correction
of the images for all effects that degrade
the quantitative content is especially difficult
to achieve for SPECT or PET images obtained
using non-pure positron emitting nuclides
[19]. However, a treatment-planning approach
23 Apr/May 2010
to radionuclide therapy as in external radiotherapy
will eventually require incorporation
of biologic and radiobiologic considerations
in order to predict response in an individual
patient [20]. Work on this is just beginning.
References
1. Sgouros G. J Nucl Med. 2005 Jan;46 Suppl 1:18S-27S.
2. Flux G et al. Med. Phys. 2006 16 47–59.
3. Siegel JA et al. Cell Mol Biol 2002; 48(5):451-9.
4. Stabin MG et al. Biomed Imaging Interv J 2007;
3(2):e28.
5. Cremonesi M et al. J Nucl Med 2006; 47:1467–1475.
6. Loevinger R et al. MIRD Primer for Absorbed Dose
Calculations 1988 (New York: Society of Nuclear
Medicine).
7. Johnson TK et al. Med Phys. 1999; 26:1389 –1395.
8. Stabin M. J. Nucl. Med. 1996 37 538–46.
9. Stabin M G et al. J. Nucl. Med. 2005 46 1023–7.
10. Kolbert K S et al. J. Nucl. Med. 1997 38 301–8.
11. Liu A et al. J. Nucl. Med. 1999 40 1151–3.
12. Clairand I et al. J. Nucl. Med. 1999 40 1517–23.
13. Dewaraja Y K et al. J. Nucl. Med. 2005 46 840–9.
14. Zaidi H et al. J Nucl Med. 2003 Feb; 44(2):291-315.
15. Watson CC et al. J Nucl Med 2005; 46:1825–1834.
16. Osman MM et al. Eur J Nucl Med Mol Imaging
2003; 30:603–606.
17. Furhang EE et al. Med. Phys. 1996; 23 (5).
18. G Loudos et al. Nucl Med Commun. 2009
Jul;30(7):504-12.
19. Glatting G et al. Nuklearmedizin. 2006;
45(6):269-72.
20. Tsougos I et al. Phys. Med. Biol. 2005; 50 3535-54.
The authors
Ioannis Tsougos 1,2 , Panagiotis Georgoulias 2 , Kiki
Theodorou 1
1 Department of Medical Physics and
2 Department of Nuclear Medicine
Medical School,
University of Thessaly, Larissa, Greece

Apr/May 2010
Introduction
Angiogenesis, the formation of new blood
vessels from existing ones, is an essential
process if solid tumors are to grow beyond
2 to 3 mm 3 , since diffusion is no longer sufficient
to supply the tissue with oxygen and
nutrients. Tumor-induced angiogenesis is
a complex multistep process that follows a
characteristic cascade of events mediated
and controlled by growth factors, cellular
receptors and adhesion molecules. Based on
a balance between pro-angiogenic and antiangiogenic
factors, a tumor can stay dormant
for a very long time period until the so-called
“angiogenic switch” occurs. In most tissues
tumors can only grow to a life threatening
size if the tumor is able to trigger angiogenesis.
In tissues with high vessel densities
(e.g. liver, brain, among others), tumors may
also progress via angiogenesis-independent
co-option of the pre-existent vasculature.
Inhibition of angiogenesis is a new cancer treatment
strategy that is now widely investigated
clinically. Researchers have begun to search
for objective measures that indicate pharmacological
responses to anti-angiogenic drugs.
Therefore there is a great interest in techniques
to visualize angiogenesis in growing tumors
noninvasively. During the past decade several
markers of angiogenesis have been identified
and specific tracers targeting these markers
have been developed.
The α v β 3 integrin receptor
The α v β 3 integrin is a transmembrane protein
consisting of two non-covalently bound
subunits, α and β. Integrin α v β 3 is minimally
24 NUCLEAr MEdiCiNE
radiolabeled probes for imaging of
tumor angiogenesis
Positron Emission tomography (PEt) and single Photon Emission Computed tomography
(sPECt) are the two radiotracer-based imaging modalities for noninvasive
depiction and quantification of biochemical processes. the development of angiogenesis-targeted
radiotracers is mainly concentrated on peptides, proteins and
antibodies which bind to the α v β 3 integrin receptor, vascular endothelial growth
factor (VEGF) and its receptor, prostate-specific membrane antigen (PMsA), matrix
metalloproteinases (MMPs) and robo-4. several ligands targeting these markers
have been tested as a radiotracer for imaging angiogenesis in tumors in animal
models. the potential of some of these tracers has already been tested in cancer
patients. in this article we present a brief overview of the imaging probes currently
used for noninvasive visualization using PEt and sPECt of α v β 3 and VEGF
expression is given.
by dr i. dijkgraaf and dr o. C. Boerman
expressed on normal quiescent endothelial
cells, but significantly upregulated on activated
endothelial cells during angiogenesis. In addition,
α v β 3 is expressed on the cell membrane of
various tumor cell types such as: ovarian cancer,
neuroblastoma, breast cancer, melanoma,
among others.
This integrin interacts with the arginine-glycine-aspartic
acid (RGD) amino acid sequence
present in extracellular matrix proteins such as
vitronectin, fibrinogen, and laminin.
Several research groups have investigated the
potential of RGD-containing peptides to target
with gamma- or positron-emitting radionuclides
α v β 3 expressed in tumors [Table 1]. Over
the past decade, many radiolabeled cyclic RGD
peptides have been evaluated as potential radiotracers
for noninvasive imaging of integrin
α v β 3 -positive tumors by SPECT or PET. After a
systematic search, the group in Munich developed
a stable 18 F-labeled galactosylated cyclic
pentapeptide ([ 18 F]Galacto-RGD), with a high
affinity and selectivity for α v β 3 that accumulates
specifically in α v β 3 -positive tumors and clears
rapidly via the kidneys. [ 18 F]Galacto-RGD and
[ 18 F]-AH111585 (of which the core peptide
sequence was originally discovered from a
phage display library as ACDRGDCFCG), are
currently under clinical investigation. Recently,
a 99m Tc-labeled RGD-containing peptide
(NC100692) was evaluated in ischemic models
and showed high uptake in areas of neovascularization
with α v β 3 integrin overexpression.
In these models it was shown that NC100692
bund to α v β 3 -expressing endothelial cells in the
regions of angiogenesis.
Clinical studies
[ 18 F]Galacto-RGD was the first radiotracer
applied in patients and could successfully
image α v β 3 expression in human tumors with
good tumor-to-background ratios. It has been
shown that molecular imaging in humans of
α v β 3 expression using [ 18 F]Galacto-RGD correlated
with α v β 3 expression as determined by
immunohistochemistry. In another study, the
tracer uptake of [ 18 F]FDG was compared with
that of [ 18 F]Galacto-RGD in patients with
non-small cell lung cancer (NSCLC, n=10)
and various other tumors (n=8). It was found
that [ 18 F]FDG uptake in tumor lesions did
not correlate with [ 18 F]Galacto-RGD uptake.
Isotope Half-life (h)
γ-emitter (SPECT) 99mTc 6.02
111In 67.2
123I 13.0
125I 59.4 days
β+-emitter (PET) 18F 1.83
11C 20.4 min
64Cu 12.9
68Ga 1.14
124I 100.3
Table 1. Half-life of several radionuclides for SPECT or PET. Half-life is given in hours unless stated otherwise.

These results showed that α v β 3 expression and
glucose metabolism are not closely correlated
in tumor lesions and consequently [ 18 F]FDG
cannot provide similar information as [ 18 F]
Galacto-RGD [Figure 1].
The second radiotracer which was applied
in patients was 99m Tc-NC100692. A clinical
study was performed to provide an initial
indication of the efficacy and safety of imaging
malignant breast tumors. Nineteen out of
22 tumors were detected with this radiotracer.
In an additional study, integrin scintimammography
with 99m Tc-NC100692 using a
dedicated γ-camera was performed to investigate
the ability to detect malignant breast
cancer lesions. All patients were known to
have lesions highly suspicious of malignancy.
Dedicated integrin scintimammography
(DISM) detected malignant lesions in seven
out of eight patients with focal uptake in all
but two tumor lesions. In a subsequent openlabel,
multicenter, phase 2a study in late-stage
cancer patients, 99m Tc-NC100692 was able to
detect lung and brain metastases from breast
and lung cancer with scintigraphy.
Multimeric RGD peptides
To improve the efficiency of tumor targeting
and to obtain better in vivo imaging properties,
multimeric RGD peptides were synthesized and
characterized. The first cyclic RGD multimers
that were developed, were E[c(RGDfK)] 2 -based
dimers. Subsequently, the use of E[c(RGDyK)] 2 -
based dimers labeled with 64 Cu or 18 F for PET
imaging was reported.
During the last years, various other RGD dimers,
tetramers, and even octamers labeled with
different radionuclides have been developed
and studied in vitro and in vivo. Generally, the
results of these studies have demonstrated that
increasing the multiplicity of the peptide can
significantly enhance the integrin α v β 3 -binding
affinity of RGD peptides and improve tumor
targeting capability of the radiotracer. In addition,
incorporation of the right spacer between
the RGD motifs can enhance the affinity for
α v β 3 and improve the tumor uptake even further.
Among mono-, di-, tetra- and octameric
cyclo(RGDfK)-based peptides, the octamer had
the highest α v β 3 affinity and usually the highest
tumor uptake. From this point of view, further
increase of RGD peptide multiplicity may
result in formation of oligomeric or polymeric
cyclic RGD peptides with improved integrin
α v β 3 -binding affinity and tumor targeting efficacy.
So far, no radiolabeled multimeric RGD
peptide have been tested in patients. The studies
on multimeric RGD peptides have recently
been reviewed [1].
VEGF receptors
Vascular endothelial growth factor (VEGF) is a
key regulator of angiogenesis during embryogenesis,
skeletal growth and reproductive functions.
The expression of VEGF is upregulated
by environmental stress caused by hypoxia,
Figure 2. Scintigraphic images of 3 athymic male mice with s.c. LS174T tumors immediately after injection and
at 1, 3 and 7 days p.i. of 111 In-bevacizumab (0.9 MBq/mouse, 3 µg/mouse).
25 Apr/May 2010
Figure 1. [ 18 F]FDG-PET of a patient with non-small cell lung cancer (NSCLC) showed intense tracer uptake in
the lesion (a). PET imaging of αvβ3 integrin expression with [ 18 F]Galacto-RGD showed heterogeneous tracer
uptake in the lesion, with a different pattern compared to the [ 18 F]FDG-PET (b). PET/CT (c) and PET/MRI (T2w)
image fusion (d) are useful for a good correlation of anatomical and biological information.
anemia, myocardial ischemia and tumor progression
to initiate neovascularization. Via
alternative mRNA splicing, the human VEGF-A
gene gives rise to four isoforms having 121, 165,
189 and 206 amino acids (VEGF 121 , VEGF 165 ,
VEGF 189 and VEGF 206 , respectively).
VEGF binds two related receptor tyrosine
kinases (RTKs), VEGFR-1 and VEGFR-2. Both
receptors consist of seven Ig-like domains in
the extracellular domain, a single transmembrane
region and a consensus tyrosine kinase
sequence that is interrupted by a kinase-insert
domain. VEGFR-1 binds VEGF with a higher
affinity compared to VEGFR-2 (K d : 25 vs.
75-250 pM).
Bevacizumab is a humanized variant of the
anti-VEGF-A monoclonal antibody (mAb)
A.4.6.1. Nagengast et al were the first to
demonstrate non-invasive VEGF imaging
using radiolabeled bevacizumab [2]. In their
study, they demonstrated the potential of
89 Zr-bevacizumab and 111 In-bevacizumab as
a specific VEGF tracer in nude mice with
human SKOV-3 ovarian tumor xenografts.
At the same time, our group showed specific
imaging of VEGF-A expression using 111 Inbevacizumab
in mice with s.c. human colon
carcinoma xenografts LS174T [Figure 2].
Recently, the potential of 111 In-labeled bevacizumab
to image the expression of VEGF-A

Apr/May 2010 26 NUCLEAr MEdiCiNE
in tumors was investigated in cancer patients.
In a study in colorectal cancer patients with
liver metastases, the liver metastases in nine
out of 12 patients were visualized with 111 Inbevacizumab.
In this study, the liver metastases
were resected after scintigraphic imaging
allowing further immunohistochemical
analysis. The VEGF-A expression in these
resected liver metastases was determined by
in situ hybridization and by ELISA. Surprisingly,
no correlation was found between the
level of antibody accumulation and expression
of VEGF-A.
Cai et al. labeled VEGF 121 with 64 Cu via DOTA for
PET imaging of VEGFR expression [3]. Smallanimal
PET imaging revealed rapid, specific
and prominent uptake of 64 Cu-DOTA-VEGF 121
in highly vascularized small U87MG human
glioblastoma tumors (high VEGFR expression),
and significantly lower uptake in large U87MG
tumors (low VEGFR expression).
Conclusions
Numerous markers of tumor vasculature have
been identified, but only a few radiotracers of
angiogenesis have been tested clinically. The
most extensively studied marker of angiogenesis
is the integrin α v β 3 . For this marker the SPECTtracer,
99m Tc-NC100692, and the PET-tracer
18 F-galacto-RGD have been successfully tested
in cancer patients.
Other targets exclusively expressed on activated
endothelial cells may eventually be better
targets for imaging angiogenesis.
In conclusion, a few radiotracers for imaging
angiogenesis in tumors have been tested in
humans. The role of these tracers in assessing
the response to anti-angiogenic therapies has
yet to be assessed.
References
1. Liu S. Radiolabeled multimeric cyclic RGD peptides
as integrin alpha-v-beta-3 targeted radiotracers
for tumor imaging. Mol Pharm 2006; 3,
472-487.
2. Nagengast WB et al. 89 Zr-bevacizumab PET of
early antiangiogenic tumor response to treatment
with HSP90 inhibitor NVP-AUY922. J
Nucl Med. 2010 May; 51(5):761-7. Epub 2010
Apr 15.
3. Cai W et al. PET of vascular endothelial growth
factor receptor expression. J Nucl Med. 2006 Dec;
47(12): 2048-56.
Acknowledgment
The authors would like to thank Dr. Ambros J.
Beer at the Technische Universität München
for providing the PET and the PET/CT-, PET/
MRI images.
The authors
Dr Ingrid Dijkgraaf and
Dr Otto C. Boerman
Department of Nuclear Medicine
Radboud University
Nijmegen Medical Center,
Nijmegen,
The Netherlands
KiMEs 2010 FULFiLs HiGH ExPECtAtioNs As GLoBAL ECoNoMiC
rECoVEry BEGiNs
The bustling exhibition was complemented by
many high level symposia and presentations.
The 26th edition of the
Korean International Medical
and Hospital Equipment
(KIMES) opened in Seoul,
South Korea in mid-March
so becoming for four days
the place to be for leading
international and Korean
medical and hospital devices
and service providers.
Since KIMES first opened in 1980, the show has grown in parallel with the
rapid development and advances of the Korean medical and healthcare
industry. Over the years, KIMES has always tried to ensure that the show
is the “must be” place so that everyone in the industry can gather information
on advanced medical and healthcare-related items and can share the
latest trends and developments in the sector. As always, there was strong
support from Korean government ministries at this year’s KIMES. The
supporting organisations included the Ministry of Knowledge Economy,
the Ministry of Health, Welfare and Family Affairs, the Seoul Metropolitan
Government, and the Korean Food & Drug Administration. Recently,
the Korean government specified the medical industry as the one of the
key leading industries driving the Korean economy in the future, and the
government has accordingly provided a blueprint for the financial and
political backing of the industry. Globalization of the medical and healthcare
service industry sector is of particular interest in Korea nowadays; in
the global environment the sharing of information and visions is vital.
Correspondence to:
Ingrid Dijkgraaf
Department of Nuclear Medicine
Radboud University Nijmegen Medical Center
PO Box 9101
6500 HB Nijmegen,
The Netherlands
E-mail: I.Dijkgraaf@nucmed.umcn.nl
Comments on this article?
Feel free to post them at
www.ihe-online.com/comment/radiolabels
The recent global economy downturn has caused severe difficulties
in the entire Korean economy; this only reinforces the need for the
development of new technologies and new markets, which is more
important than ever
Providing a timely vision of the future of the medical industry, KIMES
2010 attracted 1045 exhibitors from 35 countries. Unaffected by today’s
global shifts, the expectation for KIMES to play its role as a platform
for further development of the industry is as high as ever. The organisers
of KIMES are confident that tough conditions can yield rare
opportunities of high potential - future success is often founded in
difficult times like the present.
Many Korean medical product providers launched their newly developed
products at KIMES this year. The various exhibit categories at
KIMES this year included: consultation; clinical examination; hospital
accommodation; emergency room equipment; radiology; medical
information systems; surgical equipment; oriental medicine; pharmaceuticals,
physiotherapy equipment; obesity therapies; general healthcare;
ophthalmic and dental equipment; and many others.
In addition, there were more than 40 academic and practical seminars
during the 4 days of the exhibition, providing the opportunity for
KIMES visitors to have a chance to listen to or participate in high level
discussion and perspectives and insights on emerging trends.
The 27th edition of KIMES will take place in Seoul, Korea in March 2011.

sCiENtiFiC LitErAtUrE rEViEW: HosPitAL MANAGEMENt
on this page iHE presents a few key
abstracts from the clinical literature
about hospital management, selected
by our editorial board.
Computerised physician order
entry as a new technology for
patients’ safety.
Concern about patient safety is a priority in the
quality policy of health systems. In the pharmacotherapeutic
process, from prescription
to administration of drugs, failures that cause
unwanted effects in patients may occur. This
is especially common in patients with multiple
pathologies and polypharmacy, common
in medical specialities services. It is essential to
analyse and identify the causes that trigger medical
errors to prevent their occurrence. In this
context, computerised physician order entry is
an attractive tool for ensuring patients safety.
Villamañán E, Herrero A, Alvarez-Sala R. Med Clin
(Barc). 2010 Apr 29.
Different usage of the same
oncology information system in two
hospitals in Sydney - lessons go
beyond the initial introduction.
The experience of clinicians at two public hospitals
in Sydney, Australia, with the introduction
and use of an oncology information system
(OIS) was examined to extract lessons to guide
the introduction of clinical information systems
in public hospitals. Semi-structured interviews
were conducted with 12 of 15 radiation oncologists
employed at the two hospitals. The personnel
involved in the decision making process for
the introduction of the system were contacted
and their decision-making process revisited. The
transcribed data were analysed using NVIVO
software. Themes emerged included implementation
strategies and practices, the radiation oncologists’
current use and satisfaction with the OIS,
project management and the impact of the OIS
on clinical practice. The hospitals had contrasting
experiences in their introduction and use of
the OIS. Hospital A used the OIS in all aspects of
clinical documentation. Its implementation was
associated with strong advocacy by the Head of
Department, input by a designated project manager,
and use and development of the system by
all staff, with timely training and support. With
no vision of developing a paperless information
system, Hospital B used the OIS only for booking
and patient tracking. A departmental policy that
data entry for the OIS was centrally undertaken
by administrative staff distanced clinicians from
the system. All the clinicians considered that the
OIS should continuously evolve to meet changing
clinical needs and departmental quality improvement
initiatives. This case study indicates that
critical factors for the successful introduction of
clinical information systems into a hospital environment
were an initial clear vision to be paperless,
strong clinical leadership and management
at the departmental level, committed project
management, and involvement of all staff, with
appropriate training. Clinician engagement is
essential for post-adoption evolution of clinical
information systems.
Yu P, Gandhidasan S, Miller AA. Int J Med Inform
2010 Jun;79(6):422-9.
A critical appraisal of physicianhospital
integration models.
The economic environment and the current
healthcare debate have prompted a critical reevaluation
of previous and current physician-hospital
integration models. Even though the independent,
self-employed, private practice, medical staff
remains the most common model, surgical specialists
such as vascular surgeons are increasingly
being employed and integrated into healthcare
delivery systems. The degree of integration varies
from minimal to full integration or full employment.
This review defines the forces driving these
changes and analyses the strengths and weaknesses
of each employment model from the physicians’
point of view. Strategies for the successful
implementation of a 21st century integrative
employment model are discussed.
Satiani B, Vaccaro P. J Vasc Surg. 2010 Apr;51(4):
1046-53.
Implementing an electronic
change-of-shift report using
transforming care at the bedside
processes and methods.
Bedside nurses are well positioned to make
changes that positively affect operations and
practice. Using Transforming Care at the
Bedside processes and methods, the authors
describe the clinical nurse-led development,
testing and implementation of an electronic
template and process for change-of-shift report.
Outcomes included a reduction in time spent
in change-of-shift reports, reduced end-of-shift
overtime and a more standardised process,
27 Apr/May 2010
and staff who perceived improved information
quality and were satisfied with the process.
Nelson BA, Massey R. J Nurs Adm. 2010
Apr;40(4):162-8.
Human factors engineering
in healthcare systems:
the problem of human error
and accident management.
This paper discusses some crucial issues associated
with the exploitation of data and information
about healthcare for the improvement of
patient safety. In particular, the issues of human
factors and safety management are analysed in
relation to exploitation of reports about nonconformity
events and field observations. A
methodology for integrating field observation
and theoretical approaches for safety studies is
described. Two sample cases are discussed in
detail: the first one makes reference to the use of
data collected in the aviation domain and shows
how these can be utilised to define hazard and
risk; the second one concerns a typical ethnographic
study in a large hospital structure for the
identification of most relevant areas of intervention.
The results show that, if national authorities
find a way to harmonise and formalise critical
aspects, such as the severity of standard events,
it is possible to estimate risk and define auditing
needs, well before the occurrence of serious
incidents, and to indicate practical ways forward
for improving safety standards.
Cacciabue PC, Vella G. Int J Med Inform 2010
Apr;79(4):e1-17.
Effect of point-of-care computer
reminders on physician behaviour:
a systematic review.
The opportunity to improve care using computer
reminders is one of the main incentives
for implementing sophisticated clinical information
systems. A systematic review was conducted
to quantify the expected magnitude of
improvements in processes of care from computer
reminders delivered to clinicians during
their routine activities. The MEDLINE, Embase
and CINAHL databases (to July 2008) were
searched and the bibliographies of retrieved
articles were scanned. Studies were included
in the review if they used a randomised or
quasi-randomised design to evaluate improvements
in processes or outcomes of care from
computer reminders delivered to physicians
during routine electronic ordering or charting
activities. The results were that computer
reminders produced much smaller improvements
than those generally expected from the
implementation of computerised order entry
and electronic medical record systems. Further
research is required to identify features of
reminder systems consistently associated with
clinically worthwhile improvements.
Shojania KG et al. CMAJ. 2010 Mar 23;182(5):
E216-25.

Apr/May 2010
The wireless videocapsule was released in
2000 and has opened the last ‘black box’ of
the gastrointestinal tract, enabling complete
endoscopic visualisation of the small bowel
[1]. Since then numerous new developments
from various companies have emerged, with
improvements in image quality, number
of images recorded per second and length
of battery life. In addition the software to
read the images is becoming ever faster and
smarter, and newer developments focus upon
the design of an “interventional” capsule enabling
tissue sampling, directed medication
delivery and functional evaluation of the
small bowel.
Parallel to the development of the diagnostic
wireless videocapsule, conventional enteroscopy
was also subjected to a new evolution in
order to perform all conventional endoscopic
interventions throughout the small bowel. An
overview of the endoscopic developments to
explore the small bowel is given below.
Yesterday’s enteroscopy
Already in the 1970s complete enteroscopy
using a conventional fibre endoscope was
shown to be possible [2]. By means of the ropeway
method, a long fibre endoscope was pulled
down the gastrointestinal tract after a rope
loaded with a weight travelled from mouth to
anus along with gastrointestinal peristalsis.
The sonde type method involved a long thin fiberscope
with an inflatable balloon at its distal
tip. The scope was inserted through the nose
into the stomach from where it was further
progressed beyond the pylorus using a conventional
endoscope. Then the balloon at the
tip of the fiberscope was inflated to serve as a
bolus that was acted on by intestinal peristalsis
to carry the fiberscope down the small intestine
[3]. Although both the ropeway and sonde type
method were effective to visualise the entire
small bowel, and gave the possibility of tissue
sampling, the procedures were very inconvenient
and could last several days.
28 ENdosCoPy
Enteroscopy:
yesterday, today and tomorrow
the small bowel is the most difficult segment of the gastrointestinal tract to investigate.
the present review describes the evolution of enteroscopy, from the first
complete enteroscopy in 1971 through the current balloon-assisted and overtubeguided
methods to likely future development directions aiming for enteroscopic
perfection.
by dr tom G. Moreels
In the 1980s intraoperative enteroscopy became
available as a feasible alternative that is still used
today, although it requires a surgical approach
through laparotomy. It can be performed via
the oral route or the anal route but often enterotomy
is necessary [4]. Because of its invasiveness
the technique is generally reserved as a
last-choice approach.
At the same time push enteroscopy was developed
during the 1990s and rightfully replaced
the previous inconvenient and invasive
enteroscopy methods [5]. Longer conventional
endoscopes were developed to proceed
beyond Treitz’s angulus. Push enteroscopy
allows endoscopic evaluation of the proximal
jejunum through the oral route. Because
of the flexibility of the enteroscope and the
tortuous length of the small bowel, complete
enteroscopy is not possible. The pushing force
used to progress the enteroscope throughout
the small bowel results in stretching of the
jejunum, thus hampering further progress and
causing patient discomfort.
The introduction of a semi-rigid overtube
allows deeper intubation of the jejunum
because it helps to straighten the enteroscope
and avoids jejunal stretching [6]. The use of
an overtube was an important development,
Figure 1: Fujinon Double-Balloon Enteroscope.
leading to a major improvement in insertion
depth and an increase in the yield of push
enteroscopy. However, overtube-guided push
enteroscopy only allows intubation of the
jejunum without complete enteroscopy [7].
Today’s enteroscopy
Although both intraoperative enteroscopy
and overtube-guided push enteroscopy are
still in use, new developments have emerged
which have given rise to improved enteroscopy
performance. The concept of balloonassisted
enteroscopy is a second major breakthrough
in the evolution of the endoscopic
disclosure of the small bowel. In 2001 the
Japanese endoscopist Hirohito Yamamoto
revolutionised the concept of overtubeguided
enteroscopy by adding an inflatable
latex balloon at the distal end of the flexible
overtube, allowing better mucosal grip of the
overtube, stabilising its position within the
intestinal lumen. In addition, a second inflatable
latex balloon was added to the distal end
of the enteroscope. With this self-made double-balloon
model, he was able to intubate
the entire small bowel through the oral route
[8]. Since 2003 the double-balloon enteroscope
has been commercially available from
Fujinon [Figure 1].
Following the success of double-balloon
enteroscopy, the Olympus company developed
another system of balloon-assisted
enteroscopy that became commercially
available in 2007, namely single-balloon
enteroscopy that is largely comparable to
double-balloon enteroscopy. It consists of a
latex-free balloon-loaded overtube lacking
the balloon at the distal end of the endoscope
[Figure 2].

Figure 2: Olympus Single-Balloon Enteroscope.
Both balloon-assisted methods are based
upon the push-and-pull principle [9]. It is
a stepwise progression of the enteroscope
through the small intestine with the balloon-loaded
overtube used as a straightening
device, allowing stable position within
the intestinal lumen. The extra balloon at
the distal end of the endoscope in the double-balloon
system allows better anchoring
of the endoscope within the lumen, whereas
the single-balloon system allows faster
progression of the endoscope throughout
the small bowel. Both balloon-assisted
methods allow complete intubation of the
small bowel within a reasonable procedure
time, although often a combined approach
through the mouth and the anus is necessary
to complete enteroscopy. In addition,
all conventional endoscopic interventions,
ranging from mucosal tissue sampling, local
hemostasis, polypectomy and balloon dilation,
can now be performed throughout the
length of the small bowel thanks to balloonassisted
enterosopy. Moreover, excluded gastrointestinal
segments after previous small
bowel surgery have come within endoscopic
reach, allowing ERCP procedures in patients
with Roux-en-Y reconstruction of the small
bowel [10]. These important advantages
have led to a rapid spread of both balloonassisted
enteroscopy systems in endoscopy
suites throughout the world.
A novel alternative balloon-assisted method
is the NaviAid balloon-guided enteroscopy,
developed by Smart Medical Systems and distributed
in Europe by Pentax. It consists of a
standard enteroscope loaded with a stabilising
latex-free inflatable balloon at the distal end
of the endoscope and an advancing ballooncatheter
mounted on the outer perimeter of
the endoscope. The principle is comparable
to double-balloon enteroscopy, without an
overtube. Preliminary results reveal that this
technique allows deep intubation of the small
bowel, but complete enteroscopy has not been
achieved [11]. The results of multicenter trials
are awaited in order to determine the true clinical
value of this new device.
Next to balloon-assisted enteroscopy, Spirus
Medical adapted the overtube resulting in the
development of the EndoEase discovery small
bowel overtube. This spiral overtube enteroscopy
allows rapid and deep intubation of the small
bowel through the oral route [12]. The endoscope
remains in a stable position and by rotating
the overtube with its raised helices, the small
bowel is pulled backwards over the endoscope.
It seems to be a feasible, rapid method, however
mucosal and transmural traction lesions have
been reported. Comparative studies between
balloon-assisted enteroscopy and spiral overtube-guided
enteroscopy are awaited.
...wireless video capsule
endoscopy on the one hand and
balloon-assisted or overtube-
guided enteroscopy on the other,
will remain “yin and yang”
techniques, complementing
each other’s imperfections....
Tomorrow’s enteroscopy
Both wireless video capsule enteroscopy on the
one hand and balloon-assisted and overtubeguided
enteroscopy on the other are undergoing
significant development processes, since
no single method is ideal. Although wireless
video capsule enteroscopy allows complete
visualisation of the small bowel without discomfort,
it remains a merely diagnostic procedure
with significant level of false negative
results. On the other hand, balloon-assisted
and overtube-guided enteroscopy are invasive
and time-consuming techniques with a lower
chance of complete enteroscopy, allowing all
conventional endoscopic interventions within
the small bowel.
The aims of each of the current development
activities are a higher yield, reduced
patient discomfort, no complications and
better interventional options, which would
represent the ideal, perfect objective. However,
it is unlikely that both approaches will
ever come together in one final, perfect
endoscopic tool for the investigation and
treatment of small bowel pathology. It looks
as though, over the next few years at least,
wireless video capsule enteroscopy and balloon-assisted
and overtube-guided enteroscopy
will remain the “yin and yang” of small
29
Apr/May 2010
bowel visualisation, perfectly complementing
each other’s imperfections.
References
1. Moreels TG. History of endoscopic devices for
the exploration of the small bowel. Acta Gastroenterol
Belg 2009;72:335-337.
2. Hiratsuka H, Hasegawa M, Ushiromachi K,
Endo T, Suzuki S, Nishikawa F. Endoscopic
diagnosis in the small intestine. Stomach Intestine
1972;7:1679-1685.
3. Tada M, Akasaka Y, Misaki F, Kawai K. Clinical
evaluation of a sonde-type small intestinal fiberscope.
Endoscopy 1977;9:33-38.
4. Bosseckert H, Schramm H, Lungershausen G,
Machnik G. Oral intraoperative enteroscopy for
diagnosis of multiple jejunal ulcers. Endoscopy
1981;13:7-8.
5. Foutch PG, Sawyer R, Sanowski RA. Push-enteroscopy
for diagnosis of patients with gastrointestinal
bleeding of obscure origin. Gastrointest
Endoscopy 1990;36:337-341.
6. Shimizu S, Tada M, Kawai K. Development of a
new insertion technique in push-type enteroscopy.
Am J Gastroenterol 1987;82:844-847.
7. Wilmer A, Rutgeerts P. Push enteroscopy. Technique,
depth, and yield of insertion. Gastrointest
Clin N Am 1996;6:759-776.
8. Yamamoto H, Sekine Y, Sato Y, Higashizawa T,
Miyata T, Iino S, Ido K, Sugano K. Total enteroscopy
with a nonsurgical steerable doubleballoon
method. Gastrointest Endosc 2001;
53:216-220.
9. Gerson LB, Flodin JT, Miyabayashi K. Balloon-assisted
enteroscopy: technology and
troubleshooting Gastrointest Endosc 2008;68:
1158-1167.
10. Moreels TG, Hubens GJ, Ysebaert DK, Op de
Beeck B, Pelckmans PA. Diagnostic and therapeutic
double-balloon enteroscopy after small
bowel Roux-en-Y reconstructive surgery.
Digestion 2009;80:141-147.
11. Adler SN, Bjarnason I, Metzger YC. New balloon-guided
technique for deep small intestine
endoscopy using standard endoscopes. Endoscopy
2008;40:502-505.
12. Akerman PA, Agrawal D, Cantero D, Pangtay J.
Spiral enteroscopy with the new DSB overtube:
a novel technique for deep peroral small-bowel
intubation. Endoscopy 2008:40:974-978.
The author
Tom G. Moreels
Antwerp University Hospital
Department of Gastroenterology & Hepatology
Wilrijkstraat 10
B-2650 Antwerp, Belgium
Tel. +32-3-821 4974
E-mail: tom.moreels@uza.be
Comments on this article?
Feel free to post them at
www.ihe-online.com/comment/enteroscopy

Apr/May 2010
Rapid blood gas analyzer for
point-of-care
The new ABL90 FLEX system from Radiometer
is a cassette-based blood gas analyzer
developed for point-of-care testing (POCT)
and gives healthcare professionals more time
for patient care by providing the fastest blood
gas results available on the market today. It only
takes 35 seconds to perform a test on the comprehensive
acute care panel with 17 parameters.
This is about a third of the time spent on testing
with other analyzers. Rapid test results shorten
the time needed before an accurate diagnosis
can be made and the correct medical treatment
initiated. This provides clinical benefits in the
treatment of patients and contributes to a redution
in in-patient days and costs. For patients
under surveillance e.g. patients suffering from
respiratory diseases or postoperative patients,
it becomes less time consuming to get test
results regularly and it equally frees time for
essential patient care. A turnaround time of 60
seconds reduces time waiting for the analyzer
to be ready for the next test and thus helps to
avoid queues to use the analyzer. The ABL90
FLEX is a compact solution with a weight of
only 11 kg; it is portable or can be placed on
a rolling stand. This means that the caregivers
can perform the test and diagnose the patient
close to the bedside, which is proven to provide
better patient outcomes. The compact design
is also convenient in hospital wards that are
frequently already packed with equipment.
RAdiometeR
Brønshøj, denmark
www.ihe-online.com & search 45581
Interventional radiology
The innovative Advantage Workstation Volume-
Share 4 from GE Healthcare is a complete interventional
suite that gives interventional radiologists
the tools they need to take image-based diagnosis
and minimally invasive therapy to a higher level.
The system now incorporates advanced guidance
tools that not only provide precise anatomical
detail, but also help simplify and expedite even
the most complex and challenging diagnostic
and interventional procedures. The new system
30
ProdUCt NEWs
delivers excellent image quality, thanks to the builtin
Innova Vision software, at the lowest possible
dose in the industry. The software dynamically
overlays 2D fluoroscopic images and 3D models
from multiple modalities, and creates a fused road
mapping display that helps advance guidewires,
catheters, coils and other devices more confidently
by visualizing them on the 3D model in
real time. 3D models can be reconstructed from a
choice of subtracted or non-subtracted rotational
angiography (X-ray), CT or MR images. Registration
of the fused images adjusts automatically in
real time for all changes in C-arm angulations,
source-to-image distance, field of view, table
height and lateral/longitudinal
position, to
provide device
l o c a l i z at i on
at all times.
Fused images
are displayed
on a dedicated
monitor in
the procedure
room and are
easily controlled
from the
central touch
screen at the
tableside.
ge HeAltHCARe
Buc, France
www.ihe-online.com & search 45584
Quantitative MR flow analysis
software
The CAAS MR Flow software enables health professionals
to perform quantitative flow analysis on
phase-contrast MR images. The system reduces
the time spent on interpreting velocity-encoded
MR data by providing fast and reliable automatic
contour detection for the analysis of the blood
flow in vessels and through heart valves. The
new software offers the possibility that phase offset
correction based on phantom images can be
directly applied to the images under analysis for
faster and more accurate flow quantification. In
addition, phase offset correction can be applied
based on gradient ROIs and it is now possible to
add and remove datasets while working on an
analysis. It is also possible to add and save user
defined anatomical designations.
pie mediCAl imAging
maastricht, The netherlands
www.ihe-online.com & search 45582
Contrast injection system The EmpowerCTA
dual-syringe, fixedrate
contrast injector
incorporates
advanced technology
and patient
safety features, to
meet all clinical
and management
requirements. The
automatic syringe
initialization and
fill volume are
based on selected
protocols, which can be set to meet the requirements
of MDCT scanners. With its flexible
mounting options to meet space requirements,
the system has an exclusive tilt lockout that helps
minimize the likelihood of air embolism.
ACiSt mediCAl SYStemS
eden prairie, mn, USA
www.ihe-online.com & search 45583
Bedside patient monitor and workstation
Bringing superiormonitoringperformance
and patient
information efficiencies
to the
most demanding
care areas,
the Ultraview
SL2800 from
Spacelabs offers
complete monitoring
and
workstation performance in a single bedside
package. In addition, the SL2800 delivers
charting, lab, intranet and HIS applications
to the bedside. The system facilitates the
creation of concise and complete electronic
patient records and allows the review of
information from multiple sources without
the need to leave the patient.
SpACelABS HeAltHCARe
issaquah, WA, USA
www.ihe-online.com & search 45580

5-7 October 2010
Marina Bay Sands, Singapore
www.clinicalxasia.com
Asia’s largest CME-led Clinical
Excellence Exhibition & Congress
• Surgery Asia Congress • Imaging & Diagnostics Asia Congress
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Apr/May 2010
Meters for X-ray service and QA
The Solo range of products from Unfors is a
line of meters specifically developed for quality
assurance and service of diagnostic X-ray
machines. Designed for specific X-ray modalities
to provide the user with essential features
and high precision adapted to fit a defined
need, the Unfors Solo products share the core
technology of the market leader Unfors Xi.
Thanks to its intuitive user interface and builtin
intelligence, users can rapidly learn how to
use the system and can focus on interpreting
the measured data instead of focusing on how
to obtain the data. Not only does the ease of use
of the system save time but, more importantly,
it minimizes the risk of user errors. Depending
on the model used, parameters such as kVp,
dose, dose rate, pulses, time, mA and mAs are
simultaneously measured, with options such
as direct HVL measurements and waveform
display being further enhancements.
UnFoRS
Billdal, Sweden
www.ihe-online.com & search 45571
POC test for Clostridium difficile
Providing results to healthcare
professionals in just 20
minutes, the Remel Xpect
C. difficile Toxin A/B test
from Oxoid is a valuable
diagnostic tool for use in the
rapid detection of Clostridium
difficile infection (CDI).
Extremely easy to use, the
test provides accurate and
reliable results, with a speed and convenience
that enables healthcare professionals to initiate
appropriate patient care and infection control
procedures quickly and decisively. Elderly and
immunocompromised patients who have recently
received antibiotic therapy are most at risk of C. difficile-associated
diarrhoea (CDAD), and infection
can spread quickly throughout hospital wards and
32
ProdUCt NEWs
other healthcare institutions. Early diagnosis is
recognized as one of several factors (including
surveillance, education and infection control
measures) that combine to prevent the spread
of CDI. The Xpect Clostridium difficile Toxin
A/B Test allows the direct detection of both
C. difficile toxins A and B.
oxoid
Basingstoke, UK
www.ihe-online.com & search 45572
sNowhere is the processing of CR cassettes more
inconvenient than in a portable environment. To
meet this challenge, a new retrofit kit has been introduced.
The kit enables
popular portable
systems to use
the wireless, cassettesized
DRX-1 detector
from Carestream for
instant, high-quality
DR images. With the
DRX-Mobile Retrofit
Kit, images captured
at the point of care
are available in seconds
and can be forwarded
to multiple
network destinations via wireless communications or
cable plug-in, so clinicians can make rapid diagnoses
and begin immediate treatment. The new technology
also improves patient positioning and comfort
by eliminating cables and tethers typically required
by most DR-based systems. This makes it ideal for
confined spaces, remote locations and imaging of
patients with limited mobility in addition to emergency
rooms, operating rooms and the ICU. Facilities
that have already implemented a DRX-1 System or
a DRX-Evolution suite can use one of their existing
detectors for portable exams.
CAReStReAm HeAltH
Rochester, nY, US
www.ihe-online.com & search 45573
Protective clothing in radiology
Designed for applications in interventional radiology
and cardiology procedures, CT labs, surgery, and
general radiology, Kiran protective products are made
from proprietary materials, which can be light-weight,
lead-free or, leaded material, all giving the same level
of protection.
The company’s most
popular sheeting,
Ultralite, replaces
a large part of lead
with a combination
of tungsten,
bismuth, and antimony,
providing
the same protection
FroNt CoVEr ProdUCt
Ultrasound imaging with
elastography
With its Aixplorer product, the SuperSonic
Imagine company has developed a unique
ultrasound system with an innovative medical
platform that can measure and visualise
tissue elasticity. It is well known that manual
palpation of tissue is part of a routine medical
exam.Today, it is essential to obtain additional
information on tissue elasticity since this can
have a correlation with pathology. Quantitative
values for tissue elasticity can provide more
information about a lesion; more information
leads to enhanced diagnostic confidence. The
Aixplorer system uses the proprietary Sonic-
Software system, an all software-based architecture
that is extremely rapid and flexible and
provides impeccable image quality. Acquiring
data up to 200 times faster than conventional
ultrasound technology, the Aixplorer is fast
enough to achieve ShearWave Elastography
with ultrafast imaging. The system produces,
in real time, a color coded map which represents
tissue elasticity expressed in kilopascals.
A colorscale indicates the level of tissue elasticity
ranging from very soft (blue) to very stiff
(red). With a cutting edge compact design,
intuitive control and touch panels, ultra lightweight
transducer and cables, the system has
many features designed to provide optimal
working conditions.
SUpeRSoniC imAgine
Aix-en-provence, France
www.ihe-online.com & search 45575
as leaded sheeting but at a significantly lower weight.
The company’s Leadlite sheeting is the lightest leaded
material in the world, thanks to the use of lead particles
together with mineral oils and bonding materials
replacing artificial plasticizers.
KiRAn mediCAl SYStemS
mumbai, india
www.ihe-online.com & search 45574

Multi-channel ECG
The new EPG 6 VIEW Plus system from Progetti
is a 3/6/12 channel electrogardiograph that provides
Hes analysis and interpretation. The system
has an internal memory that can store up to 300
tests, and has a pacemaker-detection function.
The output is displayed on a LCD TFT color
display. The system has USB output ports and is
fully autonomous with built-in PC-compatible
software for data management.
pRogetti
moncalieri, italy
www.ihe-online.com & search 45577
Blood flow monitor
The CardioTrace system from Advanced Global
Health is a non-invasive clip that monitors
the blood flow in the arteries to identify
fitness levels or abnormalities, allowing users
to discover in real time whether their lifestyle,
diet and exercise routines need to change. The
monitor is attached to the patient’s finger and
connected to a computer by a USB connector.
The technology then measures for 90 seconds
the speed of the blood travelling through the
larger arteries, calculating the Arterial Stiffness
Index, before comparing the reading against
normal data collected from all ages and ethnicities.
Measuring a person’s pulse speed not
only determines their personal health levels but
also identifies if they are potentially at risk, for
example with a likelihood of developing diseases
such as diabetes or high blood pressure
in the future. The device also offers the possibility
of mass screening of populations at low
cost, and with medically accepted accuracy and
correlation. Arterial stiffness continues to be
associated with an increasing number of health
risks and is increasingly used alongside other
ProdUCt NEWs 33 Apr/May 2010
common health markers, strengthening the
value of screening in the community.
AdvAnCed gloBAl HeAltH
gravesend, Kent, UK
www.ihe-online.com & search 45578
Ultra-clean operating theatres and
suites
Jointly developed with the
internationally acclaimed
orthopaedic surgeon, Sir
John Charnley, the Exflow
air unit from Howorth has
a graded velocity airflow,
vertical in the central area
and radially outwards at
the periphery, thus creating
an exponential airflow
profile. The system is now available in two
sizes: both models provide microbiological cleanliness
and airflow results that exceed all current
regulatory requirements. The latest addition to the
Exflow family has an enlarged ultra clean operating
zone of 3.2 X 3.2m, allowing the entire operating
team and all their instrument tables to be
accommodated beneath the canopy.
HoWoRtH AiR teCHnologY
Farnworth, UK
www.ihe-online.com & search 45579
FroNt CoVEr ProdUCt
Combined PET - MRI scanner
With the installation of the first system that
combine both Magnetic Resonance (MRI )
and Positron Emission Tomography ( PET)
modalities in one single unit, Philips has
achieved a technical breakthrough by overcoming
the potential problems that could be
caused by the magnetic field generated by the
MRI scanner interfering with the operation
of the PET system. Two combined PET-MRI
systems have already been installed (one in
the Geneva University Hospital in Switzerland,
and the other in Mount Sinai Hospital
in New York City, US) and are currently being
extensively evaluated. The use of MRI images,
EyeGard is the
safe, effective way
to protect the eyes
during surgery.
• Latex free, hypo-allergenic material
• Reduces lash removals
• Faster and easier than tape
• Adult and pediatric sizes
• Gentler adhesive also available
U.S.A. 813-889-9614 • Fax 813-886-2701
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which give anatomical information (without
any of the ionizing radiation associated with
CT X-ray), together with PET images giving
functional information, is synergistic in
diagnostic efficacity and precision. Until now,
PET and MRI investigations were carried out
separately, on two separate instruments and
for scheduling reasons, often on two different
days for the same patient. The results of such
separate examinations are difficult to correlate
since the patient can never have exactly
the same position or orientation in the two
separate scanners. There are many reasons for
combining PET and MR scanners together.
The most straightforward are the excellent
soft tissue contrast, the elimination of the
extra radiation from the CT (used to provide
both anatomical and attenuation-correction
information) and the multifunctional imaging
ability (thanks to a wide spectrum of
MR sequences and techniques) that complements
the functional molecular information
from the PET. The new system are currently
being evaluated in oncology, neurology and
cardiology patients.
pHilipS HeAltHCARe
Eindhoven, The Netherlands
www.ihe-online.com & search 45576

Apr/May 2010
FroNt CoVEr ProdUCt
Urology workstation
Thanks to its new dynamic flat detector technology,
the new UROSKOP Omnia system
allows the urologist to cover the entire kidney,
ureter and bladder (KUB) tract with only one
single exposure and in exceptional image quality.
With its curved X-ray column, the new
system allows truly unrestricted patient access
from all table sides. Regardless of the type of
examination, the urologist does not have to
reposition his patient, and the anesthesiologist
can always stay in place. This is very helpful, for
example in case of lateral percutaneous interventions
and increases safety , lowers costs for
room equipment and infrastructure as there is
no need to have a mobile anesthesia workplace.
The system allows a variety of clinical applications
such as transurethral and percutaneous
urological interventions, urologic diagnostics
and even gastroenterological cases and general
radiographic applications.Thanks to the large
field-of-view it’s possible to receive a real KUB
image with just one single exposure. Compared
with standard image intensifier systems this
means reduced examination time and less dose
for the patient. Moreover, the system’s resolution
of more than 2800 X 2800 pixels exceeds
that of standard image intensifier systems. The
high-resolution images enable the physician to
zoom in without any quality loss and to see the
finest details which increases diagnostic confidence.
In addition, the UROSKOP Omnia
allows for digital RAD images, saving costs as
no cassettes are needed.
SiemenS HeAltHCARe
erlangen, germany
www.ihe-online.com & search 45567
34
Multi-modality, vendor neutral PACS
for breast imaging
The new IMPAX for Breast Imaging module
from Agfa extends the company’s PACS solution
into breast imaging with unique new features.
For example, it implements the IHE Mammography
Image profile, which solves image display
problems typically encountered in mixed vendor
environments, such as: orientation, size,
justification, consistency of grayscale contrast and
ProdUCt NEWs
completeness of annotations.
AgFA HeAltHCARe
mortsel, Belgium
www.ihe-online.com & search 45569
Fetal doppler system
The FM-200 fetal doppler system from Shenzhen
Biocare features a signal
strength indicating function
so that the probe can
be located easily. The system
is equipped with a
physiological and system
alarm function, with the
alarm limit ranges being
: lower 50 - 120 bpm and
the upper range 160 bpm - 240 bpm. Portable
(with a user belt clamp so that it can be carried
conveniently) and especially designed for pregnancy
monitoring, the system has an adjustable
volume with optional headphone use. There are
three work modes to satisfy the requirements
of all users. The system automatically powers
off if there is a signal or probe failure that lasts
for 2 minutes.
SHenZHen BioCARe
Shenzhen, p.R. China
www.ihe-online.com & search 45568
Contrast media delivery system
In addition to the development of high performance
contrast media, the Guerbet company is also
committed to improving their
presentation and delivery systems.
The first bag developed
specifically for medical imaging,
the ScanBag, is based on
the IV infusion bag concept,
which were initially made of
polyvinyl chloride (PVC) and
later of polypropylene (PP).
Polypropylene bags are light,
resistant, simple to use, safe to
handle, and provide maximum
asepsis, meet current environmental
requirements and
don’t break if dropped. For all these reasons, PP
was chosen for ScanBag. The ScanBag project was
initiated following a study of the current practices
and needs of contrast media users and is based on
technologies widely proven in medical applications,
and on technical innovations which guarantee
the compliance to current requirements in
matters of safety, convenience and environmental
protection.
gUeRBet
Roissy, France
www.ihe-online.com & search 45570
CALENdAr oF EVENts
June 1-3, 2010
Hospital Build Middle East Exhibition
and Congress 2010
Dubai, United Arab Emirates
Tel. +971 4 3365161
Fax +971 4 3364021
e-mail: hospitalbuild@iirme.com
www.hospitalbuild-me.com
June 7-9, 2010
UKRC 2010
Birmingham, UK
Tel. +44 20 7307 1410
e-mail: conference@ukrc.org.uk
www.ukrc.org.uk
June 10-13, 2010
15th Congress of the European
Hematology Association
Barcelona, Spain
Tel. +31 70 3455563
Fax +31 70 3923663
e-mail: info@ehaweb.org
www.ehaweb.org
June 12-15, 2010
Euroanaesthesia 2010
Helsinki, Finland
Tel. +32-2-743 3290
Fax +32-2-743 3298
e-mail: registration@euroanaesthesia.org
www.euroanaesthesia.com
June 16-19, 2010
World Congress of Cardiology
Scientific Sessions 2010
Featuring the 3rd International
Conference on Women, Heart
Disease and Stroke
Beijing, China
e-mail: congress@worldheart.org
www.worldcardiocongress.org
June 16-19, 2010
CARDIOSTIM 2010
17th World Congress in Cardiac
Electrophysiology & Cardiac
Techniques
Nice, France
www.cardiostim.fr?xtor=ADI-5
June 23-26, 2010
CARS 2010 - Computer Assisted
Radiology and Surgery
Geneva, Switzerland
Tel. +49 7742 922 434
Fax +49 7742 922 438
e-mail: office@cars-int.org
www.cars-int.org
August 24-26, 2010
Medifest South Africa 2010
Capetown, South Africa
Tel. +91 11 30580444
e-mail: info@vantagemedifest.com
www.vantagemedifest.com
August 28 – Sep 1, 2010
ESC Congress 2010
Stockholm, Sweden
Tel. +33 492 947 600
Fax +33 492 947 601
www.escardio.org/congresses/
esc-2010
September 14-15, 2010
MHealth 2010
Dubai, UAE
Tel. +44 20 7067 1830
www.m-healthconference.com
September 15-17, 2010
Medical Fair Asia 2010
Suntec Singapore
Tel: + 65 6332 9620
Fax: +65 6332 9655 / 6337
e-mail:
medicalfair-asia@mda.com.sg
www.medicalfair-asia.com
October 5-7, 2010
Clinical Excellence Asia
Marina Bay Sands, Singapore
www.iirme.com/clinicalasia
October 9-13, 2010
23rd ESICM Annual Congress
Barcelona, Spain
Tel. +32 2 559 03 55
Fax +32 2 527 00 62
e-mail: Barcelona2010@esicm.org
www.esicm.org
October 13-16, 2010
CMEF Autumn 2010
Shenyang, Liaoning Province, China
Tel. +86 10 6202 8899 ext 3825
Fax +86 20 6235 9314
e-mail:
jin.liu2@ReedSinopharm.com
http://en.cmef.com.cn/
November 17-20, 2010
MEDICA
Düsseldorf, Germany
e-mail: info@medica.de
www.medica.de
November 28 – December 3
RSNA 2010
Chicago, IL, USA
Tel. +1 630 571 2670
www.rsna.org
December 10-12, 2010
Medifest India 2010
New Delhi, India
Tel. +91 11 30580444
e-mail: info@vantagemedifest.com
www.vantagemedifest.com
February 24-27, 2011
International Conference on Prehypertension
& Cardio Metabolic
Syndrome
Vienna, Austria
Tel. +41 22 5330948
Fax +41 22 5802953
e-mail:
Secretariat@prehypertension.org
www.prehypertension.org
For more events see
www.ihe-online.com/events/
dates and descriptions of future events have been obtained from
usually reliable official industrial sources. iHE cannot be held
responsible for errors, changes or cancellations.

www.ihe-online.com & search 45549

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