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[Adverse effects and recovery after total intravenous anesthesia in children].

INTRODUCTION: Propofol has proven to be a reliable anaesthetic that can be used for both induction and maintenance purposes in most common surgical procedures, either in standard anaesthetic practice or as part of total intravenous anaesthesia (TIVA). MATERIAL AND METHODS: Twenty healthy (ASAI) paediatric patients scheduled for elective minor abdominal or urology surgery were studied. Patients aged 7-16 years, weighing 25-64 kg, were premedicated with midazolam 0.1mg/kg and atropine 0.01mg/kg intramuscularly, 30 minutes before surgery. Induction dose of propofol for all patients was 2.5 mg/kg. Anaesthesia was maintained with an infusion of propofol 10 to 15 mg/kg/h. Fentanyl was injected 1-2 micrograms/kg 1 minute before the start of the infusion of propofol, just before the surgery and during the surgery if necessary. Pulse, blood pressure, respiratory rate, tidal volume, ETCO2, and O2 saturation were continuously recorded before, during and after the anaesthesia. Recovery scores were assessed with the Steward scoring system 3, 5, 15, 30, after the end of anaesthetic infusion. Blood was sampled 2 and 15 minutes after the induction, 5, 15 and 30 minutes after the end of propofol infusion. RESULTS: There were no significant differences in age, weight, sort and length of the operations. After the induction spontaneous movements were registered in 35% of the patients, apnea in 25% and decrease in blood pressure in all patients. Maintenance was generally uneventful and there were no excitatory or other adverse effects. Blood concentration of propofol was followed during the anaesthesia and recovery period. Blood propofol concentration at which responses to surgery were not present were from 3.4 micrograms/ml to 4.5 micrograms/ml. Recovery was rapid and complete. All patients reached maximum value of Steward scoring system within the first 15 minutes. In the moment when patients open to command (7.2 +/- 3.2 min) average blood concentration was 1.9 micrograms/ml and when they were orientated (13.1 +/- 2.1 min) 1.3 micrograms/ml. Postoperative nausea and vomiting were not registered. DISCUSSION: This study shows that propofol provides satisfactory, stabile anaesthesia for children with rapid and complete recovery. Children may need larger doses of propofol for induction and maintenance of anaesthesia. Results from literature suggest that propofol is metabolised faster in children than in adults (9). The incidence of side effects was low. Large vein of the forearm or antecubital fossa were used for injection of propofol and there was no pain during administration the drug. Induction dose was given slowly (over 40 seconds) and apnea was relatively rare (25%). Decreases in arterial pressures from baseline levels are known to occur with propofol but in this study it was less than in others. We find a relatively high incidence of spontaneous movements during induction (35%). Nausea and vomiting were not recorded. A continuous infusion of propofol, as described here, effectively produced stable anaesthesia without use of inhalation agents. It must be remembered that propofol possesses only hypnotic properties and additional analgesia is necessary, fentanyl is a satisfactory agent in this respect. We found that average blood propofol levels of 3.5 +/- 0.9 micrograms/ml were necessary to prevent autonomic responses during this sort of surgery. Suggested hypnotic blood levels of propofol in literature are from 2.5 to 6 micrograms/ml (5). The usual endpoints of anaesthesia (eye opening and orientation) have been measured by several authors and found to occur at concentrations of the ranges of 1.0 to 2.9 micrograms/ml and 0.6 to 1.8 g/ml, respectively. CONCLUSION: Due to greater ease of control in regard to anesthetic depth and more rapid recovery, propofol is superior to other intravenous hypnotics for maintenance of anaesthesia.

Adolescent↗
PubMed2004

Sinus node function after cardiac surgery: is impairment specific for the maze procedure?

BACKGROUND: Maze surgery is a final solution for intractable atrial fibrillation (AF), but an adverse effect on postoperative sinus node function has been reported. Whether this also applies to other types of cardiac surgery is unclear. METHODS: We assessed postoperative rhythm by means of repeated exercise tolerance testing, ambulatory electrocardiography, and non-invasive testing of autonomic function between 1 and 12 months after four types of cardiac surgery. Fourteen patients without structural cardiac disease and medically refractory AF underwent the maze III procedure, 11 patients with mitral valve disease and preoperative AF underwent valvar surgery combined with a (simplified) maze III procedure, and 8 patients with mitral valve disease in sinus rhythm (SR) underwent isolated valvar surgery. The control group consisted of eight patients with sinus rhythm who underwent coronary artery bypass surgery (CABG). RESULTS: One month after surgery, the chronotropic response to exercise was depressed, mean heart rate was high, and heart rate variability (HRV) was low, especially after maze III, combined surgery, and isolated valvar surgery. Twelve months after surgery, moderate improvements were observed. After CABG, considerably fewer abnormalities were observed, and HRV parameters recovered to a large extent. Non-invasive testing of autonomic function indicated disturbed vagal modulation of heart rate in all three groups with atrial incision. CONCLUSION: Thus, attenuation of HRV and vagal modulation of sinus node function are not confined to maze surgery but also apply to isolated mitral valve surgery. Atrial incision therefore appears to be crucial and presumably produces autonomic nervous damage followed by partial reinnervation. Nevertheless, cardiac surgery in general seems initially to impair sinus node function with partial recovery in the consecutive 12 months.

Adult↗
PubMed2002

[Hereditary amyloidoses associated with transthyretin mutations].

Hereditary amyloidoses form a clinically and genetically heterogeneous group of autosomal-dominantly inherited diseases characterized by the ubiquitous extracellular deposit of fibrillary aggregated proteins. Main components of these unsolvable deposits are physiologic proteins that became amyloidogenic through genetically determined conformation changes resulting in an increase in beta-sheet structures. In the vast majority of cases, the offending protein is variant transthyretin (TTR), of which over 80 mutations are known. Among these, substitution of valine by methionine in position 30 (TTR-Met30) is the most commonly encountered. In typical cases, TTR amyloidoses present with polyneuropathy, carpal tunnel syndrome, autonomic insufficiency, cardiomyopathy, and gastrointestinal features, occasionally accompanied by vitreous opacities and renal insufficiency. Rarely, involvement of the leptomeningeal or meningovascular structures dominates the clinical picture. The clinical expression is highly variable, with many atypical manifestations. Asymptomatic mutations have recently been identified. The age of onset varies greatly between early adulthood and old age. Late-onset atypical manifestations and occurrence of asymptomatic carriers render identification of affected family members difficult despite autosomal-dominant inheritance. Orthotopic liver transplantation (OLT) is the only effective therapy available today. This OLT stops progression of the disease, which is otherwise invariably fatal, by removal of the main production site of the amyloidogenic protein. However, cardiac involvement may progress after OLT for unknown reasons. The indication for OLT and its success depend on the grade of cardiovascular and autonomic dysfunction at the time of surgery, age, comorbidity, and type of mutation. Alternative treatment modalities with drugs stabilizing the native tetrameric conformation of TTR, inhibiting fibril formation or breaking beta-sheet structures, are currently being intensively studied.

Amyloid Neuropathies, Familial↗
PubMed1999

Ondine's curse and Hirschsprung's disease: neurocristopathic syndrome.

We report a female newborn with Ondine's curse and Hirschsprung's disease--neurocristopathic syndrome. The female infant required endotracheal intubation and mechanical ventilation due to apnea which developed soon after birth. She had abdominal distension with bilious vomiting. A barium enema revealed a caliber change at the rectum and rectal biopsies showed no ganglion cells. Colostomy was performed at the age of 17 days. Hypoxemia with hypercapnia was noted during her sleep, and tracheostomy was performed at the age of 55 days. In addition, deafness and pupillary autonomic dysfunction were observed. The definitive surgery for Hirschsprung's disease was performed at the age of 4 months. She is now 2 years old with normal growth but needs ventilator support at home. In this case, we detected no mutation in the RET gene and EDNRB gene.

DNA Mutational Analysis↗
PubMed1994

Prolonged decrease in heart rate variability after elective hip arthroplasty.

The pattern of postoperative heart rate variability may provide insight into the response of the autonomic nervous system to anaesthesia and surgery. We have obtained spectral (fast Fourier transform) and non-spectral indices of heart rate variability from electrocardiographic recordings, sampled during continuous perioperative Holter monitoring in 15 otherwise healthy patients with an uncomplicated postoperative course, undergoing elective hip arthroplasty with either spinal or general anaesthesia. In both groups, total spectral energy (0.01-1 Hz), low-frequency spectral energy (0.01-0.15 Hz) and high-frequency spectral energy (0.15-0.40 Hz) decreased after surgery to 32% (95% confidence interval (CI) 10.5; P < 0.01), 29% (95% CI 12.5; P < 0.01) and 33% (95% CI 12.5; P < 0.01) of their preoperative values, respectively, and these indices remained suppressed for up to 5 days. Non-spectral indices decreased to a similar extent. These findings indicate a substantial and prolonged postoperative decrease in both parasympathetic and sympathetic influence on the sinus node.

Aged↗
PubMed1994

Ventricular late potentials: state of the art and future perspectives.

Although the signal-averaging technique is over one hundred years old, its first use was demonstrated on the human heart in 1963 and ten years later recording of His bundle potentials from the body surface became feasible. During the last decade interest has been focused on ventricular late potentials (LP) which represent zones of delayed myocardial activation occurring in hearts after myocardial infarction as well as in diffusely damaged myocardium. Presentation of LP in the 'time domain analysis' is highly standardized and widely accepted. Development of spectral analysis techniques is still advancing and promises not only a more sophisticated interpretation of LP but also detection of electrical disturbances during the whole QRS complex. In clinical cardiology LP are found in 10% to 50% of all cardiac diseases, mainly in coronary heart disease and dilated cardiomyopathy. About 80% of patients with sustained ventricular tachyarrhythmia demonstrate LP. Their value as predictive of arrhythmic events and sudden cardiac death is relatively low (10-30%), but very high in predicting a good outcome, showing 95% event free survival if LP are negative. Predictive accuracy can be enhanced by a combination of independent indices, particularly heart rate variability. Other clinical applications are prediction of patency of the infarct-related artery after thrombolysis or after angioplasty in acute myocardial infarction and prediction of success after guided anti-tachycardiac surgery. No consistent changes can be observed following elective revascularization by angioplasty or bypass surgery. Ischaemia, exercise and manipulation of autonomic tone apparently do not consistently influence LP if ensemble signal-averaging is applied, but may cause transient alterations detectable by beat-to-beat analysis. Potential future directions are (1) evaluation of spectral analysis techniques, (2) improvement of the predictive value by combining time and frequency domain analysis, (3) increased application of beat-to-beat analysis in different pathophysiological conditions, (4) enhanced diagnosis of high-risk patients by combining other independent arrhythmic indices with LP, (5) specific selection of patients for invasive electrophysiological testing and (6) the study of LP shifting during long-term therapy of heart hypertrophy, failure, inflammation and ischaemia. Dynamic or functional LP analysis during exercise testing, electrophysiological investigation or coronary angioplasty may be a further application.

Electrocardiography↗
PubMed1999

Lower urinary tract function after intra-arterial chemotherapy with concurrent pelvic radiotherapy for invasive bladder cancer.

BACKGROUND: Intra-arterial chemotherapy with concurrent pelvic radiotherapy as a bladder-sparing regimen for invasive bladder cancer is highly promising for selected patients. However, lower urinary tract function after this treatment has not been fully investigated. METHODS: The urodynamic effects of intra-arterial chemotherapy with concurrent pelvic radiotherapy were retrospectively evaluated in 14 patients with organ-confined invasive bladder cancer. The post-treatment urodynamic findings were compared with the pretreatment ones (n = 7), and a comparison was made between the serial urodynamic findings after the treatment in another seven patients who were able to undergo the pretreatment urodynamic study (UDS). RESULTS: The median follow-up period up to the latest UDS was 34 months. Of the 14 patients, the latest UDS revealed some storage dysfunctions in 11 (79%) and some emptying dysfunctions in three (23%). Uninhibited detrusor contraction and decreased bladder compliance were recorded in 29 and 43% at the pretreatment UDS and approximately 50-60 and 20-60% in the serial follow-up studies, respectively (n = 7). Impaired detrusor contractility lasted in one patient. In the seven patients without the pretreatment UDS, decreased maximum cystometric capacity and decreased compliance were recorded in approximately 50-60 and 20-60% at the serial UDS, respectively. Detrusor contractility was aggravated in one patient and completely lost in one with time. CONCLUSIONS: The urodynamic findings indicate that the bladder-sparing regimen might result in perpetuating the lower urinary tract dysfunctions due to invasive bladder cancer itself and/or transurethral surgery and might injure the infrasacral autonomic nerves and the bladder itself.

Aged↗
PubMed1992

No evidence of classical conditioning of electrodermal responses during anesthesia.

Classical conditioning of skin conductance responses was studied in 26 healthy volunteers and 31 patients who received general anesthesia (0.5 MAC isoflurane-70% nitrous oxide) for minor gynecologic surgery to determine whether there was autonomic evidence of new learning during anesthesia. In the conditioning phase, a loud noise was paired with a target word (conditioned stimulus [CS]). Conditioning was established if the CS produced conditioned responses, i.e., greater skin conductance responses than other, "filler words." In the subsequent elicitation phase, we investigated whether it was possible to elicit similar conditioned responses to the CS when it was presented without noise about 3 h later. Conditioning was established in the control group, who received no anesthesia. There were differences in response magnitudes of 0.32 and 0.27 mu siemen between responses to the CS and filler words, P less than 0.001. In contrast, there was no evidence that conditioning was established during anesthesia. In the elicitation phase, conditioned responses to the CS could be elicited in volunteers; i.e., response magnitudes were greater for the CS than other words (during the first two blocks of trials), with differences of 0.19 to 0.48 mu siemen, P less than 0.05 to P less than 0.001. In contrast, responses to the CS could not be elicited in patients after anesthesia. There was also no evidence of recognition of words that were presented during anesthesia in patients, but recognition was manifested in volunteers. Thus, in contrast to our previous demonstration of conditioning in subjects who received 30% nitrous oxide in oxygen, there was no evidence of conditioning in anesthetized patients.

Adult↗
PubMed1965

MENIERE'S DISEASE.

Explore the source record for details and available documents.

Autonomic Nerve Block↗
PubMed2001

Transthyretin-associated neuropathic amyloidosis. Pathogenesis and treatment.

Hereditary amyloidoses form a clinically and genetically heterogeneous group of autosomal dominantly inherited diseases characterized by the deposit of insoluble protein fibrils in the extracellular matrix. They typically present with polyneuropathy, carpal tunnel syndrome, autonomic insufficiency, and cardiomyopathy and gastrointestinal features, occasionally accompanied by vitreous opacities and renal insufficiency. Other phenotypes are characterized by nephropathy, gastric ulcers, cranial nerve dysfunction, and corneal lattice dystrophy. Rarely, involvement of the leptomeningeal or cerebral structures dominates the clinical picture. The age at onset is as early as 17 and as late as 78 years. The basic constituents of amyloid fibers are physiologic proteins that have become amyloidogenic through genetically determined conformation changes. Mutated transthyretin (TTR), formerly termed prealbumin, is the most frequent offender in hereditary amyloidosis. Orthotopic liver transplantation (OLT) stops the progression of the disease, which is otherwise invariably fatal, by removing the main production site of amyloidogenic protein. The indications for OLT and its success depend on the grade of cardiovascular and autonomic dysfunction at the time of surgery, age, comorbidity, and type of mutation. Alternative treatment modalities with drugs stabilizing the native tetrameric conformation of TTR and inhibiting fibril formation are currently being studied.

Age of Onset↗
PubMed1999

Acute pulmonary edema associated with placement of waist-high, custom-fit compression stockings.

Compression stockings are a safe, noninvasive treatment for patients with symptomatic orthostatic hypotension due to autonomic nervous system dysfunction. In this report, we describe a 75-year-old man who had development of pulmonary edema approximately 45 minutes after placement of compression stockings on the first postoperative day following a carotid endarterectomy. No sudden changes were noted on an electrocardiogram or echocardiogram or in the cardiac isoenzymes associated with the pulmonary edema. The patient had a history of coronary artery disease, diabetes mellitus-induced autonomic nervous system dysfunction, and recent surgery near the carotid baroreceptor. All these factors may have limited his ability to compensate for a rapid increase in central blood volume. The temporal relationship of the patient's respiratory distress to the placement of the compression stockings, in the absence of laboratory findings of primary cardiac dysfunction, make stocking-related fluid shift the likely precipitating event in the formation of acute pulmonary edema. This case suggests that compression stockings should be used with caution in patients with limited cardiac reserve.

Acute Disease↗