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PubMed1997

The use of central regional anesthesia techniques in Sweden: results of a nation-wide survey. Swedish Association of Anesthesia and Intensive care.

BACKGROUND: Epidural and subarachnoid anesthesia are well established central regional techniques for surgical anesthesia. Two additional techniques, combined spinal epidural (CSE) block and continuous spinal anesthesia (CSA), have recently become popular. However, data on nation-wide use of central regional blocks are not available. METHOD: With the aims to survey the use of central regional techniques, to evaluate the risk of complications to central regional blocks and to document the use of continuous epidural techniques for postoperative pain management in Sweden during 1993, a questionnaire was mailed to all 105 Swedish anesthesiology departments. RESULTS: Questionnaires were returned by 62 departments, representing all categories of Swedish hospitals. Central regional blocks were used for surgical anesthesia in 20-40% of reported surgical procedures. Subarachnoid anesthesia was the main technique for orthopedic surgery on the lower limb, elective cesarean section and transurethral resection of the prostate. Epidural block was used for orthopedic and vascular surgery. CSE block was used by 42 departments and CSA by 21 departments. Postoperative epidural analgesia was used by 59 departments, most commonly with continuous infusion of local anesthestics and/or epidural bolusdoses of morphine. Nineteen neurological sequelae were reported after epidural (n = 7) and subarachnoid (n = 12) blocks. Routines for registration of complications varied greatly. CONCLUSIONS: Subarachnoid block was preferred for shorter surgical procedures (< 60 min), whereas epidural and CSE blocks were chosen when severe postoperative pain could be anticipated, as continuous epidural analgesia was well established for postoperative pain management. Improved routines for registration of complications to central regional blocks are needed.

Anesthesia, Conduction↗
PubMed2001

Total intravenous anesthesia versus single breath technique and anesthesia maintenance with sevoflurane for bariatric operations.

BACKGROUND: The choice of anesthetic technique for general anesthesia in morbidly obese patients remains controversial. We aimed to compare blood gases, recovery and hemodynamic parameters using TIVA and sevoflurane anesthesia in bariatric surgery. METHODS: The study was performed with permission of the ethics committee. We studied 40 morbidly obese patients allocated to 2 groups. The total i.v. anesthesia (TIVA) group was named Group T, and the sevoflurane group was named Group S. In Group T, anesthesia induction was achieved with propofol. In Group S, anesthesia induction was achieved by sevoflurane with single breath technique, with maintenance provided with 1-2% volume sevoflurane. Student t, Chi square and ANOVA tests were used for data analysis; p-value < 0.05 was considered statistically significant. RESULTS: There was no significant difference between the 2 groups in demographic data, blood gas values and recovery characteristic. Hemodynamic values were significantly lower in Group T than Group S, during and after the operative period. CONCLUSION: While sevoflurane induction and maintenance is a suitable anesthetic modality for obese patients, TIVA can be applied easily in those patients possessing no extra risk factors other than morbid obesity.

Adult↗
PubMed2001

[The influence of age on hemodynamics and the dose requirements of propofol and buprenorphine in total intravenous anesthesia combined with continuous epidural anesthesia].

A retrospective study was performed to determine the influence of age on hemodynamics and awakening time in total intravenous anesthesia (TIVA) using propofol and buprenorphine combined with continuous epidural anesthesia for abdominal surgery. Thirty-five patients (36-87 yr) were allocated to the following five groups by age: 36-49 yr, 50-59 yr, 60-69 yr, 70-79 yr and 80-87 yr. All patients were premedicated with midazolam i.m. Anesthesia was maintained with propofol infusion with 40% oxygen in air, intravenous buprenorphine plus vecuronium and continuous epidural anesthesia using 2% mepivacaine. After extubation, the epidural bolus dose (buprenorphine 0.1-0.2 mg with droperidol 1.25-2.5 mg) and epidural infusion (buprenorphine 17 micrograms.h-1 with droperidol 0.1 mg.h-1) were administered. Intraoperative heart rate (HR) and mean arterial pressure (MAP) decreased but remained within 30% of preanesthetic level. HR did not differ in five groups, although MAP decreased significantly in patients above 50 yr of age. The doses of midazolam (1-5 mg), propofol (2.7-7.4 mg.kg-1.h-1) and buprenorphine (40-200 micrograms) decreased with age (P < 0.01), while the maintenance doses of mepivacaine (40-140 mg.h-1) and vecuronium (0.03-0.09 mg.kg-1.h-1) showed no significant decrease. Awakening time was not significantly prolonged with age (r = 0.27, P = 0.12). Two patients in each group required analgesics within 20 hours. Neither nausea, respiratory depression nor awareness was found. We suggest that the combination of TIVA and continuous epidural anesthesia would be useful to maintain stable hemodynamic state and to obtain early recovery time, especially in the elderly.

Adult↗
PubMed1993

[Intravenous anesthesia with perfused propofol combined with loco-regional spinal anesthesia].

The authors review the advantages and disadvantages of general and regional anesthesia in bad clinical conditions. The purpose of this study was to evaluate the efficacy of Blended Anesthesia (association of general anesthesia with a regional technique) in 25 patients belonging to ASA classes II-III-IV, undergoing surgery for various disease. General anesthesia was provided by perfusion of propofol, after a peridural or subarachnoid continuous anesthesia was started. Patients were either in spontaneous or controlled ventilation. There were no cases of hypotension or other important side effects and the majority of patients judged good the anesthetic technique in regard to lack of pain, exhaustion and recall of operation.

Aged↗
PubMed1998

[Total intravenous anesthesia with propofol is advantageous than thiopental-sevoflurane anesthesia in the recovery phase].

A randomized, prospective and multi-institutional study was performed to investigate whether different anesthetic methods affected differently the quality of recovery from anesthesia. Two hundred and eleven patients were allocated to one of two groups; total intravenous anesthesia (TIVA) with propofol and fentanyl (group P, n = 107) and general anesthesia with thiopental, sevoflurane and nitrous oxide (group TS, n = 104). The rapidity of emergence from anesthesia and postoperative incidence of nausea, vomiting, and headache were compared between the two groups. The group P showed significantly shorter emergence times for verbal command responses (7.4 +/- 5.6 min), extubation (10.0 +/- 6.0 min) and orientation (13.1 +/- 7.8 min) than the group TS (9.1 +/- 5.0 min, 11.7 +/- 6.2 min, 16.4 +/- 7.9 min, respectively). The postoperative incidence of vomiting was not significantly different between the two groups (3.7% in the group P and 9.6% in the group TS), but the postoperative incidences of nausea and headache were significantly lower in the group P compared with the group TS (10.3%, 17.8%, respectively in the group P and 34.6%, 29.8%, respectively in the group TS). We conclude that TIVA with propofol is advantageous than thiopental-sevoflurane anesthesia in the recovery phase.

Adult↗
PubMed1985

Computerized monitoring of the EMG and EEG during anesthesia. An evaluation of the anesthesia and brain activity monitor (ABM).

An intraoperative evaluation was made of the electroencephalographic (EEG) and electromyographic (EMG) functions of the Anesthesia and Brain activity Monitor (ABM). This device derives both these measures from a single electrode pair that is typically placed on the mid-forehead and mastoid process. The evaluation consisted of 1) quantifying the zero-crossing frequency (ZXF) of the EEG and mean integrated voltage of both measures (MIVEEG and MIVEMG) that occurred during induction and emergence from general anesthesia in 17 patients and 2) case reports sampled from an additional 41 patients. Alone or combined, variations in these parameters did not consistently accompany changes in the depth or adequacy of anesthesia as determined by standard clinical signs (e.g. heart rate, blood pressure, movement). Interpatient variability in the EEG measures during recovery from anesthesia was so large that neither the absolute value of ZXF nor that of MIVEEG could discriminate between moderate (i.e., maintenance) and light (i.e., emergence) anesthesia. Although MIVEMG uniformly decreased in anesthetized, unparalyzed patients (compared to the pre-operative awake state), noticeable increases during recovery often did not occur until limb movement was observed. Additionally, the common use of neuromuscular blockers made interpretation of low MIVEMG values quite difficult during anesthesia maintenance. However, selected individual case reports illustrated the potential benefit of routine intraoperative, microprocessor-based EEG/EMG monitoring. The single channel EEG/EMG display of the ABM seems sufficient to warn the anesthesiologist of pathologic decreases in cerebral electrical activity. Marked depression of cerebral function is associated with accidental anesthetic overdose, hypoxia or global ischemia. Additionally, the device should be useful for monitoring burst-suppression or isoelectric EEG patterns intentionally produced during barbiturate or isoflurane coma for cerebral protection.

Adolescent↗
PubMed2004

Naloxone reversal of opioid anesthesia revisited: clinical evaluation and plasma concentration analysis of continuous naloxone infusion after anesthesia with high-dose fentanyl.

PURPOSE: In spite of several advantages, the need for postoperative ventilatory support limits the use of high-dose opioid anesthesia. We prospectively evaluated the effectiveness of naloxone infusion for the reversal of high-dose fentanyl anesthesia. METHODS: Anesthesia was maintained with fentanyl in patients undergoing major abdominal surgery. After anesthesia, the trachea was extubated when intravenous naloxone, which was titrated in separate 50- micro g doses, established an acceptable level of consciousness and arterial blood gas (ABG) status under spontaneous respiration; this was followed by continuous infusion started at the rate of the sum of the bolus doses per hour. The naloxone infusion was terminated based on evaluation of the level of consciousness, ABG, and acute abstinence symptoms. Postoperative pain was evaluated using self-reported four-step categorical terms (none, mild, moderate, and severe). Plasma concentrations of fentanyl and naloxone were analyzed in 12 patients, using high-performance liquid chromatography. RESULTS: Fifty-seven out of 59 eligible patients were successfully extubated at 34 +/- 14 min after termination of fentanyl (total dose, 127 +/- 64 micro g.kg(-1); mean +/- SD) with naloxone (total bolus, 3.4 +/- 2.6 micro g.kg(-1)). All these patients recovered fully without ventilatory support under the naloxone infusion, which was terminated at 11 +/- 7 h. The reduction of the naloxone infusion rate effectively relieved the increased pain, and no supplemental analgesic was used in any patients during the naloxone infusion. Pharmacokinetic analysis did not indicate any correlations between plasma fentanyl and naloxone concentrations. CONCLUSION: The results suggest that naloxone infusion with individual dose titration facilitates the use of high-dose opioid anesthesia, maintaining the advantager of this anesthesia.

Abdomen↗
PubMed1992

The effect of the extended (3-year) anesthesia curriculum on anesthesia subspecialty education.

The purpose of this study was to determine the effect of lengthening the anesthesia residency by the American Board of Anesthesiology on the education of anesthesia subspecialists. A survey of anesthesia residency programs was conducted from 1987 to 1991. The most frequent subspecialty practice in the clinical anesthesia (CA) 3 year is cardiovascular anesthesia. However, the percentage of CA3 residents spending extended time (greater than or equal to 6 months) in subspecialty education has significantly decreased. For example, the percentage of CA3 residents spending 12 months in subspecialty education has decreased 83%. There appears to be a slight increase in the number of CA4 or PGY5 residents (fellows) electing subspecialty practice. It is concluded that the 3-year curriculum has produced a negative impact on the education of anesthesia subspecialists.

Anesthesiology↗
PubMed1990

[Hemodynamics and myocardial energy balance in coronary surgery patients during high-dose fentanyl-pancuronium anesthesia and modified neurolept-pancuronium anesthesia].

In 8 patients with coronary artery disease (CAD) classed as NYHA II or III, anesthesia was induced with high-dose fentanyl (0.05 mg/kg) and pancuronium (0.1 mg/kg). The patients were ventilated normally with the aid of a mask (O2: air 1:1, tidal volume 10 ml/kg with a rate of 10/min) for 5 min and then intubated. In 8 further patients with CAD NYHA class II or III, anesthesia was induced with 0.02 mg/kg flunitrazepam, N2O/O2 1:1 and isoflurane 0.5 vol%; they were relaxed with pancuronium (0.1 mg/kg) in combination with a bolus of 0.005 mg/kg fentanyl. These patients were also ventilated normally for 5 min and then intubated. Measurements of cardiovascular dynamics included cardiac output (CO), heart rate (HR), arterial pressure (AP), pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), myocardial blood flow (MBF), and arterial and coronary sinus oxygen and lactate contents. Cardiac index (CI), stroke volume index (SVI), total peripheral resistance (TPR), myocardial oxygen consumption (MVO2), coronary vascular resistance (CVR), coronary perfusion pressure (CPP), myocardial oxygen content difference (AVDO2cor) and myocardial lactate extraction rate (LE) were calculated from standard formulas. Measurements and an electrocardiogram were taken before anesthesia, after induction of anesthesia and after intubation. The hemodynamic parameters HR, AP, CI, CPP were relatively stable in patients anesthetized with high-dose fentanyl and pancuronium, whereas we found greater decreases in these parameters with the balanced anesthesia technique. Determinants of myocardial oxygen demand were higher in the high-dose fentanyl group; therefore, myocardial blood flow and oxygen consumption did not decrease to the same extent as in the balanced anesthesia group.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMedDate not supplied

The influence of selected antiarrhythmic drugs on the hemodynamic parameters in rabbits during anesthesia. Part I. Propofol anesthesia.

Cardiac arrhythmia can be a serious complication during general anesthesia. On the other hand, there is a need for general anesthesia of patients suffering from cardiac arrhythmias and using antiarrhythmic drugs. The aim of the present experiments was to establish the way in which procainamide, N-acetyl-procainamide, verapamil and propranolol influence hemodynamic parameters of rabbits during propofol anesthesia. The experiments were performed on rabbits. Heart rate was counted from ECG. Blood pressure was measured directly in the carotid artery. Cardiac output, stroke volume, and total peripheral resistance were estimated using the method of human Cr51 albumin dilution. Hepatic blood flow was estimated after single injection of 99mTc/Sn Hepida. Renal blood flow was estimated after a single injection of 125J-hippurate. Propofol decreases renal and hepatic blood flows, decreases blood pressure and peripheral vascular resistance. Propranolol given alone or in combination with propofol decreases hepatic blood flow. The administration of antiarrhythmic drugs during propofol anesthesia decreases renal blood flow. Propofol decreases blood pressure in rabbits as a result of decreased peripheral vascular resistance. It also decreased RBF and HBF. Disadvantages of interactions of propofol and antiarrhythmic drugs concern mainly with RBF and HBF. Propranolol (given alone or in combination with propofol) strongly decreases HBF. NAPA given during P anesthesia exerts a weaker effect on HBF. The administration of antiarrhythmic drugs during propofol anesthesia decreases RBF. The strongest disadvantageous action is exerted by propranolol, the slightest one--by verapamil.

Anesthetics, Intravenous↗
PubMed1994

Propofol-fentanyl anesthesia: a comparison with isoflurane-fentanyl anesthesia in coronary artery bypass grafting and valve replacement surgery.

The hemodynamic effects of propofol-fentanyl and isoflurane-fentanyl anesthesia during the prebypass period were compared in 42 patients undergoing coronary artery bypass grafting (CABG) and 22 patients undergoing valve replacement (VR) for stenotic lesions. Anesthesia was induced with fentanyl, 25 micrograms/kg, and pancuronium, 0.1 mg/kg, and was maintained with a propofol infusion commenced at 4 mg/kg/h (range 1 to 10 mg/kg/h) or with isoflurane commenced at 1% (range 0 to 2%). Additional fentanyl, 7.5 micrograms/kg, was given before sternotomy. Hemodynamic measurements were made before induction of anesthesia and at various times in the prebypass period. In the VR group, there were no significant differences between the two anesthetics in any hemodynamic variables during the study. Significant decreases (P < 0.05) in mean arterial pressure (MAP 14%), left ventricular stroke work index (LVSWI 29%), and stroke volume index (SVI 24%) occurred after 15 minutes of propofol anesthesia in the CABG group. With isoflurane MAP was well maintained with reductions in LVSWI and SVI of 22% and 20%, respectively. Isoflurane was, however, associated with a significant increase in heart rate (HR) in the CABG group (P < 0.05), whereas no significant change in HR occurred in CABG or VR patients receiving propofol. With both techniques there were no significant changes in right-sided or left-sided filling pressures or in systemic vascular resistance index in the CABG or VR groups, except for a decrease in pulmonary artery occlusion pressure in the propofol VR group and isoflurane CABG group at the time of aortic cannulation. Propofol produced similar hemodynamic changes in the CABG and VR groups. Both anesthetic techniques caused myocardial depression and effectively controlled the autonomic responses to sternotomy in both groups. The study suggests that propofol-fentanyl anesthesia is an acceptable technique for CABG surgery and for VR in patients with stenotic valvular heart disease.

Adolescent↗
PubMed2006

Different effects on circulatory control during volatile induction and maintenance of anesthesia and total intravenous anesthesia: autonomic nervous activity and arterial cardiac baroreflex function evaluated by blood pressure and heart rate variability analysis.

STUDY OBJECTIVE: To evaluate the different effects on autonomic circulatory control during volatile induction/maintenance of anesthesia (VIMA) vs total intravenous anesthesia (TIVA). DESIGN: Prospective study. SETTING: Operating theater of a university hospital. PATIENTS: Twenty patients, with American Society of Anesthesiologists physical status of I or II, were randomly allocated into the VIMA group (n = 10) or the TIVA group (n = 10). INTERVENTIONS: In the VIMA group, anesthesia was induced with 5% sevoflurane and 60% N2O in oxygen and maintained with 2% sevoflurane and 60% N2O in oxygen. In the TIVA group, anesthesia was induced with propofol 2.0 mg/kg intravenously by bolus injection and fentanyl 2 microg/kg, and maintained with an intravenous infusion of propofol 5 mg/kg.per hour and air-oxygen mixture. MEASUREMENTS: Monitoring included recordings of electrocardiographic and arterial blood pressure waveforms. Autonomic nervous activity and arterial cardiac baroreflex function were evaluated by analysis of blood pressure variability, heart rate variability, and transfer function analysis between these 2 variables. MAIN RESULTS: In the VIMA group, the low-frequency component of blood pressure variability (LF(SBP)) and low- and high-frequency components of the R-R interval variability (LF(RR) and HF(RR)) decreased significantly during anesthesia. In the TIVA group, LF(SBP) and LF(RR) decreased significantly. The degree of reduction in LF(SBP) was greater in the VIMA group than in the TIVA group. However, changes in R-R interval variability and cardiac baroreflex indices were not significantly different between the 2 groups. CONCLUSIONS: Our results demonstrated that although reductions in autonomic nervous modulation to the heart might not be so different between the 2 groups, reduction in sympathetic nervous modulation to peripheral vasculature is greater in the VIMA group than in the TIVA group.

Adult↗
PubMed1989

Con: regional anesthesia is not preferable to general anesthesia for the patient with heart disease.

The debate over regional anesthesia and general anesthesia with respect to relative risk in different classes of patients will probably be interminable until studies addressing the issue begin to specify the treatment protocols more carefully and to control as many variables as possible. Patients with cardiovascular disease who undergo major surgery are special cases in which either form of anesthesia may be acceptable or preferable. The benefits of lesser regional procedures do not necessarily extend to major conduction blockade in these individuals. Appropriate monitoring and goal-directed control of physiologic variables throughout the entire perioperative period may be more important than the type of anesthesia. General anesthesia that is carefully prepared, monitored, and conducted cannot be ruled out in the seriously ill.

Anesthesia, Conduction↗
PubMed2005

Conscious cardiac surgery with cardiopulmonary bypass using thoracic epidural anesthesia without endotracheal general anesthesia.

OBJECTIVE: The purpose of this study was to evaluate the feasibility of thoracic epidural anesthesia as an alternative technique to general anesthesia in patients undergoing cardiac surgery under cardiopulmonary bypass. DESIGN: A prospective study. SETTING: Tertiary referral heart hospital. PARTICIPANTS: Eleven patients underwent cardiac surgical procedures requiring cardiopulmonary bypass under thoracic epidural anesthesia from February to April 2004. INTERVENTIONS: An epidural catheter was inserted at C7 to T2 intervertebral space on the day before the operation. Subsequently, cardiac surgery was performed using cardiopulmonary bypass. MEASUREMENTS AND RESULTS: The midsternotomy approach was used in all the patients. Anticoagulation was achieved with 300 units/kg of heparin. Under normothermic cardiopulmonary bypass, 6 patients underwent closure of atrial septal defect, 3 underwent valve replacements, and 2 underwent coronary artery bypass surgery combined with valve replacements. Soon after establishing cardiopulmonary bypass, all but 1 patient developed apnea, which was reversed after termination of cardiopulmonary bypass. The mean cardiopulmonary bypass time was 102 +/- 28 minutes, the aortic cross-clamp time was 58 +/- 28 minutes, and the total duration of surgery was 229 +/- 64 minutes. There was no mortality or morbidity in this series. CONCLUSION: Cardiac surgical procedures requiring cardiopulmonary bypass may be performed under thoracic epidural anesthesia, without endotracheal general anesthesia.

Adult↗
PubMed1997

Laparoscopic tubal ligation in a minimally invasive surgical unit under local anesthesia compared to a conventional operating room approach under general anesthesia.

OBJECTIVE: This study was done to compare costs, operating and recovery times, safety, and patient acceptance between (a) minimally invasive laparoscopic tubal ligation under sedation and local anesthesia and (b) conventional laparoscopic operating-room-based tubal ligations under general anesthesia. METHODS: Fourteen women desiring sterilization were randomized between tubal ligation under sedation/local analgesia versus general anesthesia. Procedures were performed by supervised residents previously unfamiliar with the minimally invasive technique. Hospital charges were used as a surrogate for cost. Operating or procedure room times, surgical complications, and recovery times were recorded. Patient acceptance was assessed using satisfaction surveys administered in the recovery room and again 1 week postoperatively. RESULTS: The cost of minimally invasive tubal ligation was significantly lower than for the conventional technique ($1,615+/-$134 vs $2,820+/-$110, p < 0.001). Surgical times were not different between the two procedures: 40.4+/-15 min for the conventional technique versus 32.9+/-10 min for minimally invasive surgery. However, the total in-room time required in the operating room significantly exceeded that for the procedure room technique (84+/-10 min vs 60+/-2 min, p < 0.05). Likewise, recovery time for the general anesthesia technique was longer (48+/-6 min vs 14+/-7 min, p < 0.03). No complications were encountered with either surgical method. Patient satisfaction for pain, fatigue, and days of missed work was similar between the two groups. CONCLUSIONS: The use of minimally invasive surgery to perform tubal ligation is advantageous over conventional laparoscopic tubal ligation under general anesthesia with regard to cost and time utilization. The minimally invasive technique appears to be easy to learn, safe, and well tolerated.

Adult↗