Myocardial metabolism in open-heart surgery: arterial levels of metabolites, electrolytes, oxygenation, and acid-base balance.
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Acid-Base Equilibrium↗
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Results for “Balanced Anesthesia”
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[Acid-base balance].
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Acid-Base Equilibrium↗
The anaesthetic management of distal (thoracic) tracheal resection in a quadriplegic patient.
The anaesthetic management of distal tracheal resection in a quadriplegic patient is described. Ketamine, halothane, fentanyl and Entonox (50% N2O, 50% O2) were successfully employed. The major problems discussed include airway maintenance, cardiovascular instability and autonomic hyperreflexia, the dangers of depolarizers, and the need for monitoring temperature, blood pressure and fluid balance. The importance of teamwowrk is mentioned.
Adult↗
[Energy substrate metabolism in myocardium in the dynamics of hypothermic perfusion in combined cardioplegia in an experiment].
Experiments on 16 mongrel dogs have indicated that an anesthetic aid during cardiosurgical operations, which involves current multicomponent anesthesia, hypothermal perfusion and cardioplegia, fails to provide a complete protection of the myocardium from ischemia and a balanced uptake of energy substrates in the immediate postperfusion period.
Animals↗
[Changes in pulmonary shunting and blood lactate during general anesthesia with controlled hypotension in patients with idiopathic scoliosis].
In their work the authors observed the influence of controlled hypotension by means of sodium nitroprusside on the acidobasic balance, the oxygenation parameters, pulmonary shunt and lactatemia in patients with idiopathic scoliosis in the course of dorsal fusion by Harrington instrumentation. In comparison with the control group of patients there had not occurred significant - from the viewpoint of statistics - changes in ph, paCO2 and pvO2. However, the pulmonary shunt (Qva/Qt) doubled (p less than 0.002) which resulted in a significant decrease of paO2 (p less than 0.02) but in no case there occurred hypoxemia. The values of the lactate both in the venous and arterial blood were increased (p less than 0.001, or p less than 0.02) in contrast to the control group of patients, but they did not mean the increased production of lactate during intracellular hypoxia. As a result the regulated hypotension by means of sodium nitroprusside can be applied also in patients with altered pulmonary functions.
Adolescent↗
Endogenous opioid peptides inhibit oxytocin release in the lactating rat after dehydration and urethane.
One physiological role for endogenous opioid peptides is to attenuate the release of oxytocin (OT) from the hypothalamo-neurohypophysial system during dehydration and hemorrhage when vasopressin maintains fluid balance and blood pressure. During lactation, OT, which stimulates milk ejection, is released without vasopressin. The influence of endogenous opioid peptides on OT release during suckling has been studied primarily in animals anesthetized with urethane. In addition to anesthesia, urethane dehydrates the animal by elevating plasma osmolality and reducing cardiovascular volume. Thus, we examined in lactating rats the response of the magnocellular neuroendocrine system to dehydration and the role of endogenous opioid peptides in regulating OT release during suckling under conditions of altered fluid balance in conscious and urethane-anesthetized rats. Release of OT in response to an increase in plasma osmolality or a decrease in blood volume was attenuated during lactation in both conscious and anesthetized rats. Blockade of opiate receptors with naloxone (5 mg/kg) did not alter suckling-induced release of immunoreactive OT in conscious, normally hydrated rats, but did augment hormone release after urethane (1.1 g/kg, ip) or after osmotic stimulation with hypertonic sodium chloride (2.5%; 20 ml/kg, ip). During dehydration, the combination of decreased responsiveness of oxytocinergic neurons to osmotic stimulation and inhibition of OT release by opioid peptides may be important in the lactating rat for conserving pituitary stores of OT needed for milk ejection.
Anesthesia↗
Prophylactic use of epidural mepivacaine/morphine, systemic diclofenac, and metamizole reduces postoperative morphine consumption after major abdominal surgery.
BACKGROUND: Surgical trauma induces nociceptive sensitization leading to amplification and prolongation of postoperative pain. While preemptive analgesic treatment with numerous agents has been successful in experimental animals, results of human studies remain conflicting. The authors used a multimodal approach for preemptive analgesia before abdominal surgery: diclofenac and metamizole inhibit prostaglandin synthesis, thus influencing peripheral sensitization; epidural local anesthetics induce conduction block, epidural opioids inhibit nociceptive synaptic transmission, and metamizole induces descending inhibition. The interaction of these drugs might suppress spinal nociceptive sensitization and postoperative analgesic demand. METHODS: One hundred forty-two patients scheduled for major abdominal surgery were randomly assigned to one of three groups and studied prospectively. Epidural catheters in groups 1 and 2 were placed at interspaces T8-T10, the position of the catheter was confirmed by epidurography, and sensory testing after administration of 5 ml mepivacaine 1%. Group 1 received 75 mg intramuscular diclofenac, 1000 mg intravenous metamizole, 5.3 +/- 1 mg epidural morphine, and 15-20 ml mepivacaine 1% 85 +/- 41 min before skin incision. Epidural analgesia was maintained by injections of 0.1 ml.kg-1.h-1 mepivacaine 1%. Group 2 patients received the balanced analgesia regimen before wound closure (221 +/- 86 min after skin incision). Group 3 patients did not receive any study substances. General anesthesia was induced with 5 mg/kg thiopental and 2 micrograms/kg fentanyl and maintained with enflurane and nitrous oxide. Postoperative analgesia consisted of patient-controlled intravenous morphine over 5 days. RESULTS: Median visual analog scale pain intensities were < 3 cm and did not differ among the groups. Morphine consumption per hour on postoperative day 2 was 0.8 +/- 0.1 mg/h (group 1) < 1.2 +/- 0.1 mg/h (group 2) = 1.1 +/- 0.1 mg/h (group 3) and cumulative morphine consumption (in mg) on the morning of day 5 was 95 +/- 9 (group 1) < 111 +/- 11 (group 2) < 137 +/- 10 (group 3). CONCLUSIONS: A significant reduction of patient controlled analgesia requirements could be achieved by our preincisional balanced analgesia regimen compared to application before wound closure. The more distinct difference between patients receiving balanced analgesia and those in the control group is based on the analgesic action of the study substances, which lasted about 14 h.
Abdomen↗
[Propofol-remifentanil versus sevoflurane-remifentanil for anesthesia for pediatric procedures in infants, children and adolescents].
INTRODUCTION: The aim of this study was to compare total intravenous anaesthesia (TIVA) using propofol and remifentanil (P/R-group) and balanced anaesthesia (BA) using sevoflurane and remifentanil (S/R-group) for paediatric surgery. PATIENTS AND METHODS: A total of 120 patients aged 6 months to 16 years scheduled for elective minor lower abdominal surgery were randomly assigned to receive either propofol (5-10 mg/kg/h) and remifentanil (0.125-1.0 microgram/kg/min) or sevoflurane (1.0-1.5 MAC) and remifentanil (0.125-1.0 microgram/kg/min). Perioperative haemodynamics as well as recovery and discharge times, PONV and side-effects were studied. The patients vigilance, comfort and pain intensity were assessed postoperatively using the objective pain discomfort scale, the Steward post-anaesthetic recovery score and a visual analogue scale. RESULTS: Postoperative recovery (9.0 vs 11.6 min) and extubation times (11.8 vs. 15.0 min) as well as the time taken until a Steward post-anaesthetic recovery score > 3/4 (15.2 vs. 21.4 min) was reached were significantly shorter in the P/R-group. However, the length of time until discharge to the ward, postoperative comfort, pain intensity and analgesic requirements as well as PONV were comparable in both groups. CONCLUSIONS: With regards to the investigated parameters, TIVA with propofol and remifentanil is equally effective as BA with sevoflurane and remifentanil in paediatric patients. However, considering the selected dosing regimen, recovery times were significantly shorter for children after TIVA.
Abdomen↗
[Features of general anesthesia and infusion-transfusion therapy in extensive surgery of the organs of the abdominal cavity].
The article discusses variants of infusion-transfusion therapy (ITT) in early stages of expanded operations on the abdominal organs attended by massive blood loss (2 to 4 BCV and more). Seventy-three patients were examined, they underwent resection of the liver (30), pancreatoduodenal resection (37), or removal of a retroperitoneal tumor (6 patients). On the basis of precise study of central and peripheral hemodynamics, acid-base equilibrium, and blood oxygen transport function the authors find it necessary to increase the volumes of ITT to 70-80% BCV in the first stage of the operation with a colloid/crystalloid ratio of 1:4. The described method makes it possible to avoid critical fluctuations of cardiac output and blood pressure in massive bleeding. At the same time, such hemodilution causes no considerable decrease in hemoglobin concentrations (which was 79.0% of the initial level at the beginning of the main stage) and specific oxygen transport (85.0%, respectively). In absolute expression the specific oxygen transport before the hemorrhage is 465 + 29 ml/min/m2, which significantly exceeds the critical value. The authors believe the ITT method to be indicated in inevitable blood loss and absence of serious cardiovascular diseases. From comparative analysis of the different variants of general anesthesia, the authors conclude that the following combination of agents is preferable for the discussed category of patients: phentanyl, droperidol, seduxen, kalipsol (ketamine), and dalargin. Their balanced use ensures stability of the main homeostasis indices in all stages of the intervention; the hepato- and pancreatoprotective properties of dalargin are also of importance.
Abdomen↗
Myocardial metabolism and hemodynamic responses to halothane or morphine anesthesia for coronary artery surgery.
Eighteen patients having coronary artery bypass grafts were randomly anesthetized with morphine (1 mg/kg) or halothane and oxygen. Central and peripheral pressures were measured serially, plus cardiac output and total coronary sinus blood flow, both by thermodilution catheters, starting before induction of anesthesia and continuing until completion of sternotomy. No significant differences in hemodynamic responses were seen between the two anesthetic techniques during induction: blood pressure and peripheral vascular resistance decreased significantly, but not cardiac output or coronary flow. Myocardial oxygen consumption decreased significantly with induction as oxygen content of coronary sinus blood increased, indicating preservation of oxygen balance. Heart rate and blood pressure increased after sternotomy in the patients given morphine, with the myocardium producing lactate in two of six patients and with nitroprusside being required in four patients to decrease arterial pressure. Halothane-oxygen anesthesia effectively controlled autonomic responses to sternotomy, although one of 12 patients had myocardial lactate production at that time. Neither rate-pressure product or ST segment changes were useful predictors of the ratio between myocardial oxygen consumption and supply. Myocardial oxygen balance can be maintained in coronary patients before cardiopulmonary bypass if pulse rate and blood pressure are kept at less than awake levels.
Adult↗
Low-dose enflurane as adjunct to high-dose fentanyl in patients undergoing coronary artery surgery: stable hemodynamics and maintained myocardial oxygen balance.
The effects of enflurane (end-tidal concentration 0.7%) on central and coronary hemodynamics and myocardial oxygenation were studied during steady state, high-dose fentanyl anesthesia in ten patients undergoing coronary artery bypass grafting operations. Compared with the response in ten patients receiving the same fentanyl anesthesia (100 micrograms/kg) without enflurane supplementation, enflurane caused a moderate reduction in mean arterial pressure, systemic vascular resistance, and left ventricular stroke work index. No patient showed signs of myocardial ischemia, and mean coronary sinus flow and calculated coronary resistance remained unchanged. Surgical stimulation induced no central or coronary hemodynamic responses in the enflurane-fentanyl group. No coronary hemodynamic changes occurred in the fentanyl group, but a marked increase in arterial pressure and systemic vascular resistance was seen. Myocardial oxygen extraction decreased in the enflurane supplemented group although it increased in the fentanyl group after surgical stimulation. Three fentanyl group patients and one enflurane-fentanyl group patient had a low myocardial lactate extraction as a sign of myocardial ischemia during surgery. We conclude that a 0.7% enflurane supplementation of 100 micrograms/kg fentanyl anesthesia does not endanger myocardial oxygenation and effectively prevents central and coronary hemodynamic responses to skin incision and sternotomy in patients undergoing coronary artery surgery.
Anesthesia, General↗
Intraoperative awareness in fast-track cardiac anesthesia.
BACKGROUND: Fast-track cardiac anesthesia, using low-dose narcotics combined with short-acting anesthetic and sedative agents, facilitates early tracheal extubation after cardiac surgery. The incidence of awareness with this anesthetic technique has not been investigated previously. The purpose of this study was to prospectively investigate the incidence of intraoperative awareness with explicit memory of events during fast-track cardiac anesthesia. METHODS: Data were collected prospectively over a 4-month period from 617 consecutive adult patients undergoing cardiac surgery at a university hospital. All patients received a fast-track cardiac anesthetic regimen. Patients underwent a structured interview by a research nurse 18 h after extubation. A standard set of questions was asked during this interview to determine if the patient had explicit memory of any event from induction of anesthesia to recovery of consciousness. RESULTS: Nine patients did not complete a postoperative interview because of death (n = 7) or postoperative confusion (n = 2). The last memory before surgery reported in 420 (69.1%) patients was waiting in the holding area at the operating suite, and in the remaining 188 (30.9%) patients it was lying on the operating table before induction of anesthesia. Two patients (0.3%) had explicit memory of intraoperative events. One of the two patients also had explicit memory of pain. Neither patient reported adverse psychological sequelae. CONCLUSIONS: The authors report an incidence of awareness in fast-track cardiac anesthesia of 0.3%. This is the lowest incidence of awareness currently reported during cardiac surgery. This low incidence of awareness may be related to the use of a balanced anesthetic technique involving the continuous administration of volatile (isoflurane) or intravenous (propofol) anesthetic agents before, during, and after cardiopulmonary bypass.
Anesthesia↗
Fracture of the shaft of the femur in children.
Sixty-five cases of fracture of the femur shaft caused by trauma in children under age 12 were studied. All were treated by various conservative methods. Two patients later underwent open reduction and internal fixation. Children below 5 years of age were treated by Bryant's suspension traction method. Older children were treated by balanced skin traction. In a few cases where the position was not acceptable, the fracture was reduced under general anesthesia and fixed traction was applied. Patients were discharged with a hip spica when the fracture site was nontender (average three weeks). Undisplaced fractures were treated by a primary hip spica. Functional end results were good in 81.5%, fair in 15.4% and poor in 3.1%. Eight compound fractures in this series were treated conservatively.
Bandages↗
The implications of hypothermia for early tracheal extubation following cardiac surgery.
Thermoregulation is impaired during anesthesia for cardiac surgery. Redistribution of body heat and heat loss to the environment result in mild hypothermia before cardiopulmonary bypass. Maintenance of normothermia, rather than hypothermia, may facilitate early tracheal extubation. Hypothermia alters the distribution and decreases the metabolism of most drugs, including anesthetic drugs and muscle relaxants, thus prolonging recovery. Postoperative shivering increases metabolic rate and potentially leads to myocardial ischemia; prevention is therefore critical to the success of early tracheal extubation after cardiac surgery. Coagulopathies, increased incidence of surgical wound infection, and perioperative cardiac morbidity are other potential risk factors identified in noncardiac patients. Hypothermia, however, does have potential benefits to the patient, including protection from cerebral ischemia and hypoxemia. Mild core hypothermia (approximately 34 degrees C) may represent the optimal balance between risks and benefits for fast-track patients.
Anesthesia Recovery Period↗
Combined thoracic epidural with light general anesthesia for thymectomy in myasthenia gravis.
Forty-seven myasthenia gravis patients undergoing transsternal thymectomy were allocated into 2 groups. Group 1 which consisted of 27 patients was anesthetized using the balanced technique, while 20 patients in group 2 received the combination of thoracic and balanced anethesia. The ventilation was controlled through the endotracheal tube in both groups. The extubation criteria after performing the surgery were good consciousness, adequate muscle strength and adequate respiration. There were 29.2 per cent in group 1 but 77.8 per cent in group 2 (P = 0.002) with successful extubation immediately postoperation. Morphine 15.4 +/- 5.3 mg intramuscularly in group 1, and 6.5 +/- 1.2 mg epidurally in group 2 (P < 0.001) was given for postoperative analgesia. Adequacy of respiration was observed postoperatively in the intensive care unit (ICU). Group 1 patients required 76.9 per cent of further ventilatory support for the period of 37.11 +/- 39.54 hours and duration of the ICU stay was 65.52 +/- 85.84 hours, whereas, the patients in group 2 showed significantly different results, which were 15.8 per cent of ventilatory support (P = 0.002) for 10.33 +/- 6.03 hours (P = 0.014) and 22.8 +/- 8.06 hours for staying in ICU (P = 0.021). This study demonstrated that the combined thoracic epidural with light general anesthesia provides excellent intraoperative anesthesia together with postoperative analgesia, which reduces the need for postoperative respiratory support, as well as decreases the hospital cost.
Adult↗
ACID-BASE BALANCE DURING EPIDURAL ANALGESIA.
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Acid-Base Equilibrium↗
The immediate effects of respiratory depression on acid-base balance in anesthetized man.
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Acid-Base Equilibrium↗
Advantages of balanced mechanical ventilation during neurosurgical procedures.
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Analgesia↗