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PubMedDate not supplied

Effects of sevoflurane on QT dispersion and heart rate variability.

The purpose of this study was to use estimates of corrected QT dispersion (QTcd) and heart rate variability (HRV) to assess the effects of sevoflurane, an inhalation agent used frequently in clinical practice, on autonomic cardiac function. This study was conducted prospectively and in a blind manner on 20 women between 38 and 51 y of age who were classified as American Society of Anesthesiologists stage I-II and whose treatment required total abdominal hysterectomy. Electrocardiograms were recorded by 12-lead Holter monitor for 5 min before sevoflurane induction and again for 5 min at 10 min after tracheal intubation. Data on the first recording were considered as baseline; those on the second recording were viewed as final data. The study was terminated at this point, and surgery was allowed to proceed. QTcd and HRV values were assessed by a cardiologist, who was blinded to all data. All parameters were expressed as a mean value +/- standard deviation. Wilcoxon's test was used to compare baseline and final data. Statistical significance was considered as P<.05. No significant changes were observed between baseline and final QTcd values and between low- and high-frequency components (LF and HF) of HRV; nor were changes seen in the LF/HF ratio. With the patient under sevoflurane/ nitrous oxide anesthesia, no significant changes were detected in QTcd, LF, and HF values, and in the LF/HF ratio, whereas a significant increase (P=.001) was seen in standard deviation of the R-R interval, which was used as a measure of cardiac autonomic tone.

Adult↗

PubMed1998

Thoracoscopic surgery.

Video-assisted thorascopic surgery has evolved rapidly and has demonstrated utility in the diagnosis and management of a variety of chest disorders. An historical perspective, considerations on patient selection, anesthetic and operative management, and a summary of the Ochsner Clinic institutional experience with this procedure are presented. Special emphasis is given to the treatment of disorders of the autonomic nervous system, esophageal achalasia, and a rare symptomatic congenital pericardial defect. Video-assisted thorascopy provides a promising alternative to many of the more invasive open thoracic surgical procedures.

Adolescent↗

PubMedDate not supplied

Traumatically acquired conditioned dysphagia in children.

A new diagnosis identifying a nonorganic basis of dysphagia is proposed in relation to behavioral conditioning processes and thereby labeled "conditioned dysphagia" (CD). Literature review of both animal and human studies documents that rapidly acquired and persistent avoidance responses are learned when autonomic functions are contiguous with traumatic physical events. Three case studies with primary diagnoses of TE fistula, congenital heart disease and pseudobulbar palsy demonstrated an association between CD and early childhood incidence of trauma involving the esophagus. Successful treatment was achieved by operant deconditioning therapy. Results of a pilot epidemiological study of 28 postpharyngeal flap surgery children and 47 controls showed significantly higher incidence of mild to moderate CD in the surgery group.

Avoidance Learning↗

PubMedDate not supplied

[Adjuvant radiotherapy in rectal cancer and total mesorectal excision].

Local recurrence (LR) after surgical resection for adenocarcinoma of the rectum still remains an unsolved problem. Local relapse often occurs when tumor spreads in perirectal fat (mesorectum) or along the lateral iliac lymph nodes also when surgery is considered radically. There is a close relationship between local recurrence rate and lymphatic involvement, local tumor extension and tumour grading. Total mesorectal excision (TME) appears to be associated with a reduced LR rate when resection of perirectal fat is done "en-bloc" and when a negative radial margins is obtained. TME allows autonomic nerve sparing and sphincter preservation too, but lateral nodes are not treated by TME. Extended lymphadenectomy with lateral dissection for advanced rectal cancer has been often associated with an increase rate of long term morbidity, particularly regarding urinary and sexual function. Concomitant preoperative chemo-radiation for advanced rectal cancer is a relatively safe procedure with an acceptable morbidity and mortality. This approach is associated with a considerable clinical and pathologic tumor downstaging. Tumor resectability is improved and lateral spreading is also better controlled. An improving in survival and a longer disease free period has been reported. More radical sphincter saving operations are also allowed.

Digestive System Surgical Procedures↗

PubMed1985

Events leading to the treatment of coronary artery disease: implications for nursing care.

The selection of a particular treatment for CAD was found to be related to the severity of illness, patients who were more severely disabled by angina elected surgical treatment after vessel blockage was documented by angiography. Differential access to treatments was not described by study subjects and therefore cannot be evaluated as a contributing factor to the selection of treatment. Although most subjects participated in a therapeutic pharmacologic regimen, few patients in either group employed dietary or exercise programs to ameliorate CAD. Most patients received information about CAD and about surgery as a treatment option. This educational communication was directed by the cardiologist for a large majority of patients. Nurses were cited as information sources for surgical subjects only. In retrospect, more than half of the surgical subjects indicated a need for additional information. The decision regarding which type of treatment to have was made autonomously by most subjects, unlike the usual decision-making styles of families of surgical patients. A significantly greater proportion of surgical patients identified their family as a source of support during the elected treatment. Both groups described family changes specific to the illness and selected treatment.

Adult↗

PubMed2006

Comparison of ilioinguinal-iliohypogastric nerve block versus spinal anesthesia for inguinal herniorrhaphy.

OBJECTIVE: This study was carried out to determine the optimal anesthetic technique for use in elective herniorrhaphy. METHODS: We retrospectively analyzed 126 inguinal hernia repairs. The patients were allocated to one of two groups: an ilioinguinal-iliohypogastric nerve block group (IHNB group, n = 63) and spinal anesthesia group (SA group, n = 63). We recorded information about perioperative and postoperative parameters. RESULTS: There were statistically significant decreases in both mean arterial pressure and pulse rate in the SA group (P < 0.001). None of the patients in the IHNB group required recovery room care. Patients in the IHNB group initiated oral intake (0.31 +/- 0.1 h) more quickly than patients in the SA group (5.74 +/- 0.1 h) (P < 0.001). The time-to-home readiness was significantly lower (14.1 +/- 1.5h) in group IHNB, compared with group SA (42.8 +/- 5.3h) (P < 0.001). First rescue analgesic time postoperatively was 3.30 +/- 0.2 hours in group SA and 2.7 +/- 0.13 hours in group IHNB (P < 0.05). CONCLUSION: The use of IHNB for patients undergoing herniorrhaphy resulted in a shorter time-to-home readiness, quicker oral intake post surgery, and no need for recovery room care, when compared with the use of SA.

Adult↗

PubMedDate not supplied

[The application of variational cardiointervalography for optimization of anesthesia in outpatient surgery].

The vegetative regulation condition was investigated by the method of variation cardio-interval-graphy in patients who underwent the intravenous anesthesia in the outpatient setting. The experience of using, on the differential basis, the sympathomimetic and vagotonic anesthetics for different-type vegetative tonus was analyzed. An optimal state in the vegetative regulation of the cardiovascular system, a stable hemodynamics and an adequate post-narcosis rehabilitation in the anesthetic management of one-day surgery were ensured owing to the suggested method in choosing an anesthetic.

Adrenocorticotropic Hormone↗

PubMed2004

Decreased density of ganglia and neurons in the myenteric plexus of familial dysautonomia patients.

BACKGROUND: Familial dysautonomia (FD) is a hereditary disease of the autonomic and sensory nervous system. A prominent manifestation of FD is gastrointestinal dyscoordination, which contributes to the morbidity and mortality in FD. AIM: As the myenteric plexus is an essential factor in gastrointestinal motility control, we compared its morphology in appendices of FD patients and controls. METHODS: Appendices from FD patients (N=19) were obtained during surgery of fundoplication and gastrostomy; normal appendices (N=17) were obtained from patients suspected to suffer from acute appendicitis, in whom, however, the appendix was found to be normal. Specimens were stained histochemically for NADPH diaphorase (NADPH-d) and in a blinded manner examined under a light microscope for seven morphologic parameters: ganglionic density, neuronal density, ganglionic area, number of stained neurons per ganglion, nerve bundle width, ratio between nervous tissue area and total area, and neuronal area. RESULTS: Ganglionic density was 10.13 per mm(2) in controls versus 5.01 per mm(2) in FD (p<0.05). Neuronal density was 70.12 per mm(2) in controls, compared with 22.09 per mm(2) in FD (p<0.01). The other parameters were not different between the two groups. CONCLUSION: Densities of myenteric ganglia and neurons of FD patients were significantly lower than in controls. This deficiency may contribute to the pathogenesis of FD gastroenteropathy.

Adolescent↗

PubMed1998

[The organization and activity of the otolaryngological institutions in Warsaw in the second half of the 19th century and at the beginning of the 20th century].

The importance of various otolaryngological institutions: hospital wards, outpatient clinics, infirmaries and consulting rooms in the formation of the new specialization, otolaryngology, is described in this paper. An important role of surgery in the first period of the development of otolaryngology is mentioned. At that time all major otolaryngological operations were performed by general surgeons. The necessity to create new separate hospital otolaryngological wards became evident. The attainment of general surgical education and management of suitable post-operation treatment by otolaryngologists as well as creation of autonomous operating rooms were also evident. Poor state of Warsaw otolaryngological outpatient clinics is described in detail. The state of otolaryngological institutions in Europe, in the United States of North America and in the Kingdom of Poland is described briefly.

Ambulatory Care Facilities↗

PubMed2004

[Carpal tunnel syndrome].

The name of Carpal Tunnel Syndrome (CTS) refers to a complex of symptoms resulting from the pressure exerted on the median nerve in the carpal tunnel area [81]. In most cases, it is not possible to establish CTS causes, and we diagnose idiopathic CTS. CTS is the most frequent pressure neuropathy. Typical clinical symptoms include sensory effects in the forms of pain paresthesia or hypesthesia, limited to the wrist area innervated by the median nerve, presence if Tinel's symptoms, or a positive Phalen's test. In more advance cases, doctors find motor symptoms displayed by difficulties in the performance of precise activities, grasp weakness or thenar muscle atrophy. In some patients, we observe autonomous symptoms, e.g. skin perspiration disorders (dry skin on thumb, index and middle fingers), or vasomotor disorders. The most essential for diagnosis confirmation are electrophysiological examinations, which evaluate the median nerve functions. Sometimes, imaging techniques are useful, e.g. ultrasound, MRI and CTS scanning of the wrist. The most effective form of idiopathic treatment of CTS is surgery.

Carpal Tunnel Syndrome↗

PubMed1998

Power spectral analysis of arterial blood pressure after spinal anesthesia.

BACKGROUND: The continuous, on-line and real-time analysis of the power spectrum (CORAPS) of systemic arterial pressure (SAP) and heart rate (HR) signals is one of the current progresses in the development of non-invasive indexes for autonomic nervous system. It might be a useful clinical tool to monitor the progress of preganglionic block of sympathetic nervous system and the homeostatsis of cardiac neuroregulation after spinal anesthesia. The purpose of this study is to examine the relationship between the hypotensive response and the changes of components in CORAPS throughout the course of spinal anesthesia. METHODS: In 10 ASA class I-II patients (aged from 17 to 75 years) scheduled for elective surgery, we analyzed the changes of spectrum of systemic arterial blood pressure signals during spinal anesthesia. Spinal anesthesia was performed with 0.5% bupivacaine (dosage at 13-15 mg). For CORAPS, SAP signals were simultaneously relayed to an analog-digital converter connected to a computer. Power spectral density of the data was computed using a fast Fourier transform. The areas of the spectral peaks within each measurement were calculated as the follows: very low (BVLF, 0.01-0.08 Hz), low (BLF, 0.09-0.15 Hz), and high (BHF, 0.16-0.25 Hz). RESULTS: During the time interval (S2 period) when spinal anesthesia was initiated and 15 min thereafter the power density of low frequency (BLF), (1.2 vs. 2.3), and very low frequency (BVLF) components decreased, (3.4 vs. 7.8), in comparison with that at the baseline level (S1 period). We also found the shift of dominance between low frequency (BLF) and high frequency (BHF) in S2 period. The effects of intrathoracic pressure on the venous return may contribute to the increase of power density of BHF components (1.7 vs. 1.1). We also found that even in patients with stable hemodynamic variability, the decrease of BLF and BVLF components, and the shift of dominance were the same as in patients with unstable hemodynamic variability. CONCLUSIONS: It might prove that the cephalic spread of spinal block abolished the sympathetic tone of the autonomic nervous system. These results validated previous speculations of a sympathetic block during spinal anesthesia. More importantly, patients with stable hemodynamic variability still have profoundly sympathetic block with decreased power density of BLF and BVLF. The CORAPS is a good clinical monitoring tool to evaluate the homeostatsis of cardiac neuroregulation after spinal anesthesia.

Adolescent↗

PubMedDate not supplied

Clinical pharmacokinetics of propofol given as a constant-rate infusion and in combination with epidural blockade.

STUDY OBJECTIVES: To investigate the pharmacokinetics of propofol in combination with epidural anesthesia or with intravenous (i.v.) alfentanil infusion, and to investigate the clinical feasibility of this anesthetic technique in lower abdominal surgery. DESIGN: Randomized, open clinical study. SETTING: Operating theaters and postanesthesia recovery unit at the department of gynecology of a university medical center. PATIENTS: 20 healthy, consenting ASA physical status I and II adult female patients undergoing lower abdominal surgery. INTERVENTIONS: A total i.v. anesthetic technique was used in all patients. In Group 1, a continuous infusion of propofol was combined with an epidural block with bupivacaine. Group 2 patients received a combination of propofol and alfentanil infusions. MEASUREMENTS AND MAIN RESULTS: The pharmacokinetics of propofol are best fitted to a two-compartment open model and were similar in both patient groups. Propofol blood clearance was 29.8 +/- 6.51 ml/min/kg, and volume of distribution was 3.60 +/- 1.34 L/kg, resulting in a blood elimination half-life of 144 +/- 46 minutes. The entire period of anesthesia was stable in the alfentanil group. In the epidural group, the initial period of anesthesia was too light as judged by the autonomic response to tracheal intubation, which also correlated in time to a lower propofol blood concentration than was seen in the alfentanil group. No evidence was found that an epidural block induced a change in propofol kinetics, apart from the lower blood concentration during the initial period of anesthesia. CONCLUSIONS: We could not show any statistically significant influence of an epidural blockade on the pharmacokinetic parameters of propofol. Nevertheless, the concentration-time profile changed during infusion, rendering the described infusion regimen, in combination with epidural anesthesia, unsatisfactory for adequate hypnosis. The propofol infusion regimen combined with alfentanil provided immediate and stable blood concentrations that were adequate for surgery.

Adult↗

PubMed1990

[Use of pervomur in surgery].

The authors show the results of 15-year use of Pervomur solutions for sterilization of surgical material and treatment of the hands of surgeons in medical institutions of the country. Due to the high bactericidal properties of the agent its disinfectant effect is produced within a short time, which is of particular importance in mass admission of casualties in field conditions, in remote and mountainous wilderness, during natural disasters , and in performing surgical interventions on ships under conditions of prolonged autonomous cruises. The absence of an unfavourable effect of solutions of the agent on live tissue allows it to be considered a very promising antiseptic not only for sterilization but also for topical treatment of purulent wounds and cavities, particularly in contamination by polyinfection.

Anti-Infective Agents, Local↗

PubMed2003

An artificial somatic-central nervous system-autonomic reflex pathway for controllable micturition after spinal cord injury: preliminary results in 15 patients.

PURPOSE: Neurogenic bladder dysfunction after spinal cord injury (SCI) is a major medical and social problem for which there is no definitive solution. After the successful establishment in animals of a skin-central nervous system-bladder reflex pathway for micturition we performed this procedure on 15 patients with SCI who had 3 years of followup. MATERIALS AND METHODS: A total of 15 male volunteers with hyperreflexic neurogenic bladder and detrusor external sphincter dyssynergia (DESD) caused by complete suprasacral SCI underwent limited hemilaminectomy and ventral root (VR) micro anastomosis, usually between the L5 and S2/3 VRs. The L5 dorsal root was left intact as the trigger of micturition after axonal regeneration. Mean followup was 3 years. All patients underwent urodynamic evaluation before surgery and during followup. RESULTS: Preoperative studies in patients with complete suprasacral SCI revealed hyperreflexic neurogenic bladders and DESD with some differences in storage function during infusion cystometrograms. Of the 15 patients 10 (67%) regained satisfactory bladder control within 12 to 18 months after VR micro anastomosis. Average residual urine decreased from 332 to 31 ml and urinary infection as well as overflow incontinence disappeared. Urodynamic studies revealed a change from detrusor hyperreflexia with DESD and high detrusor pressure to almost normal storage and synergic voiding without DESD. Impaired renal function returned to normal. Two patients (13%) who required a skin stimulator to evoke voiding following the VR anastomosis had partial recovery but more than 100 ml residual urine. One patient was lost to followup and 2 had failure. CONCLUSIONS: An artificial somatic-central nervous system-autonomic reflex arc can be established surgically to provide a novel method for controlling bladder function in patients with complete suprasacral SCI who have hyperreflexic bladder and DESD. Nerve impulses delivered from the efferent neurons of a somatic reflex arc can be transferred to initiate the response of an autonomic effector.

Adult↗

PubMed2004

Influence of coronary artery bypass grafting on heart rate turbulence parameters.

This study evaluated the influence of coronary artery bypass grafting on heart rate turbulence (HRT) parameters assessed during 1-year follow-up in patients with coronary artery disease. HRT and heart rate variability (HRV) parameters significantly worsened 3 months after surgery. After 1 year, HRV parameters and turbulence onset returned to preoperative values, whereas turbulence slope remained significantly attenuated. Our results show that there is a marked attenuation of HRT parameters in the early postoperative period, indicating an impairment of baroreflex sensitivity after coronary artery bypass grafting. Concomitant depression of HRV parameters points to dysfunction of the autonomic nervous system, provoked by perioperative attenuation, as a potential underlying cause of impaired baroreflex response.

Aged↗

PubMed2001

Saving the diabetic foot with special reference to the patient with chronic renal failure.

The chronic renal failure patient with diabetes has a lower limb amputation rate 10 times greater than the diabetic population at large. In studies of causal pathways leading to non-traumatic related lower extremity amputation, foot ulcers preceded approximately 84% of the amputations. Even though foot ulcers are more likely to develop in patients with diabetic nephropathy, they are no less likely to heal than are those in diabetic patients with normal renal function. Consequently, attempts to save the diabetic foot even in this high-risk population are justified. The pathogenesis of foot ulceration in the chronic renal failure patient with diabetes is primarily due to peripheral neuropathy. Loss of protective sensation due to sensory neuropathy combined with motor and autonomic neuropathy and macrovascular compromise result in increased risk for foot complications. Evaluation of the foot includes a selective history and a focused examination of skin integrity, presence of sensory neuropathy or vascular insufficiency, and biomechanical and footwear inspection. Effective treatment of diabetic foot complications include appropriate antibiotics (when indicated), meticulous wound care, off-loading, vascular surgery (when indicated), and selective/elective or prophylactic nonvascular surgery. Failure to heal an ulcer can often be traced to common pitfalls, which include: A "cavalier" attitude. W.N.L. exam (We Never Looked). Inadequate off-loading. Failure to establish depth of ulcer and miss "probe to bone." Non-healing means unrelieved pressure and/or no blood. Failure to correct edema. The multidisciplinary diabetic foot clinic model provides an ideal setting for early intervention, treatment, and assistance with preventive strategies.

Amputation, Surgical↗

PubMed2001

Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience.

OBJECTIVE: In our previous randomized trial, we suggested a possible role for endoscopic ultrasound (EUS) guided celiac plexus block in the treatment of abdominal pain associated with chronic pancreatitis. The purpose of this study was to evaluate our prospective experience with EUS-guided celiac plexus block for controlling pain attributed to chronic pancreatitis, including follow-up on response rates and complications. METHODS: All subjects enrolled had documented chronic pancreatitis by ERCP and EUS criteria and presented with chronic abdominal pain unresponsive to current treatment options. All were treated with EUS-guided celiac plexus block under the guidance of linear array endosonography using a 22-gauge FNA needle (GIP, Mediglobe Inc., Tempe, AZ) inserted on each side of the celiac area, followed by injection of 10 cc bupivacaine (0.25%) and 3 cc (40 mg) triamcinolone on each side of the celiac plexus. Individual pain scores, based on a visual analog scale (0-10), were determined preblock and postblock by a nurse at 2, 7, 14 days and monthly thereafter. Subjects also rated their overall comfort level during the EUS procedure. RESULTS: EUS-guided celiac plexus block was performed in 90 subjects (40 males, 50 females) having a mean age of 45 yr (range 17-76 yr) between July 1, 1995 and December 30, 1996. A significant improvement in overall pain scores occurred in 55% (50/90) of patients. The mean pain score decreased from 8 to 2 post EUS celiac block at both 4 and 8 wk follow-up (p < 0.05). In 26% of patients there was persistent benefit beyond 12 wk, and 10% still had persistent benefit at 24 wk, including three patients who were pain-free between 35 and 48 wk. Younger patients (<45 yr of age) and those having previous pancreatic surgery for chronic pancreatitis were unlikely to respond to the EUS-guided celiac block. Three patients experienced diarrhea post EUS celiac block, which resolved in 7-10 days; however, it is unclear whether this diarrhea was due to the block or to refractory disease. A cost comparison between the EUS ($1200) and CT ($1400) techniques shows the EUS celiac block to be less costly and perhaps more cost efficient in a subset of subjects. CONCLUSIONS: EUS-guided celiac plexus block appears to be safe, effective, and economical for controlling pain in some patients with chronic pancreatitis. Younger patients (<45 yr) and those having prior pancreatic surgery for chronic pancreatitis do not appear to benefit from this technique. Prophylactic antibiotics should be considered if acid suppressing agents are being taken.

Abdominal Pain↗

PubMed1976

Preclinical hyperthyroidism in multinodular goiter.

The thyrotropin (TSH) response to thyrotropin-releasing hormone(TRH) (200 mug iv) was determined in 80 surgical patients with nontoxic multinodular goiter. The TSH reserve was normal in multinodular goiter. The TSH reserve was normal in 55 and elavated in 8 patients. No TSH response to TRH (deltaTSH less than or equal to 1 muU/ml) was detectable in 17 patients (21%). Individual and mean serum T4, FT4I and serum T3 values did not differ from normal in 13 of the TRH unresponsive patients; in 4 patients FT4I or serum T3 was marginally elevated. No statistical differences were noted for I131-uptake, PBI131 and conversion rate between controls and TRH unresponsive patients. All patients who failed to respond to TRH were euthyroid on clinical evaluation. Goiters were large multinodular and long-standing in most instances. In 12 tested subjects TRH responsiveness recovered following partial thyroidectomy. In 3 of 7 TRH unresponsive euthyroid patients tested 9-12 days post surgery a transient lack of TSH to respond to TRH was observed. Recovery of TRH responsiveness was accompanied by a significant (P IS LESS THAN 0, 02) decrease in serum T4and FT4I in the euthyroid range, whereas no change in serum T3 occurred. It is suggested that TRH unresponsiveness represents a state of preclinical hyperthyroidism maintained by autonomously functioning goiter compartments.

Adult↗