Bilateral intercostal block for abdominal surgery. (A reappraisal).
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Abdomen↗
SEARCH · PubMed Health
Results for “Autonomous surgery”
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[Evaluation of a total ophthalmoplegia by damage of the ciliary ganglion in connection with ethmoid bone surgery].
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Ciliary Body↗
[The operative treatment of Raynaud's disease by thoracic preganglionic sympathectomy].
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Ganglia, Autonomic↗
The aging process: anesthetic implications.
Recent improvement in our understanding of the physiology and pharmacology of aging has occurred in large part because investigators have been able to separate the effects of aging from the consequences of age-related disease. As a group, elderly patients are at increased risk of perioperative morbidity and mortality because of the high incidence of coexisting age-related disease. Even in the absence of chronic disease, organ function remains adequate to meet the basal metabolic requirements of older adults, but the functional reserve and maximal capacity of all major organ systems are significantly reduced and may not meet the increased demands associated with acute illness surgery. Increased rate and severity of perioperative complications may specifically reflect decreased autonomic homeostasis, impaired immune functions, and reduced aerobic capacity to tolerate or compensate for imposed pathology or surgical stress. Age-related chronic disease and, to a lesser extent, progressive erosion of functional capacity explain the increase in perioperative complications seen in an elderly surgical patient population. Therefore, optimal anesthetic management of elderly patients requires adequate diagnosis and treatment of concurrent diseases, meticulous attention to the details of preparation and positioning, and use of monitoring techniques that permit adjustments of drug dosage appropriate for their altered requirements for anesthetic and adjuvant drugs.
Acute Disease↗
[The outcome of the postoperative radiotherapy of autonomic nerve preserving operation for lower rectal cancer].
PURPOSE: It is unclear whether adjuvant radiotherapy before or after surgery is effective for locally advanced, resectable lower rectal cancer. This study consists of a prospective randomized trial of postoperative radiotherapy for locally advanced curatively resected lower rectal carcinoma. METHODS: We divided patients into two groups, one with postoperative 50 Gy radiation therapy to pelvic wall (N = 64), and the other with no radiation therapy (N = 46). RESULTS: The 5 year disease-free rate was 61.8% in the radiation group and 70.6% in the no radiation group. There was statistically no significant difference between these two groups. The local recurrence rate was 2.7% (radiation therapy group: 1.6%, no radiation therapy group: 4.3%). This local recurrence rate was very low. These results made us suspect that postoperative radiation therapy was not always necessary to prevent local recurrence. Postoperative complications had a higher incidence in the radiation therapy group than in the no-radiation therapy group. In the radiation therapy group, 35.5% of the patients suffered from diarrhea or frequent defecation, and 10.8% from severe abdominal pain. We operated on 4 cases of radiation-induced ileal stenosis and ileus. CONCLUSION: Postoperative radiation therapy did not help prevent local recurrence even though many complications resulted.
Aged↗
Changes in expression of autonomic nerves in aging and disease.
Mechanisms of autonomic neuroeffector transmission are summarised, including evidence for a multiplicity of transmitters, co-transmission, neuromodulation and 'chemical coding' of individual autonomic neurons, where the combination of transmitters they contain is known, as well as their projections and central connections. Changes in expression of autonomic nerves and co-transmitters that occur during development and aging, following trauma, surgery, after chronic exposure to drugs, and in a number of disease situations are described. It is suggested that in neuropathological analysis, compensatory increases in innervation should be considered as well as loss or damage to nerves. Studies of the molecular mechanisms involved in the control of co-transmitter and receptor expression are now needed.
Aging↗
Reconstruction of the sympathetic pathway projecting to the prostate, by nerve grafting in the dog.
OBJECTIVES: To examine the possibility of nerve grafting to repair the sympathetic pathway projecting to the prostate, as contraction of the prostate is known to be controlled by the sympathetic pathway via the hypogastric nerve (HGN), and injuries to the pathway cause significant disturbances in prostatic secretion. MATERIALS AND METHODS: In six dogs both of the HGNs were partly removed and immediately repaired with an autologous nerve graft. The left HGN was repaired with a colonic (autonomic) nerve graft and the right with a genitofemoral (somatic) nerve graft. Twenty months after surgery the reconstruction of the sympathetic pathway was assessed by measuring contraction of the prostate after stimulating the lumbar splanchnic nerves (LSNs). RESULTS: Nine of the 17 right LSNs stimulated elicited prostatic contractions. After transecting the left HGN five of these nine responses were restored. Seven of the 11 left LSNs stimulated elicited prostatic contractions; after transection of the left HGN four of these seven responses were preserved. CONCLUSION: The sympathetic pathways via the HGN to the canine prostate can be reconstructed by nerve grafting, regardless of the use of autonomic or somatic nerve grafts, and the cross-innervation mechanism from the LSN to the prostate can also be repaired.
Animals↗
Power spectral analysis of heart rate and blood pressure variability in lumbar epidural anaesthesia.
The purpose of this study was to evaluate autonomic nervous system activity during high and low lumbar epidural anaesthesia. Ten patients undergoing lower limb surgery with lumbar epidural anaesthesia (low epidural anaesthesia group; mean upper dermal block level, T10.7 +/- 1.1), and ten patients undergoing either abdominal total hysterectomy or inguinal hernia under lumbar epidural anaesthesia (high epidural anaesthesia group; mean upper dermal block level, T5.1 +/- 1.0). Ten healthy volunteers were used as the control group. The autonomic nervous system activity was measured by heart rate and blood pressure variability with power spectral analysis. For the analysis of heart rate variability, frequency components were divided into two factors, a low frequency component RR (LFCRR: 0.03 Hz-0.15 Hz) that mediated sympathetic and parasympathetic activity and a high frequency component RR (HFCRR: 0.15 Hz-0.4 Hz) that mediated parasympathetic activity. In the analysis of blood pressure variability, the frequency components were also divided into two factors; a low frequency component of systolic blood pressure and diastolic blood pressure (LFCSBP and LFCDBP: 0.03 Hz-0.15 Hz) that was mediated by peripheral sympathetic vasomotor activity and a higher frequency component of systolic blood pressure and diastolic blood pressure (HFCSBP and HFCDBP: 0.15 Hz-0.4 Hz) that was mediated by a mechanical consequence of respiration. There were no changes in heart rate variability during epidural anaesthesia. However, LFCSBP and LFCDBP decreased in high epidural anaesthesia (P < 0.01). On the contrary, LFCSBP increased in low epidural anaesthesia (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Assessing autonomic disturbances of hypertension in the general practitioner's office: a transtelephonic approach to spectral analysis of heart rate variability.
OBJECTIVES: Spectral analysis of heart rate variability (HRV) provides potentially useful information on autonomic disturbances of human hypertension. However, its practical use outside the clinical laboratory is largely unexplored. The aim of this study was to test the feasibility of assessing HRV from the general practitioner's (GP's) office, using a novel transtelephonic approach. DESIGN: Parallel study on two similar groups: 150 subjects (100 hypertensives and 50 normotensives) studied in our hospital clinic and compared with 150 subjects studied in an out-of-hospital practice (100 hypertensive subjects from GPs' surgeries and 50 normotensive subjects participating in a multinational company's health maintenance programme). METHODS: Spectral analysis of RR interval variability was used to assess autonomic regulation of the sino-atrial (SA) node, both at rest and during standing. For the out-of-hospital practice, strings of continuous electrocardiograms (ECGs), recorded with a microminiature instrument, were fed, off line, through standard telephone lines to our laboratory for subsequent spectral analysis. RESULTS: RR spectral profiles obtained from healthy controls or hypertensive patients examined in their GPs' surgeries were similar to those obtained in a hospital clinic, both at rest and when standing up. CONCLUSIONS: The present study shows the feasibility of using a transtelephonic approach to perform spectral analysis of heart rate variability from physicians' surgeries. This method could favour a more widespread use of autonomic assessment in the clinical management of hypertension.
Adult↗
Treatment decision-making in a group of patients with colo-rectal cancer before surgery and a one-year follow-up.
Encouraging patient participation in medical and nursing care is an active expression of respect for a person's autonomous choice. The aim of the present study was to compare preferences about the degree of participation in treatment decision-making in a group of patients with colo-rectal cancer before and one-year after surgery, and further to compare these preferences to the patients' actual participating role before surgery and their sense of coherence. Fifty-five persons diagnosed as having rectal or colon cancer were studied. The following instruments were used: The Control Preferences Scale (CPS) and the Sense of Coherence Scale (SOC). Results show that 71% and 75%, respectively, chose a collaborative participation role, before surgery and at follow-up. A majority, 64%, maintained their preferred role from before surgery to the one-year follow-up. Agreement between the preferred and the actual participating role was achieved by 31%. There were no statistically significant differences between the preferred role and with respect to the participants' sense of coherence either before surgery or at follow-up. The sense of coherence seemed not to be related to the preferences before surgery or at follow-up preferences. Further research is needed to elaborate the understanding about patients' preferences for participating in treatment and care decisions.
Adult↗
Changes in heart rate variability in elderly patients undergoing major noncardiac surgery under spinal or general anesthesia.
BACKGROUND AND OBJECTIVES: Heart rate variability (HRV), widely used as an indicator of activity of the autonomic nervous system, has been reported to decrease during and after both spinal and general anesthesia in patients without cardiovascular disease. We evaluated the changes in HRV bands in 40 patients with a high risk of ischemic heart disease. METHODS: The patients were randomly assigned to receive either spinal (SA) or general anesthesia (GA) for elective total hip arthroplasty or peripheral vascular surgery. Anesthetic techniques and perioperative fluid administration were standardized. Holter monitoring was started preoperatively and continued until the third postoperative day. Three HRV frequency bands were analyzed. RESULTS: A significant decrease was seen in very low frequency (VLF) and low frequency (LF) bands during GA but not during SA. Also the LF/high frequency (HF) ratio decreased during GA but not during SA. A decrease in all HRV frequency bands was seen after both types of anesthesia. None of the frequency bands returned back to the preoperative level during the 3-day trial. Postoperatively circadian variation was found only in the VLF band after SA. CONCLUSIONS: The sympathovagal balance (LF/HF) is more stable during SA than during GA in patients with a high risk of ischemic heart disease. The postoperative decrease in HRV bands, however, is independent of the anesthetic technique.
Aged↗
Sympathetic muscle nerve activity, peripheral blood flows, and baroreceptor reflexes in humans during propofol anesthesia and surgery.
BACKGROUND: With percutaneous recordings of muscle nerve sympathetic activity (MSA), it is possible to study interactions between the autonomic nervous system and anesthetics. This study describes the effects of propofol infusion both before and during microlaryngoscopy. METHODS: Nine patients participated. MSA was recorded, muscle and skin blood flows were measured. Sodium nitroprusside-induced decreases in blood pressure were used to quantitate baroreceptor reflex sensitivity. RESULTS: During steady state propofol anesthesia (0.1 mg.kg-1.min-1), "total MSA" (MSA burst area per minute) was 37% (P < 0.05) of awake control value; leg blood flow recorded by strain-gauge plethysmography was 227% (difference not significant); and skin blood flow recorded by laser Doppler flowmetry and finger pulse plethysmography was 300% (P < 0.05) and 376% (P < 0.05) of respective awake control values. During microlaryngoscopy, when mean arterial blood pressure was controlled as close as possible to mean arterial blood pressure in the awake state by individually adjusted propofol infusion rates (average 0.33 mg.kg-1.min-1) MSA was restored to 93% of the activity before anesthesia, and leg blood flow increased further. Both cardiac and muscle sympathetic baroreflex sensitivities were depressed by propofol. During surgery the cardiac baroreflex sensitivity decreased further, whereas the muscle sympathetic baroreflex sensitivity was unchanged. CONCLUSIONS: Propofol is a potent inhibitor of sympathetic neuronal activity and decreases the sensitivity of the baroreflex. When used to control the pressor response during surgery, the vasodilatating effect of propofol overrides the neural vasoconstriction induced by surgery, and a further inhibition of the cardiac baroreflex is observed.
Adult↗
Open surgery in VR: inguinal hernia repair according to Lichtenstein.
VREST (Virtual Reality Educational Surgical Tools) is developing a universal and autonomous simulation platform which can be used for training and assessment of medical students and for continuing education of physicians. A workstation consisting of two haptic devices and a 3D vision system is part of the VREST platform. Another part of the platform is a generic software environment in which lessons can be built by the teacher and performed by their students. Using the platform one can see, feel and decide as in reality. With the assessment tool the progress and skills of the students can be supervised. The first lesson build on the VREST platform is an inguinal hernia repair according to Lichtenstein. This is an open surgery procedure. The VREST platform is used prior to the first operating room surgery of the resident. Interactive models and case dependent feedback is used to enlarge the residents' cognition. This should reduce the training time in the operating room.
Computer Simulation↗
Postoperative pain and its management.
In recent years tremendous progress has been made in our understanding of peripheral, spinal cord and brain mechanisms involved in acute pain and in the neurophysiologic description of nociceptive pathways, receptors and mediators. Great strides have been made in our knowledge of pharmacokinetics and pharmacodynamics of drugs used to treat pain. However, in spite of unprecedented interest in pain and its management, most patients undergoing surgery still receive treatments that have changed little in the past decades. Untreated severe postoperative pain has many deleterious effects on respiration, circulation, autonomic activity, renal function and gastrointestinal activity. The technique of pain control does have a significant influence on postoperative complications particularly in high risk patients undergoing major surgery. Today we have a variety of effective modalities to control postoperative pain. These include different opioid administration techniques such as spinal opioids (epidural, intrathecal), patient controlled analgesia (i.v., subcutaneous, epidural), i.v. infusions, sublingual, oral transmucosal ("lollipop"), rectal, nasal, intra articular. Non-opioid analgesics such as non-steroidal anti-inflammatory drugs and alpha-adrenergic agents (systemic, epidural, intrathecal) are available. Various combinations of the above are also possible. However, it is increasingly recognised that the solution to the problem of inadequate pain relief on surgical wards lies not so much in the development of new drugs and new techniques but in the development of a formal organisation for better use of existing drugs and techniques. A simple, low-cost organisation model for acute pain services (APS) is described.
Adult↗
Supplementing desflurane-remifentanil anesthesia with small-dose ketamine reduces perioperative opioid analgesic requirements.
UNLABELLED: Relative large-dose intraoperative remifentanil could lead to the need for more postoperative analgesics. Intraoperative N-methyl-D-aspartate receptor antagonists, such as ketamine, decrease postoperative opioid use. We therefore tested the hypothesis that intraoperative small-dose ketamine improves postoperative analgesia after major abdominal surgery with remifentanil-based anesthesia. Fifty patients undergoing abdominal surgery under remifentanil-based anesthesia were randomly assigned to intraoperative ketamine or saline (control) supplementation. The initial ketamine dose of 0.15 mg/kg was followed by 2 microg. kg(-1). min(-1). In both groups, desflurane was kept constant at 0.5 minimum alveolar anesthetic concentration without N(2)O, and a remifentanil infusion was titrated to autonomic responses. All patients were given 0.15 mg/kg of morphine 30 min before the end of surgery. Pain scores and morphine consumption were recorded for 24 postoperative h. Less of the remifentanil was required in the Ketamine than in the Control group (P < 0.01). Pain scores were significantly larger in the Control group during the first 15 postoperative min but were subsequently similar in the two groups. The Ketamine patients required postoperative morphine later (P < 0.01) and received less morphine during the first 24 postoperative h: 46 mg (interquartile range, 34-58 mg) versus 69 mg (interquartile range, 41-87 mg, P < 0.01). No psychotomimetic symptoms were noted in either group. In conclusion, supplementing remifentanil-based anesthesia with small-dose ketamine decreases intraoperative remifentanil use and postoperative morphine consumption without increasing the incidence of side effects. Thus, intraoperative small-dose ketamine may be a useful adjuvant to intraoperative remifentanil. IMPLICATIONS: Supplementing remifentanil-based anesthesia with small-dose ketamine decreased intraoperative remifentanil use and postoperative morphine consumption. These data demonstrate that N-methyl-D-aspartate antagonists, such as ketamine, can be a useful adjuvant to intraoperative remifentanil.
Adjuvants, Anesthesia↗
Results following surgical treatment of hyperthyroidism.
In the years 1965-1978 1,222 patients with different types of thyrotoxicosis underwent surgical treatment at the 1st Department of Surgery, University of Vienna. Wherever possible a sparing selective surgical approach was considered preferable: autonomous adenoma (45%) enucleation resection or subtotal uni-lateral resection; multinodular toxic goiter (36%) and Graves disease (5%) uni- or bilateral subtotal resection. The remaining 5% were rather rare types of goiter (recurrent goiter, thyroiditis, adenocarcinoma). Overall mortality due was 0.7%. One-hundred and seven patients (8.76%) were over 70 years old at the time of the operation. Post-operative death occurred in the group of patients with toxic adenomas (2.7%). Four-hundred and ninety-five patients were followed up from 3-13 years postoperatively: the rate of recurrent thyrotoxicosis was 4.4%, 4.8% of the patients with hypothyroidism. In this paper the significance of the rapid effect of surgery in cases of hyperthyroidism is discussed and the results are compared with findings in other studies.
Female↗
Patients with diabetic neuropathy are at risk of a greater intraoperative reduction in core temperature.
BACKGROUND: Core hypothermia develops after the induction of general anesthesia, but intraoperative vasoconstriction usually prevents its progression. However, diabetes mellitus is often associated with autonomic neuropathy, which leads to abnormal peripheral neurovascular function. Accordingly, we tested the hypothesis that diabetic patients experience a greater reduction in core temperature during general anesthesia than nondiabetic patients. METHODS: We studied 36 nondiabetic patients (control group) and 27 diabetic patients (diabetic group) undergoing elective abdominal surgery. Both groups were divided into young (< 60 yr) and older age (>/= 60 yr) groups. Standard noninvasive autonomic tests (heart rate variation at deep periodical breathing, Valsalva maneuver, and head-up tilt) were carried out for each patient. The relation between the results of these tests of autonomic function and the tympanic membrane temperature during general anesthesia was assessed in relation to peripheral vasoconstriction. RESULTS: Thirteen patients in the diabetic group showed abnormal responses to two or more of the basal autonomic function tests (patients with autonomic dysfunction). Changes in core temperature among the groups were similar at 90 min after the induction of anesthesia. However, the core temperature of the diabetic patients with autonomic dysfunction was lower from 120 min (35.1 degrees C) onward compared with the young or older nondiabetic patients and the diabetic patients with normal autonomic function. Peripheral vasoconstriction, evaluated using the forearm-fingertip skin surface temperature gradient, was delayed in patients with autonomic dysfunction compared with the others. CONCLUSIONS: The current results indicate that diabetic autonomic neuropathy is associated with more severe intraoperative hypothermia. We postulate that diabetic patients become more hypothermic because their peripheral neuropathy delays the onset of thermoregulatory vasoconstriction and reduces its efficacy once triggered. These patients may therefore fail to develop a normal core temperature plateau.
Abdomen↗
[Nerve sparing radical hysterectomy in the case of cervical cancer].
Autonomous pelvic nerves are essential for bladder and rectum function as well as sexuality. These nerves are usually permanent damaged during radical oncological surgery and this results in urological, sexual and proctological morbidity. Japanese surgeons have paved the way for surgical approaches to dissect these nerves during surgery and leave them intact. At the Department of Gynaecology of the Leiden University Medical Center, the Netherlands, a new surgical technique has been developed to spare the autonomous pelvic nerves during radical hysterectomy. In this procedure the lateral parts of the sacro-uterine ligament, through which the N. hypogastricus passes bilaterally, are left intact. The initial results of this nerve-sparing surgical technique during radical hysterectomy seem to be promising. The operation was easy to perform, with almost no extra blood loss and an extra operating time of just 10-15 minutes. Postoperative recovery of the bladder function occurred after a mean period of 9 days.
Female↗