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PubMed1989

Intravenous nicardipine for treatment of intraoperative hypertension during abdominal surgery.

Twenty patients, American Society of Anesthesiologists class I or II, who developed intraoperative hypertension (mean arterial pressure greater than 110 mm Hg) during abdominal surgery under balanced general anesthesia were randomly assigned to two groups. The nicardipine group (n = 10) received 5 mg of nicardipine hydrochloride, and the placebo group (n = 10) received 5 mL of nicardipine solvent injected intravenously over a 5-minute period in a blind manner. Arterial pressure was recorded for 15 minutes after the injection was started. If the mean arterial pressure did not decrease at least 10% at 15 minutes, the trial was opened and patients received 5 mg of nicardipine. None of the patients in the nicardipine group received nicardipine in an open manner, in contrast with 7 of the 10 patients in the placebo group (P less than 0.03, Fisher exact test). During both the blind period and the open trial, nicardipine induced a 34% decrease in systolic, diastolic, and mean arterial pressure. Minimal values of pressure were noted at 6 minutes; however, arterial pressure remained below the pre-nicardipine injection values and near preoperative values for 45 minutes. No severe hypotension was observed, but the nicardipine injection was stopped at 3 mg in two cases during the blind period because of the rate of pressure reduction. Heart rate remained unchanged during the decrease in arterial pressure in both groups. This study indicates that nicardipine is an effective, long lasting, and safe therapy for intraoperative hypertension during abdominal surgery.

Abdomen↗
PubMed2001

Hemodynamics and emergence profile of remifentanil versus fentanyl prospectively compared in a large population of surgical patients.

STUDY OBJECTIVE: To compare the responses to, and hemodynamics associated with surgical stress, recovery profiles, and anesthesiologists' satisfaction following balanced general anesthesia using either remifentanil or fentanyl in a large-scale population. DESIGN: Prospective, 1:1 single blind, randomized, controlled effectiveness study in which patients received either remifentanil or fentanyl in combination with a hypnotic-based anesthesia regimen of either isoflurane or propofol. SETTING: Multicenter study including 156 hospitals and ambulatory surgery facilities. PATIENTS: 2,438 patients (1,496 outpatients and 942 inpatients), 18 years of age or older, scheduled for elective surgeries under general endotracheal anesthesia, with an expected duration of unconsciousness > or =30 minutes. INTERVENTIONS: Patients were randomized to receive either intravenous (IV) remifentanil (0.5 microg/kg/min for induction and intubation, with the infusion rate decreased to 0.25 microg/kg/min after intubation) or IV fentanyl (administered according to anesthesiologists' usual practice) as the opioid during surgery. Concomitant hypnotic drugs were either propofol and/or isoflurane (with or without nitrous oxide) titrated according to protocol. Transition analgesia with either morphine or fentanyl was given to the remifentanil patients and, at the anesthesiologists' discretion, in the fentanyl patients. MEASUREMENTS: Vital signs, adverse events, and emergence profiles were assessed and recorded. Recovery profile was assessed by recording time spent in the postanesthesia care unit and step-down recovery unit, number and timing of adverse events, timing and dosage of rescue medications, and time to eligibility for discharge (to home or to hospital room). Anesthesiologists' satisfaction with the anesthetic regimen was assessed at the end of surgery. MAIN RESULTS: Remifentanil-treated patients exhibited lower systolic and diastolic blood pressures (by 10-15 mmHg) and lower heart rates (by 10-15 bpm) intraoperatively compared to the fentanyl-treated patients. This difference promptly disappeared on emergence. Remifentanil-treated patients responded to verbal command, left the operating room, and (for outpatients) were discharged home sooner than fentanyl-treated patients. Anesthesiologists rated the predictability of response to intraoperative titration, assessment of hemodynamic profiles, and the quality of anesthesia higher in the remifentanil-treated patients. CONCLUSIONS: This study confirms previous observations on the hemodynamic properties associated with remifentanil and extends these to a wider context than previously reported. These characteristics provide clinicians with an alternative in opioid-based anesthesia.

Adult↗
PubMed2003

Interleukin balance and early recovery from anesthesia in elderly surgical patients exposed to beta-adrenergic antagonism.

STUDY OBJECTIVE: To determine whether proinflammatory and antiinflammatory cytokines, as measured in blood specimens, would correlate with improved SF-36 physical composite scores observed in elderly surgical patients who were administered perioperative atenolol. DESIGN: Post hoc analysis of data from a randomized clinical study. SETTING: Department of Anesthesiology, Mount Sinai Medical School, New York. PATIENTS: 59 ASA physical status II, III, and IV patients > or =65 years of age, who were scheduled for major elective noncardiac surgery. INTERVENTIONS: Patients were randomized to one of three anesthetic regimens to receive 1) perioperative management without beta-adrenergic antagonism, 2) preoperative and postoperative administration of atenolol, or 3) intraoperative atenolol as a major component of the anesthetic regimen. MEASUREMENTS AND MAIN RESULTS: Blood samples were drawn perioperatively at seven different time points. Interleukin-1 beta, interleukin-6, interleukin-1ra, and interleukin-10 were measured using enzyme-linked immunosorbent assay (ELISA) kits. Also, recovery from anesthesia and physical/mental well-being (SF-36 questionnaire) were determined perioperatively. Compared with control patients, atenolol-treated patients experienced improved postoperative physical well-being, which paralleled the previously reported faster recovery from anesthesia and a decreased need for perioperative analgesics. Improved postoperative physical well-being of atenolol-treated patients was specifically caused by an ameliorated bodily pain score, a major component of the physical composite score of the SF-36 questionnaire. The cytokine response of these elderly surgical patients was similar to that of younger patients, and the perioperative profile of proinflammatory and antiinflammatory cytokines was not affected by atenolol. CONCLUSIONS: Perioperative administration of atenolol to elderly surgical patients markedly improves physical sense of well-being, which coincides with improved postoperative pain control and decreased analgesic requirements. This improvement experienced by patients receiving atenolol is not related to alterations in perioperative cytokine response.

Adrenergic beta-Antagonists↗
PubMed1999

A comparison of the onset and clinical duration of high doses of cisatracurium and rocuronium.

STUDY OBJECTIVE: To determine the onset and clinical duration of cisatracurium and rocuronium in equipotent doses in balanced opioid/isoflurane anesthesia. DESIGN: Randomized, controlled study. SETTING: University hospital. PATIENTS: 40 healthy patients scheduled for elective surgery. INTERVENTIONS: Patients underwent anesthesia induction with thiopental or propofol with a cisatracurium intubating dose of either 0.15 or 0.2 mg/kg or a rocuronium dose of either 0.9 or 1.2 mg/kg. These doses correspond to three and four times the ED95 dose. MEASUREMENTS AND MAIN RESULTS: The onset time and time to 25% recovery of baseline first twitch in a train-of-four were determined using an accelerometric sensor. Rocuronium had a faster onset time that cisatracurium at equipotent doses (3 x ED95: 134 vs. 220 sec respectively, and at 4 x ED95: 95 vs. 162 sec). Recovery tended to be faster, but not statistically different for cisatracurium compared to rocuronium. CONCLUSIONS: With equipotent intubating doses of rocuronium and cisatracurium, rocuronium produces a more rapid onset of muscle relaxation. The data suggest a tendency toward more rapid clinical recovery of cisatracurium compared to equipotent doses of rocuronium, although these differences were not statistically significant.

Androstanols↗
PubMed2000

Pooled analysis of three large clinical trials to determine the optimal dose of dolasetron mesylate needed to prevent postoperative nausea and vomiting. The Dolasetron Prophylaxis Study Group.

STUDY OBJECTIVE: To identify the maximally effective dolasetron dose (i.e., maximum efficacy with minimum adverse events) for prevention of postoperative nausea and vomiting (PONV) using the statistical power generated in a pooled patient sample from three large, nearly identical clinical trials. DESIGN: Three randomized, multicenter, placebo-controlled, double-blinded trials. SETTING: Trials 1, 2, and 3 enrolled patients at 10, 25, and 17 hospitals and/or surgical centers, respectively. PATIENTS: A total of 1,946 ASA physical status, I, II, and III patients. Trials 1 and 2 enrolled only female patients (n = 916) undergoing gynecologic surgery. Trial three enrolled 722 females (approximately 70% gynecologic surgeries) and 308 males (approximately 46% orthopedic surgeries) undergoing a variety of surgical procedures. INTERVENTIONS: All surgical procedures used balanced general anesthesia. Patients received 12.5, 25, 50, or 100 mg of the antiemetic, dolasetron, near the end of anesthesia. MEASUREMENTS AND MAIN RESULTS: Efficacy endpoints were identical and measured for 24 hours: complete response (no vomiting or rescue medication) and maximum nausea, reported using a 100-mm visual analog scale (VAS). Safety was assessed using adverse event reports, laboratory and electrocardiographic data, and vital signs. All four dolasetron doses produced significant increases in complete response and decreases in maximum VAS nausea compared with placebo (p < 0.01). No increased efficacy was observed with dolasetron doses higher than 12.5 mg. Safety was similar between each dolasetron dose and placebo. CONCLUSION: Dolasetron 12.5 mg, given near the end of anesthesia, is the maximally effective dose studied for preventing postoperative nausea and vomiting.

Adult↗
PubMed2000

Oxygen-carrying capacity during 10 hours of hypercapnia in ventilated dogs.

OBJECTIVE: To test if a relatively long-term exogenous hypercapnia, equivalent to those maintained during permissive hypercapnia, can persistently increase oxygen-carrying capacity in ventilated dogs. DESIGN: Prospective study. SETTING: Research laboratory in a hospital. SUBJECTS: Six mongrel dogs (3 males; 3 females). INTERVENTIONS: The dogs were anesthetized (30 mg/kg pentobarbital, i.v.), intubated, and cannulated in one femoral artery, one femoral vein, and the right jugular vein. The mean arterial blood pressure, heart rate, and mean pulmonary artery pressure were continuously recorded. Anesthesia, fluid balance, and normothermia were maintained. Arterial hypercapnia was generated by the addition of 60 torr dry CO2 (8 kPa) to the inspired air for 10 hrs, continuously. All subjects were paralyzed (vecuronium bromide) and ventilated with room air, while the ventilator settings were kept constant. MEASUREMENTS AND MAIN RESULTS: Arterial and venous gas exchange profiles, hemoglobin concentration, oxygen saturation, oxygen content, cardiac output, and oxygen consumption were determined, before, during, and after 10 hrs of hypercapnia, periodically. Both hemoglobin concentration and oxygen content were gradually increased during hypercapnia and reached significant levels at 8 and 10 hrs of hypercapnia, respectively. These increases continued up to 2 hrs after termination of hypercapnia. The PaO2/FIO2, as an index of arterial oxygenation, was significantly increased during the first 3 hrs of hypercapnia and then remained at the normoxic level up to 10 hrs of hypercapnia. No significant changes occurred in the mean arterial blood pressure and oxygen consumption. The heart rate and cardiac output were significantly reduced at 4 and 8 hrs of hypercapnia, respectively. The mean pulmonary artery pressure was increased throughout the hypercapnic trial. CONCLUSIONS: A relatively long-term exogenous hypercapnia can significantly increase oxygen-carrying capacity in normal ventilated dogs. Whether this effect can occur during permissive hypercapnia because of controlled ventilation in patients warrants investigation.

Animals↗
PubMed1993

Enalapril premedication attenuates the blood pressure response to tracheal intubation and stabilizes postoperative blood pressure after controlled hypotension with sodium nitroprusside in neurovascular patients.

Oral premedication with enalapril, 0.1 mg/kg was compared with placebo in 22 patients subjected to craniotomy and ligation of an intracranial aneurysm or extirpation of an arteriovenous malformation. Balanced hypotensive anesthesia was used with sodium nitroprusside (SNP) as the main hypotensive agent. The hypertensive response to laryngoscopy and tracheal intubation was significantly attenuated by enalapril (p = 0.020). The mean blood pressure was lower and more stable in the intensive care unit after enalapril than after placebo (p = 0.044). The median SNP dose rate tended to be lower in the enalapril-pretreated patients [0.6 (range of 0-3.5) micrograms/kg/min] compared to the placebo group [1.4 (0.4-5.8) micrograms/kg/min] (p = 0.12). Concentrations of plasma catecholamines, vasopressin, and endothelin as well as serum osmolality, arterial blood gases, and plasma electrolytes and level of consciousness were repeatedly measured. Enalapril had no significant effects on these variables. Plasma renin activity was increased and serum angiotensin converting enzyme (ACE) activity was reduced in the expected manner by enalapril. We found premedication with an ACE inhibitor favorable for hypotensive anesthesia in neurovascular patients as assessed by the circulatory responses.

Administration, Oral↗
PubMed2007

Giant intracranial aneurysms treated with deep hypothermia and circulatory arrest.

The use of deep hypothermic circulatory arrest (DHCA), using groin cannulation with the chest closed (CCDHCA), has improved the surgical treatment of large and giant cerebral aneurysms. Twelve consecutive ASA I-II patients (10 women and 2 men), with a mean age of 35 years (range 14 to 55 y) underwent DHCA for clipping or trapping of their aneurysm (giant, n=10; large, n=2; 42% posterior circulation), under balanced general anesthesia. Intraoperative standard monitors were completed with jugular oxygen saturation, pulmonary artery, pulmonary artery occlusion, central venous pressures, electroencephalography, evoked potentials, and cerebral (subdural), and core temperature. At the start of circulatory arrest, brain temperature was 15.1+/-1.1 degrees C (range 13.5 to 17.5), and core temperature 14.1+/-1.1 degrees C (range 12.7 to 17.0). Mean circulatory arrest time was 26.5+/-13.9 minutes (range 9 to 54) and anesthesia lasted 14+/-1 hours. Only one patient underwent DHCA with standard sternotomy, because of aortic insufficiency. Follow-up (up to 70 mo) revealed no deaths and Glasgow Outcome Scale at 6 months revealed good recovery in 9, moderate disability in 1, and severe disability in 2 patients. Selected patients with large/giant intracranial aneurysms, deemed unapproachable by conventional surgical techniques, were successfully treated using CCDHCA. Mortality rate was 0% and neurologic complications occurred in 25% of the patients.

Adolescent↗
PubMed2005

Transfusion requirements during cadaveric and living donor pediatric liver transplantation.

Surgical techniques that have been used during liver transplantation (LT) together with patient's coagulation profile and institutional practices are reported to have an effect on transfusion requirements. The aim of this study is to evaluate the transfusion requirement in both cadaveric (CDLT, n = 22) and living donor (LDLT, n = 24) pediatric LT performed in our institution. Balanced general anesthesia was used for all patients. Transfusion requirements were met to maintain a hemoglobin concentration of 8-10 g/dL, platelet level >50 x 10(3)/mL, prothrombin time <20 s and hemodynamic course with observing heart rate, arterial and central venous blood pressures and hourly urine output. Blood loss was replaced by using whole blood. Both groups' perioperative total blood and fresh-frozen plasma (FFP) volumes transfused, fluid requirements and hemodynamic courses, standard coagulation profile and metabolic variables determined in time periods of operations, patients' preoperative characteristics, operative features and postoperative events were compared. The mean transfusion requirements were 37.1 +/- 33.4 and 74.8 +/- 90.8 mL/kg of whole blood (p = 0.059) and 34.5 +/- 24.9 and 51.5 +/- 59.7 mL/kg of FFP for CDLT and LDLT, respectively (p = 0.519). The mean ages and mean body weights of the CDLT patients were higher than LDLT patients (9.7 +/- 5.3 vs. 6.6 +/- 4.4 yr, p = 0.015 and 32.4 +/- 17.7 vs. 21.0 +/- 14.8 kg, p = 0.032, respectively) while the mean operation time (493 +/- 135 vs. 323 +/- 93 min, p = 0.0001) and PELD score (13.1 +/- 11.2 vs. 20.1 +/- 11.8, p = 0.036) were higher for LDLT. In the entire population, multiple regression analysis showed that age, body weight and operation time have a significant combined effect on blood consumption (r2= 0.29, p = 0.003) meanwhile operation time was found to be an effective single variable (p = 0.002). None of the single or combined variables was found to have a significant effect on FFP consumption (r2= 0.17, p = 0.63) and crystalloid use (r2= 0.19, p = 0.11). Hemodynamic courses of both groups were similar. The incidences of metabolic acidosis and hypothermia during the anhepatic periods were higher in the CDLT group (p < 0.05). However, transfusion requirement in the ICU were higher in LDLT group [6.9 +/- 2.2 (n = 6) vs. 18.6 +/- 19 (n = 11) mL/kg, p < 0.05] after LT. As a result of this study in a pediatric patient population, no statistical significance was found in whole blood transfusion and FFP requirements between CDLT and LDLT. Duration of the operation was the primary factor effecting transfusion volume showing the importance of continued small volume losses during uncomplicated LT in this small sized patient population. Transfusion need for pediatric LT should be individualized for each patient based on the intraoperative conditions including surgical and patient features.

Biliary Atresia↗
PubMed2001

Anesthetic management for coronary bypass patients on hemodialysis: report of 4 patients.

We reported our own experience in four patients with chronic renal failure on maintenance hemodialysis undergoing coronary artery bypass graft surgery (CABGS). A balanced general anesthesia with endotracheal intubation was successfully achieved by using midazolam, atracurium, fentanyl, pentothal, nitrous oxide in oxygen and isoflurane. All patients were hemodialyzed within 24 hours before operation. One patient started peritoneal dialysis 10 hours after surgery. Three other patients were managed by hemodialysis the day after surgery. There was no hospital mortality. Many aspects of management of these patients which differ from those of routine cardiac surgical patients are outlined and discussed.

Aged↗
PubMed2002

Awareness under general anesthesia.

OBJECTIVE: To determine the occurrence and associated factors of awareness in the patients undergoing elective surgery under general anesthesia. METHODS: A prospective cohort study of 802 patients, scheduled for elective general and gynecological surgery under endotracheal anesthesia was performed at Siriraj Hospital. Balanced general endotracheal anesthesia was performed as routine practice. Standard monitoring and clinical observation for movement, tear, sweat, and eye-lid opening were obtained. They were interviewed during the first 12 hours after a surgical completion. If the patient was suspected to have awareness, then a second interview was performed on postoperative day 3. RESULTS: The ages of the study population were 16-84 years. There were 659 females and 143 males. Awareness was found in 5 patients (3 females, 2 males) as an occurrence of 0.62 per cent. The only positive clinical observation found was hand movement. The cause of awareness should be inadequate anesthesia. Apart from that, data gathered from interviews with the group who had no awareness (797 patients), the last thing they could remember before unconsciousness was auditory perception. Also hearing someone calling was the first thing upon awakening. Most of the patients did not dream during anesthesia. No serious psychological disorder occurred. CONCLUSION: The occurrence of awareness was 0.62 per cent in the patients undergoing surgery under anesthesia. Inadequate anesthesia was the most likely cause of awareness. No postoperative sequelae of awareness occurred.

Adolescent↗
PubMed2003

[Polyuria as postoperative complication of frontal meningioma].

We report the case of a 56-year-old man with a frontal meningioma who underwent scheduled surgery under balanced general anesthesia without complications and was then transferred to the intensive care postoperative recovery unit for observation. On the day of admission he developed polyuria and a decrease in central venous pressure. Plasma sodium and osmolarity were in the normal ranges but urine analysis showed hyponatremia and hypo-osmolarity, suggesting cerebral salt wasting syndrome. Physiological saline solution was infused to maintain osmolarity and plasma concentrations of sodium within normal ranges. Diuresis peaked on the sixth day after surgery at 17,600 mL in 24 hours and decreased gradually to normal on the eleventh day after admission. Elevated plasma concentrations of atrial natriuretic peptides confirmed the diagnosis. Correct management is essential when neurosurgery patients develop altered plasma and urinary sodium concentrations and osmolarity. Differential diagnosis involves considering diabetes insipidus, inappropriate secretion of antidiuretic hormone and salt wasting syndrome. Transfer to an intensive care postoperative recovery unit and early treatment are important for lowering the risk of complications and death.

Frontal Lobe↗
PubMedDate not supplied

[Nasotracheal fiberoptic intubation under remifentanil for sedation and analgesia in a boy with a difficult airway due to giant gingival hypertrophy].

A 9-year-old boy diagnosed with gingival hypertrophy and with a history of West syndrome and associated low platelet levels underwent gingival reduction surgery. Because difficult intubation was foreseen, the fiberoptic tube was inserted through the nose with the patient breathing spontaneously under remifentanil for sedation and analgesia. The procedure was carried out under balanced general anesthesia and with standard monitoring. At the end of gingivectomy, a tracheostomy was performed and the patient was transferred to the pediatric intensive care unit for postoperative observation.

Airway Obstruction↗
PubMedDate not supplied

Measurement of femoral head microcirculation by laser Doppler flowmetry.

Perfusion of the capital femoral epiphysis was measured by laser Doppler flowmetry (LDF) in a series of skeletally immature pigs. After induction of balanced general anesthesia, selective occlusion of the arterial blood supply to the hip was performed with continuous monitoring by a laser Doppler probe applied to the articular surface of the femoral head. The lateral femoral circumflex artery, a main branch of the superficial femoral artery in the pig, was largely responsible for femoral head perfusion in eight of nine pigs, according to LDF measurements. This finding was confirmed by postmortem silicone rubber injections and Spalteholz preparations of the femoral heads.

Animals↗
PubMed1991

[Postoperative analgesia following spondylodesis using a peridural catheter placed during surgery. Results of a pilot study].

For the treatment of postoperative (p.o.) pain following vertebral surgery, systemic analgesics are frequently used in high doses with a variety of side effects. It was the aim of this study to investigate p.o. epidural catheter analgesia in 20 patients following surgical correction of scoliosis using the Cotrel and Dubousset technique. METHODS. The patients received balanced general anesthesia with fentanyl and isoflurane. At the end of the operation, before closing the fascia, an epidural catheter was placed by the orthopedic surgeon. After extubation and following evaluation of the motor function of all extremities. 6-10 ml bupivacaine 0.25% was injected into the epidural catheter followed by continuous administration of 0.25% bupivacaine 4-8 ml/h. Analgesic level and hemodynamic parameters were monitored. Pain was measured by the visual analogue scale. If analgesia was not sufficient, the patients received tramadol or piritramide intravenously. RESULTS. In 11 of 20 patients epidural analgesia was rated adequate; 5 needed additional systemic analgesics, and in 4 effective analgesia was not achieved with either epidural analgesia or systemic opioids. No complications were observed. DISCUSSION. The pilot study documented that epidural analgesia using an intraoperatively placed epidural catheter can be used for p.o. pain relief after vertebral surgery using the Cotrel and Dubousset technique. Additional studies will compare the method described to other pain-relieving procedures.

Adolescent↗
PubMed1995

[Postoperative analgesia in herniated disk surgery. Comparative study of diclofenac , lysine acetylsalicylate, and ketorolac].

INTRODUCTION: Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating musculoskeletal pain and are theoretically ideal for treating postoperative pain of the lumbar column. OBJECTIVES: To compare the analgesic efficacy and side effects of treatment with 3 NSAIDs (lysine acetylsalicylate, ketorolac and diclofenac) in the treatment of pain after surgery for lumbar disc hernia. PATIENTS AND METHODS: We enrolled 75 ASA I-II patients undergoing discectomy because of lumbar disc hernia; balanced general anesthesia was used in all cases. The patients were randomly distributed in 3 groups based on type of analgesia given in the immediate postoperative period. Group A received lysine acetylsalicylate (1800 mg), group B received ketorolac (30 mg) and group C received diclofenac (75 mg). The analgesics were diluted in 100 mg of saline solution and administered through a peripheral vein over 10 min. We evaluated the analgesia attained on a visual analog scale (VAS) and the physiological response to pain was assessed by monitoring changes in arterial pressure, heart rate and breathing frequency. If analgesia was insufficient 30 min after administration of the drug, 200 mg of lysine cloximate was given as a top-up. The side effects of each drug were also recorded. RESULTS: VAS evaluation showed significant reductions in pain 60 min after administration in groups A and B and after 120 min in group C. Nine patients in each group required lysine cloximate. There were no significant differences in physiological response among the 3 groups. No patient suffered major side effects. Mild side effects were reported most often in group B. CONCLUSIONS: The NSAIDs studied were inadequately for treating pain after surgery for lumbar disc hernia. Ketorolac was no better than the other analgesics studied but was associated with a higher number of mild side effects.

Adult↗