Biomedical subjects
J T Møller
Publications and source records attributed to J T Møller.
A random trial comparing recovery after midazolam-alfentanil anesthesia with and without reversal with flumazenil, and standardized neurolept anesthesia for major gynecologic surgery.
STUDY OBJECTIVE: To compare the recovery characteristics of total intravenous anesthesia (TIVA) using midazolam-alfentanil, with or without reversal with flumazenil to a standardized neurolept anesthesia with nitrous oxide (N2O). DESIGN: Randomized, double-blinded clinical study. SETTING: University medical center. PATIENTS: 80 ASA physical status I and II women scheduled for major elective gynecologic surgery. INTERVENTIONS: Patients were anesthetized with one of three different anesthetic techniques. Patients in the TIVA group with reversal received midazolam-alfentanil reversed with flumazenil (Group 1), the TIVA group without reversal received midazolam-alfentanil reversed with placebo (Group 2), and patients in the neurolept group received anesthesia using thiopental sodium, droperidol, fentanyl, and N2O (Group 3). MEASUREMENTS AND MAIN RESULTS: Recovery was assessed by an observer blinded to the treatment allocation, using a Modified Steward Recovery Score and judgment of orientation and comprehension, collaboration and degree of sedation for the first 4 hours after extubation. Arterial blood gases were measured 30 minutes after extubation. A questionnaire regarding the degree of perioperative amnesia was presented to the patients 4 and 24 hours after surgery. The recovery scores were better in the TIVA group with reversal than in the other two groups from 0 to 30 minutes postoperatively. No difference between the groups could be found thereafter, although after 30 minutes some resedation occurred in the TIVA group with reversal. The median injected amount of flumazenil in Group 1 was 0.5 mg. Respiratory depression (breathing frequency below 10 breaths/min) was reversed with naloxone in one patient in the TIVA group with reversal, five patients in the TIVA group without reversal, and no patient in the neurolept group (p < 0.001). On blood gas analysis, there was no evidence of hypoxemia or carbon dioxide retention. No difference was seen between the groups regarding consumption of analgesics, degree of amnesia, or patient rating of the quality of anesthesia. One patient in Group 2, however, recorded awareness at skin incision when questioned 4 hours after the operation, but could not recall this 20 hours later. CONCLUSIONS: TIVA with midazolam and alfentanil can be used for major gynecologic surgery. Recovery in the neurolept group was equal to recovery in the TIVA group without reversal, and flumazenil improves the recovery after midazolam anesthesia. Overall, in comparison with the neurolept technique no major advantage could be demonstrated using TIVA with midazolam-alfentanil.
Impact of immediate and delayed myocardial scintigraphy on therapeutic decisions in suspected acute myocardial infarction.
Early myocardial scintigraphic imaging has become technically feasible in patients admitted to hospital with suspected acute myocardial infarction. After prompt injection of 99mTc-sestamibi, subsequent scintigraphic imaging of perfused myocardium can be performed. During a 5-month period, 237 patients were admitted to the coronary care unit of a district hospital on suspicion of acute ischaemic syndrome, and injection of 99mTc-sestamibi for the performance of myocardial scintigraphy was carried out in 134 patients, on average 2 h after onset of symptoms. The investigation was repeated in 126 patients, on average 18 h after the injection. Three planar views were taken in the coronary care unit with a mobile gamma camera. The prevalence of acute myocardial infarction was 53%. The predictive value at the first scintigraphic imaging for a positive or negative test for myocardial infarction 54% and 56%, respectively. Even exclusion of patients with a previous infarction did not increase the diagnostic validity. The predictive value of a negative test, 77%, at the second scintigraphy was still insufficient to make immediate therapeutic decisions. Myocardial scintigraphy performed early, on suspicion of acute myocardial infarction, cannot therefore be used routinely as a diagnostic test prior to intervention in unselected patients because some 90% of this patient group have myocardial perfusion defects.
Anesthesia related hypoxemia. The effect of pulse oximetry monitoring on perioperative events and postoperative complications.
The objectives of the present investigation were to evaluate the extent of perioperative hypoxemia and to investigate the impact of pulse oximetry monitoring on the extent of hypoxemia and on perioperative morbidity in adults. To accomplish these objectives a number of prospective studies were carried out. The incidence, duration, and severity of hypoxemia were evaluated in two single blinded observer studies in the operating room (N = 296) (I) and in the Postanesthesia Care Unit (N = 200) (II). Pulse oximetry monitoring's effect on the extent of hypoxemia was evaluated in a randomized blinded observer study of 200 patients (III). The impact of pulse oximetry on the frequency of perioperative events, changes in patient care, and post-operative complications were studied in a randomized evaluation of 20,802 patients (IV-V). Finally, a subgroup of 736 patients already included in the randomized evaluation was psychologically evaluated pre- and postoperatively (VI). In the observer studies in the OR and PACU mild hypoxemia (SpO2 86-90%) was recorded in 53% and 55% of the patients, respectively. Severe hypoxemia with SpO2 values < 81% was recorded in 20% and 13% of the patients, respectively. In the randomized blinded observer study, patients with pulse oximeter data available had a significantly reduced incidence of perioperative hypoxemia when compared to patients where the data were unavailable. Most noteworthy was that in the available group extreme hypoxemia (SpO2 < 76%) was not encountered in the OR and both severe (SpO2 76-80%) and extreme hypoxemia were not observed in the PACU. In the randomized evaluation of pulse oximetry significantly more patients in the oximetry group experienced at least one respiratory event than did control patients in both the OR and in the PACU. This was a result of a 19 fold increase in the incidence of diagnosed hypoxemia in the oximetry group than in the control group. In the OR cardiovascular events were observed in a similar number of patients in both groups, except myocardial ischemia, which was detected in 12 patients in the oximetry group and in 26 patients in the control group (P < 0.03). Several changes in PACU care were observed in association with the use of pulse oximetry. These included higher flow rates of supplemental oxygen (P < 0.00001), increased use of supplemental oxygen at discharge (P < 0.00001), and increased use of naloxone (P < 0.02). One or more postoperative complications occurred in 10% of the patients in the oximetry group and in 9.4% in the control group (NS).(ABSTRACT TRUNCATED AT 400 WORDS)
[Does peroperative monitoring with pulse oximetry reduce the occurrence of hypoxemia?].
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Plain radiography, renography, and 99mTc-DMSA renal scintigraphy before and after extracorporeal shock wave lithotripsy for urolithiasis.
Eighteen patients were evaluated before and 5 weeks after the first treatment with extracorporeal shock wave lithotripsy (ESWL) using abdominal plain radiography, 131I-hippuran probe renography, and 99mTc-dimercaptosuccinic acid scintigraphy. In 6 patients no urolithiasis was present on the post ESWL plain radiograph, in 7 the size had decreased, and in 5 the stone mass was unchanged. The renograms were within normal range in the 6 patients who were cured by ESWL, whereas this was the case for only 4 of the 12 who still had renal calculi. In 2 patients pelvic stones had descended into the ureter after ESWL, and the renograms indicated obstruction. Another 3 patients had ureteral stones, whereas in the remaining 7 patients only pelvic stones were found on the plain radiographs. In no patient did the scintigrams reveal scars. It is concluded that abdominal plain radiography of the urinary tract and probe renography are complementary and sufficient in the monitoring of patients with urolithiasis post ESWL.
Myocardial perfusion at fatal infarction: location and size of scintigraphic defects.
In a consecutive study of myocardial scintigraphy in acute ischemic syndrome, four patients had 99mTc-hexamibi injected intravenously before they developed fatal cardiogenic shock. Planar scintigraphy was performed after death. Slices of the hearts after autopsy were analyzed for scintigraphic and pathoanatomic abnormalities. Location of perfusion defects in planar views of the heart was in good agreement with the scintigraphied, sliced sections. The extent of infarction judged from inspection and formasan staining was much smaller (7%-40% and 6%-43% of the total slice area) than found at scintigraphy, where 83%-92% of the myocardium showed ischemia as defined by a 99mTc-hexamibi uptake below an arbitrary limit on half maximum uptake. Myocardial hypoperfusion might thus aggravate the functional impairment at myocardial infarction and lead to cardiogenic shock.
[Peroperative and early postoperative hypoxemia].
Arterial hypoxaemia is observed during operation and also in the recovery room. Hypoxaemia during operation may be due to altered pulmonary mechanical conditions, drug-induced physiological changes and technical errors. Early postoperative hypoxaemia is frequently observed after general anaesthesia and may, among other things, be due to diffusion hypoxaemia, hyperventilation-induced hypoventilation, residual curarization, hypoventilation induced by sedatives or analgesics and ventilation/perfusion alterations. The clinical significance of peroperative and early postoperative hypoxaemia is not yet elucidated and treatment consists primarily of increasing the oxygen concentration in the inspired air.
Incidence and prediction of postdural puncture headache. A prospective study of 1021 spinal anesthesias.
The incidence of postdural puncture headache (PDPH) was investigated prospectively in 873 consecutive patients undergoing a total of 1021 spinal anesthesias, and its association to age, sex, needle size, number of attempted dural punctures, needle bevel direction, duration of postoperative recumbency, and previous PDPH was analyzed. Multivariate analysis showed that age (P less than 0.0001), direction of the bevel of the needle when puncturing the dura mater (P = 0.022), and a history of previous PDPH (P = 0.018) were significant predictors of PDPH. The estimated relation between PDPH, on the one hand, and age and orientation of the bevel, on the other, enables the anesthetist to predict the risk of PDPH and thereby to choose an acceptable age limit for spinal anesthesia.
[Monitoring routines at Danish anesthesia departments].
By means of a questionnaire investigation, 84 Danish anaesthetic departments were questioned in January 1987 about their monitoring routines during anaesthesia and recovery. 100% replied. The investigation revealed that measurement of the blood pressure in adults was the routine in all of the departments. Patients were monitored routinely with EGG in 62 departments where minor surgical interventions were concerned while, in major surgical intervention, ECG monitoring was the routine in 91% of the departments. Patients were observed postoperatively in the recovery room or intensive care unit in 51% of the departments. The questionnaire investigation revealed great variation in the monitoring and supervision routines in the anaesthetic departments in Denmark. Hitherto, it has not been possible to demonstrate that monitoring of the functions of vital organs in operation patients can reduce the morbidity and mortality connected with the anaesthesia. It is concluded that it would be desirable to carry out clinically controlled investigations to illustrate whether monitoring equipment can reduce the morbidity connected with anaesthesia and to develop a Danish recommendation concerning peroperative monitoring and postoperative observation.
[Acute poisoning with organic phosphates treated at an intensive care unit].
During the period 1.1.1976 to 31.12.1985, 23 patients were treated in an intensive care unit following acute poisoning with organic phosphates. Sixteen of the cases of poisoning were intentional and were part of attempted suicide. Eight were accidental. The severe cases of poisoning were all attempted suicides. Nineteen of the cases of poisoning occurred during the months from April to August during which these sprays are employed. The average age was 41 years ant the sex ratio men: women was 3:0. Respirator treatment was necessary in six patients. Sixteen patients were treated with a bolus injection of atropine and/or continuous infusion and six of these patients received antidote treatment with obidoxim, simultaneously. It is concluded that the majority of cases of poisoning are with suicidal intent and employ preparations which are freely obtainable and that only very few cases of poisoning occur in professional persons in connection with their employment. Treatment of cases of acute poisoning with organic phosphates is both specific and symptomatic. A therapeutic programme is established which aims primarily at ensuring free respiration, prevention of further absorption of poison, specific antidote therapy with atropine and obidoxim and symptomatic therapy.
[Cytoplasmic changes in neutrophilic granulocytes. Diagnostic characteristics in septicemia].
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[Pulsoximetry. A new monitoring possibility for clinical use].
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[Oxygen measurement during transport to the recovery room].
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[Death among outpatients and inpatients discharged after acute drug and alcohol poisoning in 1980. A historical prospective study of total of 347 patients].
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Midazolam combined with paracervical blockade compared to general anaesthesia for curettage of the uterus.
Two anaesthetic techniques were compared in a randomized trial of 60 ASA I and II women admitted for diagnostic dilatation and curettage of the uterus. Group I had fentanyl 2.5 micrograms/kg and thiopentone 2 mg/kg i.v. Supplementary thiopentone 50 mg was given every 15 s until loss of the eyelid reflex. Anaesthesia was maintained with nitrous oxide in oxygen 2/1 together with supplementary thiopentone 50 mg as required. Group II had midazolam 0.1 mg/kg i.v. and a supplementary 0.025 mg/kg every second min until sleep or dysarthria, followed by paracervical blockade with 1% mepivacaine 10 ml on each side of the portio. There was no significant depression of the cardiovascular system. The working conditions for the gynaecologist were good in both groups. The midazolam technique gave just as good amnesia as did general anaesthesia, and there was a high degree of patient satisfaction in both groups. In the thiopentone group there was a significant depression of the respiratory rate and a significantly higher frequency of adverse effects (nausea and vomiting) as compared to the midazolam group. It is concluded that paracervical blockade combined with midazolam, titrated i.v., until sleep or dysarthria, is a recommendable anaesthetic technique for diagnostic dilatation and curettage.
[Combined spinal and epidural analgesia. Spinal analgesia via a Tuohy cannula prior to insertion of epidural catheters].
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[Acute poisoning in adults].
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