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PubMed1992

[Peroperative cholangiography during laparoscopic cholecystectomy].

The aim of this study was to assess the ease and the success of a laparoscopic technique of cholangiography. Following an initial period of training to gain expertise in laparoscopic surgery, 70 patients were included in the study. Six of them had a history of suggestive choledocholithiasis. Intraoperative cholangiography was performed using an angled catheter (Judkins) and a specific tubular cannula (Olsen, Storz) designed to guide and maintain the catheter in the cystic duct. Catheterization of the cystic duct and cholangiography were achieved in 61 patients. In 3 cases, stones were found in the common bile duct. The mean duration of the examination was 11 minutes (6.21). Cholecystectomy was performed after cholangiography. No biliary injuries were observed. These results show that intraoperative laparoscopic cholangiography is easy and not time-consuming. It obviates the need for preoperative investigations looking for biliary stones and provides an excellent definition of the biliary anatomy for safety purposes.

Cholangiography↗
PubMed2004

Liver tissue partial pressure of oxygen and carbon dioxide during partial hepatectomy.

BACKGROUND: Data on tissue oxygen partial pressure (PtO2) and carbon dioxide partial pressure (PtCO2) in human liver tissue are limited. We set out to measure changes in liver PtO2 and PtCO2 during changes in ventilation and a 10 min period of ischaemia in patients undergoing liver resection using a multiple sensor (Paratrend Diametrics Medical Ltd, High Wycombe, UK). METHODS: Liver tissue oxygenation was measured in anaesthetized patients undergoing liver resection using a sensor inserted under the liver capsule. PtO2 and PtCO2 were recorded with FIO2 values of 0.3 and 1.0, at end-tidal carbon dioxide partial pressures of 3.5 and 4.5 kPa and 10 min after the onset of liver ischaemia (Pringle manoeuvre). RESULTS: Data are expressed as median (interquartile range). Increasing the FIO2 from 0.3 to 1.0 resulted in the PtO2 changing from 4.1 (2.6-5.4) to 4.6 (3.8-5.2) kPa, but this was not significant. During the 10 min period of ischaemia PtCO2 increased significantly (P<0.05) from 6.7 (5.8-7.0) to 11.5 (9.7-15.3) kPa and PtO2 decreased, but not significantly, from 4.3 (3.5-12.0) to 3.3 (0.9-4.1) kPa. CONCLUSION: PtO2 and PtCO2 were measured directly using a Paratrend sensor in human liver tissue. During anaesthesia, changes in ventilation and liver blood flow caused predictable changes in PtCO2.

Anesthesia, General↗
PubMed1987

The effect of intracameral carbachol on intraocular pressure after cataract extraction.

We randomly assigned 44 patients undergoing extracapsular cataract extraction and posterior chamber lens implantation to two equal groups. The treatment group received intracameral carbachol during the operative procedure, and the control group received only balanced salt solution. Intraocular pressures were measured preoperatively, and at three, six, nine, and 24 hours postoperatively. Preoperatively, the mean pressures in the two groups were not significantly different. Three hours postoperatively, the mean pressure in the control group was 3.9 mm Hg above the preoperative baseline, whereas in the treatment group the mean pressure was 3.1 mm Hg below the baseline. This difference was statistically significant (P = .002). Similar differences between the two groups persisted throughout the study period.

Aged↗
PubMed1990

Transhepatic sampling during experimental porcine liver autotransplantation--its application to measurements of insulin, glucagon, and glucose.

Controversy still exists in the published literature about the need for administration of intravenous glucose during liver transplantation. The ability of the grafted liver to metabolize insulin and glucagon and the appropriateness of secretion of these hormones are addressed in the present study. Two groups of pigs received unstored liver autografts, one with free infusion of 10% glucose and the other with limited infusion of 2.5% glucose solution, while attempting to maintain plasma glucose levels less than 200 mg/100 ml. In these animals, irrespective of moderate or major hyperglycemia, serum insulin levels were appropriate for blood glucose concentrations. However, in both groups, plasma glucagon levels rose three- to fourfold more than preoperative values and were inappropriate. Although facilities for measurement of blood flow were not available, application of the technique of transhepatic sampling has revealed that hepatic handling of insulin seems to be unimpaired after autograft with limited ischemia. Pancreatic secretion of glucagon, however, appeared to increase during the period immediately after revascularization. It is suggested that transhepatic sampling methods may be used in experimental transplantation to elucidate the effects of storage for prolonged periods.

Animals↗
PubMed1990

Intra-operative epidural blockade with local anaesthetics and postoperative protein breakdown associated with hip surgery in elderly patients.

The effect of epidural anaesthesia of limited duration on postoperative protein breakdown was studied in elderly patients undergoing hip arthroplasty. Two groups of six patients each were studied. One group with halothane (C) and one with an epidural block, T8-S4, (E) as part of their general anaesthetic for surgery. The urinary excretion of urea nitrogen and 3-methylhistidine (3-MeH), an indicator of muscle protein breakdown, increased significantly in both groups after surgery, by the same amount (P less than 0.05). The total concentration of plasma and muscle aminoacids decreased after surgery in both groups. Muscle glutamine was decreased by 50% after surgery on the fourth postoperative day in both groups (P less than 0.05). Therefore epidural anaesthesia, limited to the period of surgery, did not attenuate the loss of body proteins which occurred during the postoperative period.

Aged↗
PubMed1980

[Chlormetiazole in anaesthesia (author's transl)].

The use of a vitamin derivate (chlormethiazole) in anaesthesia. Owing to its hypnotic properties and its wide margin of safety, "chlormethiazole" (a derivate of vitamin B1) was used in 30 patients which underwent varying surgical procedures. Since the drug exhibits no analgetic effect, fentanyl was added to maintain a sufficient depth of anesthesia. The patients were artificially ventilated with N2O/O2 at a rate of 3/1. Chlormethiazole, even when used in large doses (2400 mg) over a long period of time (5 hours was well tolerated. The technique therefore offers another opportunity to replace droperidol in classical neuroleptanaesthesia, which is often the cause for uncomfortable neurovegetative side-effects in the post-operative period.

Adolescent↗
PubMed2002

Morphologic changes in the upper airway of children during awakening from propofol administration.

BACKGROUND: The purpose of this study was to determine the morphologic changes that occur in the upper airway of children during awakening from propofol sedation. METHODS: Children undergoing magnetic resonance imaging of the head underwent additional scans of the upper airway during deep sedation with propofol; this was repeated on awakening. Axial views were obtained at the most posterior sites of the pharynx at the levels of the soft palate and tongue. Measurements were then obtained of the anterior-posterior (A-P) diameter, transverse diameter, and cross-sectional areas at these levels. RESULTS: Data were obtained on 16 children, aged 10 months to 7 yr. In both sedated and awakening states, most children had the smallest cross-sectional area of the pharynx at the level of the soft palate. During the sedated state, at the soft palate level, the transverse diameter was most narrow in 11 children, the A-P diameter was most narrow in 1 child, and they were equal in 2 children. During the sedated state, at the level of the tongue, the transverse diameter was most narrow in 9 children, the A-P diameter was most narrow in 5 children, and they were equal in 2 children. During awakening, at the soft palate level, the transverse diameter was most narrow in none of the children, the A-P diameter was most narrow in 13 children, and they were equal in 1 child. At the level of the tongue, the transverse diameter was most narrow in 4 children, and the A-P diameter was most narrow in 12 children. During awakening, the A-P diameter of the pharynx at the level of the soft palate decreased in 12 children, increased in 1 child, and remained the same in 1 child. (P < 0.001). The transverse diameter increased in 11 children, decreased in 1 child, and remained the same in 2 children (P = 0.001). The cross-sectional area at the level of the soft palate increased in 4 children, decreased in 8 children, and stayed the same in 2 children (P = 0.5). During awakening, the A-P diameter of the pharynx at the level of the tongue decreased in 11 children, increased in 4 children, and remained the same in 1 child. (P = 0.01). The transverse diameter increased in 11 children and decreased in 5 children (P = 0.07). The cross-sectional area at the level of the tongue increased in 7 children, decreased in 7 children, and stayed the same in 2 children (P = 0.9). CONCLUSIONS: The dimensions of the upper airways of children change shape significantly on awakening from propofol sedation. When sedated, the upper airway is oblong shaped, with the A-P diameter larger than the transverse diameter. On awakening, the shape of the upper airway in most children changed such that the transverse diameter was larger. Cross-sectional areas between sedated and awakening states were unchanged. These changes may reflect the differential effects of propofol on upper airway musculature during awakening.

Anesthesia Recovery Period↗
PubMed1987

Alfentanil infusions. Comparison of bolus administration of fentanyl with three alfentanil infusion regimens.

Three different dosage regimens of alfentanil were compared with boluses of fentanyl in 80 patients who underwent a variety of surgical procedures. Alfentanil given by infusion at a rate of 7.5 micrograms/kg/minute for 10 minutes followed by 0.75 micrograms/kg/minute, was shown to provide a stable anesthetic which minimises the use of a volatile agent for surgery that lasts more than 45 minutes.

Adolescent↗
PubMed1994

Changes in circulating levels of atrial natriuretic factor (ANF) during orthotopic liver transplantation in humans.

Atrial natriuretic factor (ANF) is a 28 amino acid peptide secreted by the atrial cardiocytes. Clearance is via the lung (50%) and the liver (25%). The main stimulus to ANF secretion is atrial distension but vasoconstrictors, sympathetic stimulation, catecolamines and tachycardia are able to enhance its circulating blood levels. ANF blood concentrations were measured during orthotopic liver transplantation in six postnecrotic cirrhotic patients. Significant increases in ANF blood levels occurred at the end of the anhepatic phase (P < or = 0.02 vs baseline) associated with low cardiac filling pressures (P < or = 0.02 vs baseline) and increased systemic vascular resistances (P < or = 0.02 vs preanhepatic phase). Aldosterone blood levels showed a similar behaviour, increasing significantly (P > or = 0.001 vs baseline) at the end of the anhepatic phase. ANF fell after reperfusion of the graft and returned towards baseline values at the end of the procedure. Since most of the total body clearance of ANF is performed by the lungs, its sharp increase at the end of the anhepatic phase could be considered a counterregulatory response to vasoconstricting stimulation and to fluid-sparing mechanisms in the presence of relative hypovolaemia. Its decrease after reperfusion could be related to volume normalization and partly to the enhanced clearance performed by the newly grafted liver.

Adult↗
PubMed1991

Superior vena cava and central venous reconstruction.

Partial or complete obstruction of the superior vena cava and its major tributaries occassionally results in incapacitating venous hypertension of the upper extremities and/or head and neck. Factors intrinsic and extrinsic to the central veins play a role in the pathogenesis. The more common causes include mechanically and chemically induced intimal injury with resultant fibrosis, sclerosis, or thrombosis and neoplastic masses with external compression or direct extension in the central venous structures. Medical therapy is indicated in the acute situation and generally allows the time necessary for development of collateral drainage routes. Persistent or progressive symptomatic venous hypertension develops in 5% to 40% of these patients, and approximately 10% of the patients will remain incapacitated. Presented here is a series of 10 patients who underwent reconstruction of the superior vena cava or central veins for incapacitating venous hypertension of the upper extremities and/or head and neck. Reconstruction was accomplished by venous transposition (three patients), externally reinforced ePTFE (six patients), and reversed saphenous vein graft (one patient). No perioperative deaths occurred; however, two late deaths occurred at 3 and 9 months after reconstruction from causes unrelated to the operative procedure. One patient experienced early postoperative graft thrombosis requiring thrombectomy, after which the graft remained patent. All patients had patent grafts and were asymptomatic with respect to their venous disease at the time of preparation of this manuscript, with a mean follow-up period of 30 months. Specific details concerning these 10 cases are discussed and integrated with a focused review of the literature and the historic development of the intraoperative techniques and postoperative care that facilitate the successful management of patients with symptomatic central venous occlusion.

Blood Vessel Prosthesis↗
PubMed2000

Aortic dissections complicating open cardiac surgery: report of three cases.

Between June 1991 and February 1999, three patients suffered ascending aortic dissection as a complication of cardiopulmonary bypass operations with aortic cannulation at our hospital. The dissection occurred during the operation in two of the three patients and several months after the operation in one. Among a total of 2207 cardiac operations performed during this period, the incidence of perioperative ascending aortic dissection was 0.14%. In addition to visual inspection and palpation, either epicardial or transesophageal echocardiography proved extremely useful for establishing an intraoperative diagnosis of ascending aortic dissection as a complication of open cardiac operation. One of the three patients underwent closed plication but subsequently died of vital organ ischemia. In this case, failure of reapproximation of the injured intima by closed plication might have led to extension of the dissection. Despite prolonged cardiopulmonary bypass and myocardial ischemic time, graft replacement of the ascending aorta was successfully carried out in the other two patients. Thus, we believe that graft replacement of the ascending aorta should be performed for patients with extensive aortic dissection complicating an open cardiac operation.

Aged↗
PubMed2006

Emergence delirium in adults in the post-anaesthesia care unit.

BACKGROUND: Emergence delirium in the post-anaesthesia care unit (PACU) is poorly understood. The goal of this prospective study was to determine frequency and risk factors of emergence delirium in adults after general anaesthesia. METHODS: In this prospective study, 1,359 consecutive patients were included. Contextual risk factors and occurrence of delirium according to the Riker sedation scale were documented. Groups were defined for the analysis according to the occurrence or not of agitation, then after exclusion of patients with preoperative anxiety and neuroleptics, or both, and antidepressants or benzodiazepines treatments. RESULTS: Sixty-four (4.7%) patients developed delirium in the PACU, which can go from thrashing to violent behaviour and removal of tubes and catheters. Preoperative anxiety was not found to be a risk factor. Preoperative medication by benzodiazepines (OR=1.910, 95% CI=1.101-3.315, P=0.021), breast surgery (OR=5.190, 95% CI=1.422-18.947, P=0.013), abdominal surgery (OR=3.206, 95% CI=1.262-8.143, P=0.014), and long duration of surgery increased the risk of delirium (OR=1.005, 95% CI=1.002-1.008, P=0.001), while a previous history of illness and long-term treatment by antidepressants decreased the risk (respectively, OR=0.544, 95% CI=0.315-0.939, P=0.029 and OR=0.245, 95% CI=0.084-0.710, P=0.010). CONCLUSIONS: Preoperative benzodiazepines, breast and abdominal surgery and surgery of long duration are risk factors for emergence delirium.

Abdomen↗
PubMed2006

Propofol/remifentanil vs sevoflurane/remifentanil for long lasting surgical procedures: a randomised controlled trial.

We compared the haemodynamics, emergence and recovery characteristics of total intravenous anaesthesia using propofol/remifentanil with sevoflurane/remifentanil anaesthesia, under bispectral index guidance, in 103 patients undergoing surgical procedures lasting > 3.5 h. Time to tracheal extubation was significantly shorter in the propofol group than in the sevoflurane group (mean (SD) 8.3 (3.5) min vs 10.8 (4.6) min, respectively; p = 0.0024), but further recovery was comparable in both groups. There were no significant differences in haemodynamic parameters, intensity of pain or postoperative nausea and vomiting. During and after anaesthesia of comparable depth for long lasting surgical procedures, both propofol/remifentanil and sevoflurane/remifentanil enable haemodynamic stability and fast emergence. The shorter time to extubation in the propofol group does not offer a relevant clinical advantage.

Abdomen↗
PubMed1983

Catecholamine responses during anaesthesia for phaeochromocytoma.

Plasma catecholamine concentrations were measured, at frequent intervals, in a 40-yr-old female patient undergoing resection of a phaeochromocytoma under enflurane anaesthesia. Measurements before operation revealed that the tumour secreted predominantly noradrenaline and during surgery the plasma concentration of the hormone increased markedly (180 pmol ml-1; normal range 1.5-3.0 pmol ml-1). Plasma adrenaline concentrations increased markedly only at endotracheal intubation and in the period immediately after operation.

Adrenal Gland Neoplasms↗
PubMed1988

Bladder temperature as an estimate of body temperature during cardiopulmonary bypass.

Bladder temperature measured by a thermistor-tipped urinary catheter, was compared to oesophageal, nasopharyngeal, rectal and cutaneous temperatures in 33 patients during cardiopulmonary bypass. The bladder site was warmer than all other monitored sites in the pre-bypass period and showed least variation in temperature. The rate of change of bladder temperature during cooling and rewarming on bypass was significantly (p less than 0.01) lower than for oesophageal and nasopharyngeal temperatures, but was greater than or similar to the rate of change of rectal and cutaneous temperatures. This method of temperature measurement was found to be satisfactory during major surgery and also during the postoperative period in the intensive care unit.

Body Temperature↗
PubMed1985

Hemodynamic and anesthetic effects of sufentanil as the sole anesthetic for pediatric cardiovascular surgery.

The efficacy, safety, and hemodynamic response to 5 micrograms/kg, 10 micrograms/kg, or 20 micrograms/kg of sufentanil and 0.1 mg/kg pancuronium was evaluated in children between 4 and 12 years of age scheduled for open heart surgery. Systolic time intervals, 2-D echocardiograms, systolic blood pressures (SBP), diastolic blood pressures (DBP), and heart rates (HR) were recorded before and after induction of anesthesia. Significant changes 10 min following induction of anesthesia but before intubation included increases in SBP in the 5 micrograms/kg group (P less than 0.01) and in the ratio of preejection period to left ventricular ejection time in the 20 micrograms/kg group (P less than 0.05). Instances of myoclonic jerking and coughing episodes were observed in all three study groups. Following intubation there were significant (P less than 0.05) increases in SBP in all groups, in DBP in the 5 micrograms/kg group, and in HR in the 5 micrograms/kg and 10 micrograms/kg groups. Smaller increases in SBP, DBP, and HR were seen in all groups after skin incision and sternotomy. Mean plasma catecholamine levels showed nonsignificant increases following periods of intraoperative stimulation with wide patient variations. Recovery of responsiveness to command occurred in all groups within one hour from the end of surgery but extubation was impeded by shallow periodic breathing and hypercapnea. The authors conclude that for children undergoing open heart surgery use of sufentanil as a sole anesthetic in bolus form did not provide a reliable depth of anesthesia with any of the induction doses studied.

Anesthesia, Intravenous↗
PubMed1997

Hemodynamic changes during laparoscopic cholecystectomy in patients with severe cardiac disease.

STUDY OBJECTIVE: To evaluate the hemodynamic changes and need for pharmacologic interventions during laparoscopic cholecystectomy in patients with severe cardiac dysfunction. DESIGN: Prospective open study. SETTING: University hospital. PATIENTS: 17 ASA physical status III and IV patients with severe cardiac dysfunction undergoing elective laparoscopic cholecystectomy. INTERVENTIONS: A standardized general anesthetic and surgical technique was used for all patients. In addition to routine monitoring, invasive hemodynamic monitoring included radial and pulmonary artery (PA) cannulation. MEASUREMENTS AND MAIN RESULTS: Hemodynamic parameters were recorded prior to induction of anesthesia, 5 minutes after induction of anesthesia but prior to incision, 5 minutes after carbon dioxide (CO2) insufflation and head-up tilt, every 10 minutes after change of position, after deflation of the abdomen and return to supine position, and 10 minutes after attaining supine position. Need for any pharmacologic interventions [to maintain mean arterial pressure (MAP) < 100 mmHg and/or systemic vascular resistance (SVR) < 2,000 dynes sec/cm-5, and/or cardiac index (CI) > 1.5 L/min/m2] and the incidence of any myocardial morbidity and mortality was noted. CI decreased significantly (p < 0.05) following insufflation and remained low until exsufflation. MAP, SVR, and PA occlusion pressure increased significantly (p < 0.05) after CO2 insufflation. Three of the 17 patients required administration of nitroglycerin to maintain the MAP and SVR within the accepted limits, one of whom also required administration of dobutamine to maintain CI. There was no myocardial morbidity or mortality in the perioperative period. CONCLUSION: Laparoscopic cholecystectomy in patients with severe cardiac dysfunction results in significant hemodynamic changes.

Adult↗