Search PubMed⌕ Search

Biomedical subjects

J Sprung

Publications and source records attributed to J Sprung.

At least 19 recordsLinked to original sources
PubMed2007

Perioperative management of familial dysautonomia: a systematic review.

BACKGROUND AND OBJECTIVE: Familial dysautonomia (FD), a rare genetic disorder, is characterized by autonomic instability, pulmonary infections, oesophageal dysmotility, spinal abnormalities and episodic "dysautonomic crisis" characterized by rash, vomiting, sweating and hypertension. Frequent anaesthetic complications have been reported. METHODS: We performed a comprehensive literature search of perioperative management of FD using an OVID-based search strategy. Identified reports were reviewed to identify perioperative complications as well as anaesthetic techniques and perioperative management strategies developed to minimize or prevent these complications. RESULTS: Eighteen case reports or series of perioperative management of FD were identified in the literature for a total of 179 patients undergoing 290 anaesthetics. Intraoperative cardiovascular lability, including cardiac arrests and postoperative pulmonary complications were commonly reported. Preoperative hydration, minimizing the use of volatile anaesthetic agents, postoperative ventilation, use of regional anaesthesia and minimally invasive surgical techniques reduced the incidence of these complications. CONCLUSIONS: While patients with FD are reported to have a relatively high rate of various perioperative complications, a full understanding of its pathophysiology can be used to develop a perioperative management strategy to anticipate and prevent many of these complications.

Anesthesia↗
PubMed2001

Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of "limited" resuscitations.

BACKGROUND: The results of in-hospital resuscitations may depend on a variety of factors related to the patient, the environment, and the extent of resuscitation efforts. We studied these factors in a large tertiary referral hospital with a dedicated certified resuscitation team responding to all cardiac arrests. METHODS: Statistical analysis of 445 prospectively recorded resuscitation records of patients who experienced cardiac arrest and received advanced cardiac life support resuscitation. We also report the outcomes of an additional 37 patients who received limited resuscitation efforts because of advance directives prohibiting tracheal intubation, chest compressions, or both. MAIN OUTCOME MEASURES: Survival immediately after resuscitation, at 24 hours, at 48 hours, and until hospital discharge. RESULTS: Overall, 104 (23%) of 445 patients who received full advanced cardiac life support survived to hospital discharge. Survival was highest for patients with primary cardiac disease (30%), followed by those with infectious diseases (15%), with only 8% of patients with end-stage diseases surviving to hospital discharge. Neither sex nor age affected survival. Longer resuscitations, increased epinephrine and atropine administration, multiple defibrillations, and multiple arrhythmias were all associated with poor survival. Patients who experienced arrests on a nursing unit or intensive care unit had better survival rates than those in other hospital locations. Survival for witnessed arrests (25%) was significantly better than for nonwitnessed arrests (7%) (P =.005). There was a disproportionately high incidence of nonwitnessed arrests during the night (12 AM to 6 AM) in unmonitored beds, resulting in uniformly poor survival to hospital discharge (0%). None of the patients whose advance directives limited resuscitation survived. CONCLUSIONS: Very ill patients in unmonitored beds are at increased risk for a nonwitnessed cardiac arrest and poor resuscitation outcome during the night. Closer vigilance of these patients at night is warranted. The outcome of limited resuscitation efforts is very poor.

Adult↗
PubMed2001

The effects of propofol on the contractility of failing and nonfailing human heart muscles.

We determined the direct effects of propofol on the contractility of human nonfailing atrial and failing atrial and ventricular muscles. Atrial and ventricular trabecular muscles were obtained from the failing human hearts of transplant patients or from nonfailing hearts of patients undergoing coronary artery bypass surgery. Isometric contraction variables were recorded before and after propofol was added to the bath in concentrations between 0.056 and 560 microM. The effects of propofol were compared with its commercial vehicle intralipid. To test beta-adrenergic effects in the presence of propofol, 1 microM isoproterenol was added at the end of each experiment. To determine the cellular mechanisms responsible for the actions of propofol, we examined its effects on actomyosin ATPase activity and sarcoplasmic reticulum (SR) Ca(2+) uptake in nonfailing atrial tissues. Propofol caused a concentration-dependent decrease in maximal developed tension in all muscles, which became significant (P < 0.05) at concentrations exceeding the clinical range (> or =56 microM). Isoproterenol restored contractility to the level achieved before exposure to propofol (P > 0.05 compared with baseline). Failing ventricular muscle exposed to propofol exhibited somewhat diminished ability to recover contractility in response to isoproterenol (P < 0.05 versus failing muscle exposed to intralipid only). Propofol induced a concentration-dependent decrease in the uptake of Ca(2+) into SR vesicles. At the same time, in the presence of 56 microM propofol, the Ca(2+)-activated actomyosin ATPase activity was shifted leftward, demonstrating an increase in myofilament sensitivity to Ca(2+). We conclude that propofol exerts a direct negative inotropic effect in nonfailing and failing human myocardium, but only at concentrations larger than typical clinical concentrations. Negative inotropic effects are reversible with beta-adrenergic stimulation. The negative inotropic effect of propofol is at least partially mediated by decreased Ca(2+) uptake into the SR; however, the net effect of propofol on contractility is insignificant at clinical concentrations because of a simultaneous increase in the sensitivity of the myofilaments to activator Ca(2+).

Aged↗
PubMed2001

Normal saline versus lactated Ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study.

UNLABELLED: Metabolic acidosis and changes in serum osmolarity are consequences of 0.9% normal saline (NS) solution administration. We sought to determine if these physiologic changes influence patient outcome. Patients undergoing aortic reconstructive surgery were enrolled and were randomly assigned to receive lactated Ringer's (LR) solution (n = 33) or NS (n = 33) in a double-blinded fashion. Anesthetic and fluid management were standardized. Multiple measures of outcome were monitored. The NS patients developed a hyperchloremic acidosis and received more bicarbonate therapy (30 +/- 62 mL in the NS group versus 4 +/- 16 mL in the LR group; mean +/- SD), which was given if the base deficit was greater than -5 mEq/L. The NS patients also received a larger volume of platelet transfusion (478 +/- 302 mL in the NS group versus 223 +/- 24 mL in the LR group; mean +/- SD). When all blood products were summed, the NS group received significantly more blood products (P = 0.02). There were no differences in duration of mechanical ventilation, intensive care unit stay, hospital stay, and incidence of complications. When NS was used as the primary intraoperative solution, significantly more acidosis was seen on completion of surgery. This acidosis resulted in no apparent change in outcome but required larger amounts of bicarbonate to achieve predetermined measurements of base deficit and was associated with the use of larger amounts of blood products. These changes should be considered when choosing fluids for surgical procedures involving extensive blood loss and requiring extensive fluid administration. IMPLICATIONS: Predominant use of 0.9% saline solution in major surgery has little impact on outcome as assessed by duration of mechanical ventilation, intensive care unit stay, hospital stay, and postoperative complications, but it does appear to be associated with increased perioperative blood loss.

Aged↗
PubMed2000

Anesthetic aspects of laparoscopic and open adrenalectomy for pheochromocytoma.

OBJECTIVES: To compare the anesthetic aspects and intraoperative hemodynamic data and immediate postoperative outcomes in patients whose pheochromocytoma resection was performed either laparoscopically or by traditional open surgery. METHODS: Fourteen consecutive patients who underwent laparoscopic procedures (a single surgeon) were compared with 20 patients who underwent open surgery. The patients' records were reviewed for demographic information, preoperative medical history and therapy, intraoperative hemodynamic data, fluid balance, and immediate postoperative course. RESULTS: No differences between the highest intraoperative blood pressures and number of hypertensive episodes between the two groups were found. However, in laparoscopic patients, the intraoperative hypotension was less severe (mean lowest blood pressure 98/57 mm Hg versus 88/50 mm Hg, P = 0.05), and the hypotensive episodes were less frequent (median 0 versus 2, P = 0.005) and required fewer interventions with vasopressors (P = 0.02). Extreme high and extreme low heart rates did not differ between the two groups. The estimated blood loss was lower in the laparoscopic group (P = 0.0001), but the total intraoperative fluid requirement and operative times were similar in the two groups. Patients in the laparoscopic group resumed walking earlier (median 1.5 versus 4 days, P = 0.002) and resumed oral food intake sooner (median 1 versus 3.5 days, P = 0.0001). The median duration of hospitalization in patients who underwent laparoscopic and open adrenalectomy was 3 and 7.5 days, respectively (P = 0.001). CONCLUSIONS: Intraoperative hemodynamic values during laparoscopic adrenalectomy for pheochromocytoma were comparable to those of traditional open surgery, but the patients who underwent the laparoscopic procedure had a faster postoperative recovery.

Adolescent↗
PubMed2000

Anesthesia for kidney transplant surgery.

Organ viability associated with renal transplantation is a product of the managing of the donor patient, the allograft, and the recipient patient. Short- and long-term outcome is influenced by perioperative fluid and drug treatment, and the function and viability of the transplanted kidney seem to be optimized if graft perfusion is maximized through mild hypervolemia. At the same time, careful balancing of intraoperative fluids is necessary against cardiovascular problems frequently encountered in patients with uremia. Close intraoperative monitoring, optimization of intravascular fluid volume status to maximize kidney perfusion, and prompt correction of electrolyte disturbances (especially potassium) are key to short- and long-term success of renal transplants.

Anesthesia↗
PubMed2000

Small-dose dopamine increases epidural lidocaine requirements during peripheral vascular surgery in elderly patients.

UNLABELLED: We studied 20 patients over the age of 65 yr undergoing prolonged peripheral vascular surgery under continuous lidocaine epidural anesthesia, anticipating that the increased hepatic metabolism caused by small-dose IV dopamine would lower plasma lidocaine concentrations. Subjects were assigned (random, double-blinded) to receive either a placebo IV infusion or dopamine, 2 microg. kg(-1). min(-1) during and for 5 h after surgery. Five minutes after the IV infusion was started, 20 mL of 2% lidocaine was injected through the epidural catheter. One-half hour later, a continuous epidural infusion of 2% lidocaine at 10 mL/h was begun. The epidural infusion was temporarily decreased to 5 mL/h or 5 mL boluses were added to maintain a T8 analgesic level. Arterial blood samples were analyzed for plasma lidocaine concentrations regularly during and for 5 h after surgery. Plasma lidocaine concentrations increased continuously during the epidural infusion and, despite wide individual variation, were similar for the two groups throughout the observation period. During the observation period, the mean maximal plasma lidocaine concentration was 5.8 +/- 2.3 microg/mL in the control group and 5.7 +/- 1.2 microg/mL in the dopamine group. However, the mean hourly lidocaine requirement during surgery was significantly different, 242 +/- 72 mg/h for control and 312 +/- 60 mg/h for dopamine patients (P < 0.03). At the end of Hour 4, the last period when all 20 patients were still receiving the epidural lidocaine infusion, the total lidocaine requirement was significantly different, 1088 +/- 191 mg for the control group and 1228 +/- 168 mg for the dopamine group (P < 0.05). Despite very large total doses of epidural lidocaine (1650 +/- 740 mg, control patients, and 1940 +/- 400, dopamine patients) mean maximal plasma concentrations remained below 6 microg/mL, and no patient exhibited signs or symptoms of toxicity. We conclude that small-dose IV dopamine increased epidural lidocaine requirements, presumably as a consequence of increased metabolism. IMPLICATIONS: We tested dopamine, a drug that increases liver metabolism of the local anesthetic lidocaine to determine if it would prevent excessively large amounts of lidocaine in the blood during prolonged epidural anesthesia in elderly patients. Dopamine did not alter the blood levels of lidocaine, but it did increase the lidocaine dose requirement to maintain adequate epidural anesthesia.

Adjuvants, Anesthesia↗
PubMed2000

The effects of etomidate on the contractility of failing and nonfailing human heart muscle.

UNLABELLED: We measured the effects of etomidate on contractility of human cardiac muscle. Muscles were obtained from the left ventricle and right atrium of 12 patients undergoing cardiac transplantation, and from the right atrium of 12 patients undergoing coronary artery bypass surgery. Muscles were studied at 37 degrees C and 1.0 Hz. Variables of isometric contraction were recorded before and after etomidate (0.04-80 microM) or its solvent, propylene glycol. The ability of beta-adrenergic stimulation to cause an inotropic effect after etomidate was also assessed. Etomidate caused a dose-dependent decrease in developed tension, which was statistically significant only at concentrations exceeding clinical doses (> or =20 microM; P < 0. 05). Decreases in maximum rates of contraction and relaxation paralleled changes in developed tension. beta-Adrenergic stimulation reversed the etomidate-induced decreases in developed tension and rates of contraction and relaxation to baseline (P > 0.05 compared with baseline). Thus, in human myocardium, etomidate exerts a dose-dependent negative inotropic effect, which is reversible with beta-adrenergic stimulation. Concentrations required to produce these negative inotropic effects are, however, in excess of those reached during clinical use. Therefore, etomidate-induced negative inotropy is unlikely to be a problem clinically, even in patients with cardiac dysfunction. IMPLICATIONS: Etomidate produced a similar dose-dependent negative inotropic effect in both failing and nonfailing human myocardium. This effect was present only at concentrations exceeding those attained clinically and was reversible with beta-adrenergic stimulation.

Adolescent↗
PubMed2000

Analysis of risk factors for myocardial infarction and cardiac mortality after major vascular surgery.

BACKGROUND: Patients undergoing vascular surgical procedures are at high risk for perioperative myocardial infarction (PMI). This study was undertaken to identify predictors of PMI and in-hospital death in major vascular surgical patients. METHODS: From the Vascular Surgery Registry (6,948 operations from January 1989 through June 1997) the authors identified 107 patients in whom PMI developed during the same hospital stay. Case-control patients (patients without PMI) were matched at a 1x:x1 ratio with index cases according to the type of surgery, gender, patient age, and year of surgery. The authors analyzed data regarding preoperative cardiac disease and surgical and anesthetic factors to study association with PMI and cardiac death. RESULTS: By using univariable analysis the authors identified the following predictors of PMI: valvular disease (P = 0.007), previous congestive heart failure (P = 0.04), emergency surgery (P = 0.02), general anesthesia (P = 0.03), preoperative history of coronary artery disease (P = 0.001), preoperative treatment with beta-blockers (P = 0.003), lower preoperative (P = 0.03) and postoperative (P = 0.002) hemoglobin concentrations, increased bleeding rate (as assessed from increased cell salvage; P = 0.025), and lower ejection fraction (P = 0.02). Of the 107 patients with PMI, 20.6% died of cardiac cause during the same hospital stay. The following factors increased the odds ratios for cardiac death: age (P = 0.001), recent congestive heart failure (P = 0.01), type of surgery (P = 0.04), emergency surgery (P = 0.02), lower intraoperative diastolic blood pressure (P = 0.001), new intraoperative ST-T changes (P = 0.01), and increased intraoperative use of blood (P = 0.005). Patients who underwent coronary artery bypass grafting, even more than 12 months before index surgery, had a 79% reduction in risk of death if they had PMI (P = 0.01). Multivariable analysis revealed preoperative definitive diagnosis of coronary artery disease (P = 0.001) and significant valvular disease (P = 0.03) were associated with increased risk of PMI. Congestive heart failure less than 1 yr before index vascular surgery (P = 0. 0002) and increased intraoperative use of blood (P = 0.007) were associated with cardiac death. The history of coronary artery bypass grafting reduced the risk of cardiac death (P = 0.04) in patients with PMI. CONCLUSIONS: The in-hospital cardiac mortality rate is high for patients who undergo vascular surgery and experience clinically significant PMI. Stress of surgery (increased intraoperative bleeding and aortic, peripheral vascular, and emergency surgery), poor preoperative cardiac functional status (congestive heart failure, lower ejection fraction, diagnosis of coronary artery disease), and preoperative history of coronary artery bypass grafting are the factors that determine perioperative cardiac morbidity and mortality rates.

Analysis of Variance↗
PubMed1999

Use of preoperative autologous blood donation in patients undergoing radical retropubic prostatectomy.

OBJECTIVES: To evaluate the appropriateness of autologous blood (AB) transfusion during radical retropubic prostatectomy in relation to the cardiopulmonary risk of the patient. METHODS: We reviewed the medical records of 100 patients with American Society of Anesthesiologists status I, II, or III who underwent radical retropubic prostatectomy under general or combined general and epidural anesthesia. All patients had donated 2 units (U) of autologous blood, received 0, 1, or 2 U of autologous blood perioperatively, and received no allogeneic blood. Patients were placed in three cardiopulmonary risk groups on the basis of risk factors or documented cardiopulmonary disease. The low-risk group was assigned a target discharge hematocrit of 24% or less; moderate-risk, 25% to 28%; and high-risk, 29% or greater. The appropriateness of transfusion was determined by whether patients' hematocrit was in their group's preassigned range at discharge. RESULTS: On the basis of discharge hematocrit, significantly more low-risk patients underwent inappropriate transfusion than moderate-risk (64% versus 26%, P = 0.006) or high-risk (64% versus 13%, P = 0.001) patients. Seventy-five AB units were discarded and at least 53 U were inappropriately transfused. We found an increase in the number of units of autologous blood transfused when a larger estimated blood loss was reported (P < 0.001). The estimated charge for the units discarded and inappropriately transfused exceeded $12,000. CONCLUSIONS: Sixty-four percent of autologous blood units were discarded or inappropriately transfused during radical retropubic prostatectomy. Transfusion of autologous blood was not governed by cardiopulmonary risk stratification. If the decision to transfuse had been based on cardiopulmonary risk factors instead of estimated blood loss, fewer patients would have received autologous blood.

Blood Transfusion, Autologous↗
PubMed1999

Predicting the difficult neuraxial block: a prospective study.

UNLABELLED: Anticipated technical difficulty is one factor that can influence the anesthesiologist's decision to perform neuraxial (spinal or epidural) blockade. Problems during the procedure may be associated with patient dissatisfaction, neurologic sequelae, or hematoma. We designed this study of 595 neuraxial blocks to determine whether any patient characteristics would be useful in predicting a difficult neuraxial block. Before the procedure, the following data were noted: demographic data, body habitus (normal, thin, muscular, obese), spinal landmarks (good = easily palpable spinous processes, poor = difficult to palpate spinous processes, none = unable to positively identify spinous processes), and spinal anatomy (assessed by inspection and examination as normal or deformed). We noted the technique, approach, needle type, needle gauge, etc. We also recorded whether the procedure was completed at the first (first-level success) or second spinal level and the total number of new skin punctures (attempts) necessary to complete the procedure. Of all the factors considered, the quality of landmarks best correlated with technical difficulty as measured by both first-level success and number of attempts. Abnormal spinal anatomy correlated with difficulty as measured by number of attempts. Body habitus also correlated with difficulty, but only as measured by number of attempts. There was no association between either measure of difficulty and any of the following: age, sex, spinal versus epidural, approach, needle type, needle gauge, or training level of the provider. Thoracic epidurals were less difficult than lumbar epidurals by both measures of difficulty. We conclude that body habitus does not seem to be the best predictor of technical difficulty. An examination of the patient's back for the quality of landmarks and obvious anatomical deformity better predicts the ease or difficulty of neuraxial block. Other factors seem to have little or no influence on the difficulty of neuraxial block procedures. IMPLICATIONS: We studied a number of factors, including equipment, technique, and patient characteristics, that may indicate the ease or difficulty of performing neuraxial (spinal and epidural) blocks. Of these factors, only patient characteristics had significant predictive value. We found that an examination of the patient's back for the quality of landmarks and obvious anatomical deformity better predicts the ease or difficulty of neuraxial block than does body habitus.

Adolescent↗