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SummaryWe measured concentrations of the natural anticoagulant protein C; its cofactor, protein S; and the carrier protein C4bbinding protein (C4BP), in 24 patients with severe infection and 13 with septic shock. Decreased antithrombin III levels were found in 16 of 24 infection patients and all shock patients; high thrombin-antithrombin (TAT) complexes were present in 16 of 24 infection and 12 of 13 shock patients. Protein C concentrations were significantly reduced compared to healthy blood donors, to 60 ± 14% (infection) and 47 ± 20% (septic shock) (mean ± 1 SD). Total protein S levels were not reduced (119 ± 36.7 and 88 ± 20.0%, normal value 96±15%). Free protein S was also normal (27 ± 9.4 and 30 ± 8.7%, normal value 29 ± 9%). The percentage free of total protein S was normal in shock patients (35 ± 8.5%), but significantly reduced in patients without shock (23 ± 5.3%). C4BP was significantly higher than normal in the latter group (135 ± 43%), but not in the shock group (118 ± 40%), possibly due to increased consumption. Thus, no deficiency of total or free protein S was found in these patients, who had evidence of activated coagulation but no clinical DIC.

A marked hypertensive response is often seen when the Mayfield skull-pin device is applied to stabilize the head of the anesthetized patient for neurosurgery. In a prospective, blinded and randomized trial, 10 patients received an infiltration block of 0.5% mepivacaine with epinephrine 5 micrograms/ml (3 ml at each pin site) 1 min before the Mayfield holder was applied. Ten patients received normal saline and served as controls. All patients were under general anesthesia induced with sodium pentothal, fentanyl and pancuronium, and maintained with isoflurane in nitrous oxide/oxygen and increments of fentanyl. In the control group, there were significant increases in mean arterial pressure (mean increase 43%, P less than 0.001) and heart rate (15%, P less than 0.01) at 0.5, 1 and 2 min after application. In the mepivacaine group, no significant changes occurred. Infiltration of local anesthetic with epinephrine can thus safely protect against potentially dangerous increases in arterial pressure when the Mayfield holder is used.

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In morbidly obese patients, low-pressure CPAP combined with low-pressure PSV during pre-oxygenation resulted in better oxygenation, compared with neutral-pressure breathing, and prevented desaturation episodes.