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The patient with a current or former history of substance use disorder can be challenging to adequately care for in the perioperative period. A thorough preoperative evaluation is essential. In addition to drug abuse screening, the evaluation should include an assessment of the effects of the substance abuse, associated diseases, end-organ damage, and an awareness of the potential perioperative risks so appropriate plans are developed to minimize the risks. Intraoperatively, anesthetic management needs to be appropriately modified. Signs and symptoms of withdrawal should be monitored for postoperatively. Pain management is particularly challenging. After discharge, this patient population is vulnerable and requires close follow-up and early referral to appropriate specialists when needed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Pathologic changes can occur during pregnancy requiring diagnostic tests and procedures. A preoperative assessment and perioperative planning are essential. Normal physiologic changes include increased cardiac output and decreased functional residual capacity. Perioperative care should follow American Congress of Obstetricians and Gynecologists guidelines. Anesthetic concerns include desaturation during periods of apnea, aspiration, difficult intubation, friable nasal tissue, decreased MAC, and hypotension and/or decreased uterine perfusion from the uterus. Anesthesia and medications must be individualized and given only as needed. Limit exposure to multiple drugs and monitor for fetal wellbeing and premature labor per consultation and guidelines., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Unlabelled: Predonation of autologous blood (PAD) is a standard of care for patients undergoing radical prostatectomy, but recent studies have shown that PAD is not cost-effective. Acute normovolemic hemodilution (ANH) is an alternative autologous blood procurement technique that is much less costly than PAD. We compared the efficacy and costs of ANH alone to ANH combined with PAD. Two hundred-fifty patients who predonated fewer than 3 units of autologous blood before radical prostatectomy underwent ANH to a target hematocrit of 28%. Perioperative hematocrit levels, transfusion outcomes and costs, and postoperative outcomes were compared for patients who predonated 0, 1, or 2 units of blood before surgery. A computer model was used to estimate the savings in red blood cells (RBC) associated with each autologous intervention. ANH alone resulted in a 21% allogeneic transfusion rate and contributed a mean net savings of 112 mL RBC in blood conservation (equivalent to 0.6 unit of blood). The addition of 1 or 2 units of PAD reduced allogeneic exposure rates to 6% or 0%, respectively. Overall, patients who predonated blood had a mean net loss of 198 mL of RBC (equivalent to 1 blood unit), due to both an absence in compensatory erythropoiesis and to the wastage of 60% of the blood units donated. Patients who underwent ANH alone had a 60% reduction in mean total transfusion costs ($103 +/- $102) compared with patients who predeposited 2 units of autologous blood in addition to ANH ($269 +/- $11, P < 0.05). We conclude that ANH can replace PAD as an autologous blood option because it is less costly and equally effective. A combination of ANH and PAD can further decrease allogeneic blood exposure, but it increases transfusion costs and wastage., Implications: A patient's own blood can be obtained for use in surgery by predonation or acute normovolemic hemodilution on the day of surgery. Both blood collection techniques decrease the need for blood bank transfusions, but acute normovolemic hemodilution is less expensive and more convenient for patients.

The use of isoflurane in patients with coronary artery disease remains controversial because of the possibility of "coronary steal". In this study, the effects of isoflurane and halothane on global and regional myocardial blood flow and metabolism were compared, and the relationship between steal-induced myocardial ischemia and the administered volatile anesthetic was investigated in 40 patients with steal-prone coronary anatomy undergoing elective coronary artery bypass operations. The patients were randomly assigned to receive either isoflurane or halothane (0.5 MAC inspired concentration) immediately after induction with fentanyl (50 micrograms/kg). Hemodynamic measurements and blood samples were obtained at preinduction, postintubation, preincision, poststernotomy, at 60 min after beginning isoflurane or halothane, and precannulation (a total of 238 study events). Throughout the study, heart rate was kept constant by atrial pacing at approximately postintubation values while arterial pressure was maintained within 10% of postintubation values with fluid administration or phenylephrine infusion. Overall, systemic hemodynamic changes observed during the study were similar in the two groups. Myocardial ischemic episodes were defined as a new electrocardiographic ST-segment shift of greater than or equal to 0.1 mV, new echocardiographic regional wall motion abnormalities (RWMA) and/or myocardial lactate production (MLP). A total of 18 new ischemic episodes were detected in 15 patients (7 episodes during isoflurane in 7 patients and 11 during halothane in 8 patients). Ten (56%) episodes were related to acute hemodynamic abnormalities, whereas 8 (44%) were random and unrelated to changes. Seven episodes were detected by echocardiography (38%), 6 by MLP (33%) and 1 by ECG (6%) only, whereas concomitant echocardiographic abnormalities and MLP were observed during 2 episodes (11%), echocardiographic and ECG during 1 (6%), and ECG and MLP during 1 other (6%). Ratios of regional to global coronary venous flow, coronary vascular resistance, myocardial oxygen content, and lactate extraction, along with hemodynamic data obtained during these episodes, do not support coronary steal for the development of myocardial ischemia. We conclude that in patients with steal-prone coronary anatomy anesthetized with fentanyl, neither isoflurane nor halothane administered at concentrations used in the current study is likely to cause myocardial ischemia by the coronary steal mechanism.

The acute effect of epidermal growth factor (EGF) on progesterone biosynthesis by hen granulosa cells in short term culture was investigated. Pretreatment of cells for 5 h with EGF at concentrations of 1000-4000 ng/ml inhibited LH-stimulated progesterone production by 54%. Shorter EGF pretreatment times of 1 and 3 h caused 25% and 35% inhibition of LH-stimulated progesterone production, respectively. In additional experiments, EGF was found to inhibit progesterone production in response to 8-bromo-cAMP (1 mM) and forskolin (100 microM) by 34% and 35%, respectively. EGF had no effect on the conversion of 25-hydroxy-cholesterol or pregnenolone to progesterone, indicating that one site at which EGF inhibits progesterone biosynthesis is distal to cAMP generation, but before the side-chain cleavage step. EGF also inhibited LH-stimulated cAMP production by 32%, but had no effect on forskolin-stimulated cAMP accumulation. This indicated that there was a second site of EGF action in these cells, probably at the level of LH receptor coupling to the adenylate cyclase. Nerve growth factor (4000 ng/ml) had no effect on progesterone production, but fibroblast growth factor (4000 ng/ml) facilitated LH-stimulated progesterone production. The results demonstrate that the acute inhibitory effect of EGF on LH-stimulated progesterone biosynthesis in hen granulosa cells is due to its action at two sites: one at a site before the production of cAMP and the other at a step beyond cAMP generation.