Metabolic effects of anesthesia in man; acid base balance during ether anesthesia.
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Acid-Base Equilibrium↗
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Balanced regional anesthesia for hand surgery.
In summary, the clinical goal in regional anesthesia for hand surgery is to constantly approach the ideal of a well-conducted, smooth, "balanced regional technique." This begins with the preoperative interview, assurance, and preoperative sedation (po). In the operating room, monitoring (EKG, BP) and safety measures (IV port, nasal oxygen) precede the regional technique. The block is performed with asepsis, minimal "needling," and correct dosages. The complement to neural blockade anxiolytic medication is titrated, thus the balance of IV sedation and regional block is achieved. The patient's symptoms, vital signs, and general comfort should be attended to during the hand surgery. Monitoring is continued in the recovery room, where special attention is given to positioning, cushioning of pressure areas, dressing, analgesia, and specific physical rehabilitation exercises. With a "balanced regional technique," the patient becomes an early participant in his or her own postoperative care and result. This balanced technique reduces the patient's overall operative risk and maximizes the surgical result.
Anesthesia, Intravenous↗
Fluid balance during anesthesia.
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Anesthesia↗
Comparison of low-dose sufentanil and fentanyl in balanced intravenous anesthesia for orthotopic cardiac transplantation.
A retrospective review was made of the records of 118 patients who received orthotopic heart transplant. Anesthetic techniques, drugs, dosage, hemodynamic profiles, intubation time, and intensive care unit stay were evaluated. The efficacy of sufentanil was compared to fentanyl in a balanced anesthetic when given in lower doses. Patients were given adequate anesthesia with total opioid doses of sufentanil, 6.5 +/- 2.9 micrograms.kg-1, or fentanyl, 58.9 +/- 24.9 micrograms.kg-1. Midazolam was used in all patients (mean dose 7.6 +/- 3.8 mg). There were no differences between the groups in complications, requirements for inotropic support, or time to extubation. A significantly higher pulmonary artery pressure was noted in patients who received sufentanil, but not fentanyl, pretransplant. The pulmonary artery pressures were not significantly elevated posttransplant. This review indicated that patients can be safely anesthetized with either combination of drug in lower doses than previously recommended.
Adolescent↗
[Coronary circulation and myocardial oxygen balance in anesthesia].
It is generally believed that in patients with impaired coronary reserve an imbalance between myocardial O2-demand and O2-supply is the main cause of myocardial ischaemia. However, clinical experience as well as recent experimental results indicate that this global view may not always explain the occurrence of regional myocardial ischaemia. It was therefore investigated whether in patients before and after induction of anaesthesia as well as during sternotomy metabolic indices of ischaemia, i.e. lactate and/or hypoxanthine release into the coronary sinus, are related to global indices of myocardial O2-balance. It was found that neither myocardial O2-demand or O2-supply nor O2-balance correlated with myocardial ischaemic events. Conversely it was observed that in contrast to expectations lactate and/or hypoxanthine release occurred more often in conjunction with high values of coronary venous oxygen saturation than with low values. Since coronary venous oxygen saturation can be considered as a physiological index of global myocardial O2-balance, the data of the present investigation suggest that during anaesthesia a global imbalance between myocardial oxygen supply and demand is not the main cause of myocardial ischaemia. Thus, regional factors seem to be more important for initiation of myocardial ischaemic events than global O2-balance.
Anesthesia↗
Pro: midazolam is the sedative of choice to supplement narcotic anesthesia.
Having examined the options for adjuvant drug use during cardiac anesthesia, it becomes increasingly apparent that midazolam is "the drug" of choice and that supplementation with an opioid is an ideal adjuvant. In the hands of experienced cardiac anesthesiologists, the majority of the drugs discussed could provide adequate anesthesia with outcomes that would be difficult to distinguish, with the exception of awakening and time to extubation. Regardless of the inability to differentiate overall outcome, when comparing ease of providing complete "balanced" anesthesia, minimal cost increase, ease of use, hemodynamic stability, reliability of amnesia and ability to decrease narcotic requirement and allow early extubation, midazolam is a clear winner. Given as a continuous infusion or a bolus, potent opioids such as alfentanil, fentanyl or sufentanil enhance the amnestic and hypnotic effect of midazolam, decreasing the required dose. In addition, the combination of midazolam and narcotics decreases the catecholamine response that either one alone would produce. This removes the necessity of marked narcotic overdose required when narcotics alone are used. The result of this anesthetic combination is a technique that can be used in the majority of cardiac patients regardless of their ventricular performance, allowing options for earlier awakening, earlier extubation and decreased ICU stay. The goal of complete "balanced" anesthesia is best achieved with continuous infusions of midazolam and opioids. Accepting recall of intraoperative events as a necessary evil is unacceptable in the stable cardiac surgery patient.(ABSTRACT TRUNCATED AT 250 WORDS)
Anesthesia, Intravenous↗
Intracuff pressure and tracheal morbidity: influence of filling with saline during nitrous oxide anesthesia.
BACKGROUND: Diffusion of nitrous oxide into the cuff of the endotracheal tube results in an increase in cuff pressure. Excessive endotracheal tube cuff pressure may impair tracheal mucosal perfusion and cause tracheal damage and sore throat. Filling the cuff of the endotracheal tube with saline instead of air prevents the increase in cuff pressure due to nitrous oxide diffusion. This method was used to test whether tracheal morbidity is related to excess in tracheal cuff pressure during balanced anesthesia. METHODS: Fifty patients with American Society of Anesthesiologists physical status I or II were randomly allocated to two groups with endotracheal tube cuffs initially inflated to 20-30 cm H(2)O with either air (group A) or saline (group S). Anesthesia was maintained with isoflurane and nitrous oxide. At the time of extubation, a fiberoptic examination of the trachea was performed by an independent observer, and abnormalities of tracheal mucosa at the level of the cuff contact area were scored. Patients assessed their symptoms (sore throat, dysphagia, and hoarseness) at the time of discharge from the postanesthesia care unit and 24 h after extubation on a 101-point numerical rating scale. RESULTS: Cuff pressure increased gradually during anesthesia in group A but remained stable in group S. The incidence of sore throat was greater in group A than in group S in the postanesthesia care unit (76 vs. 20%) and 24 h after extubation (42 vs. 12%; P < 0.05). Tracheal lesions at time of extubation were seen in all patients of group A and in eight patients (32%) of group S (P < 0.05). CONCLUSION: Excess in endotracheal tube cuff pressure during balanced anesthesia due to nitrous oxide diffusion into this closed gas space causes sore throat that is related to tracheal mucosal erosion.
Anesthetics, Inhalation↗
Safety and efficacy of atracurium (BW33A) in surgical patients receiving balanced or isoflurane anesthesia.
Atracurium was administered in a dose range of 0.027-0.4 mg/kg and dose-response curves were established for both balanced and isoflurane anesthetic techniques. With balanced anesthesia, ED50 and ED95 were 0.12 and 0.27 mg/kg, respectively, while with isoflurane they were 0.07 and 0.13 mg/kg and the least-squares regression line R2 values were 0.71 and 0.64, respectively. With balanced anesthesia there was a significant increase in systolic blood pressure at the 0.04 mg/kg dose (P = 0.02), while with isoflurane the systolic and diastolic blood pressures decreased at the 0.3 mg/kg dose (P less than 0.03). These changes were clinically insignificant. Atracurium is a potent nondepolarizing muscle relaxant which is potentiated by isoflurane. Its cardiovascular effects appear clinically nonsignificant. There is no evidence of histamine release.
Adolescent↗
Large-dose intrathecal sufentanil prevents the hormonal stress response during major abdominal surgery: a comparison with intravenous sufentanil in a prospective randomized trial.
We studied the effect of large-dose intrathecal sufentanil (ITS) for major abdominal surgery on the hormonal stress response. Forty patients were randomly allocated to receive either IV sufentanil (IVS) or 150 microg of ITS as part of general anesthesia. In the IVS group, adrenocorticotropic hormone (ACTH) and cortisol concentrations were larger than baseline and the ITS group, 60 min after incision and at skin closure. Plasma concentrations of cortisol and ACTH were not different from baseline in the ITS group during surgery. Six hours after skin closure, cortisol concentrations were larger than baseline in both groups. Twenty-four and 48 h after skin closure, ACTH and cortisol values were similar between groups. Norepinephrine concentrations increased after surgery in both groups. Blood glucose levels increased in both groups during and after surgery. Pain scores and morphine consumption during the first 48 h after surgery were lower in the ITS group. The data show that large-dose ITS prevents the intraoperative hormonal stress response in comparison with balanced anesthesia. We speculate that this is due to the highly specific binding of sufentanil to spinal and supraspinal receptors. This technique improves postoperative analgesia when compared with balanced anesthesia.
Abdomen↗
Neuromuscular and cardiovascular effects of mivacurium chloride (BW B109OU) during nitrous oxide-narcotic, nitrous oxide-halothane and nitrous oxide-isoflurane anesthesia in surgical patients.
One hundred seventeen adult surgical patients were studied to compare neuromuscular and cardiovascular effects of mivacurium chloride during nitrous oxide-narcotic (BAL, n = 45) nitrous oxide-halothane (HAL, n = 27) and nitrous oxide-isoflurane (ISF, n = 45) anesthesia. Anesthesia was maintained with nitrous oxide (60%-70%) and oxygen (30%-40%) with end-tidal concentrations of halothane or isoflurane to yield a total MAC of approximately 1.25, or with supplemental fentanyl and thiopental as clinically indicated. Twitch response of the adductor pollicis muscle was elicited by supramaximal square wave pulses of 0.2 msec duration at a frequency of 0.15 Hz (Grass S44 stimulator) to the ulnar nerve and quantitated by a Grass FT10 transducer. Nine patients in each of the HAL and ISF groups received one of four doses of mivacurium (0.03, 0.05, 0.10 or 0.15 mg/kg). Ninety patients in the balanced anesthesia group received one of seven doses of mivacurium (0.03, 0.04, 0.05, 0.08, 0.15, 0.20, 0.25 mg/kg). The ED50, ED75 and ED95 of mivacurium in each group were estimated from linear regression plots of log dose versus probit of maximum percentage depression of twitch height. The ED50, ED75 and ED95 for halothane and isoflurane are 0.040, 0.053 and 0.081 and 0.037, 0.043 and 0.053, respectively. The ED50, ED75, and ED95 for the balanced group are 0.039, 0.050, and 0.073 mg/kg respectively. There was no significant difference between the slopes of the HAL and BAL inhalation anesthetic dose-response curves. The slope of the ISF group was significantly than the slope of the BAL group. Intercepts of the HAL and BAL curves were not different. The isoflurane curve's intercept was significantly less than the other groups' intercepts, lying above the halothane curve, but below the BAL curve. For the 0.05 mg/kg dose, maximum block was greater in the ISF group (89.1 +/- 2.7%, n = 9) than in the HAL (70.3 +/- 7.6%, n = 9) or BAL (67.7 +/- 6.4%, n = 9) groups. At higher doses of mivacurium, isoflurane produces a greater potentiation of neuromuscular block than halothane or balanced anesthesia. There were no significant cardiovascular changes seen in any group following mivacurium doses up to 0.15 mg/kg (approximately 2xED95).
Adult↗
[Clonidine within the scope of balanced inhalation anesthesia with sevoflurane--effects on pEEG parameters].
The anaesthetic-saving property of clonidine has often been reported. In our own prospective, randomized study, in which the depth of anaesthesia was controlled by using spectral edge frequency (target-SEF90 = 10 Hz) and clinical parameters, we confirmed the anaesthetic-saving property only for fentanyl (-20%). On the other hand, there was no difference in MAC-sevoflurane values between the groups in keeping a steady target-SEF. For this reason, we analysed the stored pEEG data with regard to clonidine-specific effects. Twenty-eight patients were included in our study. The patients were randomly treated preoperatively with an infusion of 4 micrograms/kg KG Clonidine (clonidine group) or a placebo (placebo group). For anaesthesia, a standardized procedure with fentanyl, propofol, rocuronium, N2O/O2/sevoflurane was performed. The depth of anaesthesia was controlled by using SEF90 and clinical parameters. SEF90, SEF50 and the EEG power-spectrum were analysed over a five-minute period in the steady state of anaesthesia without surgical manipulation. Both placebo and the clonidine showed comparable values for SEF90 (9.9 +/- 1 vs. 10.7 +/- 0.9 Hz). On the other hand, there were differences in the SEF50 values between the groups (3.3 +/- 0.7 vs. 6.4 +/- 2.2 Hz). In the clonidine group, relative alpha-power was higher than in the placebo group (36.3 +/- 15.8 vs. 16.8 +/- 8.8%). Parallel to this effect, there was a reduction in relative delta-power in the clonidine group (47.6 +/- 15.2 vs. 65.4 +/- 9.1%). The described EEG effects on the power-spectrum inevitably influence SEF50 and SEF90. In our opinion, SEF50 is not a powerful predictor of depth of anaesthesia, when anaesthesia is performed in the way described. By performing this variation of balanced anaesthesia and co-medication with clonidine, higher values of SEF90 (11-14 Hz) seem to be adequate for surgical manipulation.
Adrenergic alpha-Agonists↗
A comparison of desflurane and isoflurane in prolonged surgery.
STUDY OBJECTIVE: To compare desflurane with isoflurane in several anesthetic situations. DESIGN: Intubating conditions, hemodynamic response to intubation, maintenance hemodynamics, and speed of recovery from desflurane and isoflurane anesthesia were evaluated. In addition, interaction with a muscle relaxant at low and high concentrations of the anesthetics were compared. SETTING: Thomas Jefferson University Hospital. PATIENTS: Thirty-two patients who received general anesthesia for lengthy, mostly orthopedic procedures. INTERVENTIONS: Immediately after induction with thiopental sodium, desflurane or isoflurane in nitrous oxide-oxygen was administered via face mask. Anesthesia was deepened until end-tidal concentration reached 1.7 minimum alveolar concentration (MAC). The trachea was intubated without the aid of a muscle relaxant. Heart rate (HR) and blood pressure (BP) were recorded before and at 1, 2, 4, 5, and 10 minutes after intubation. Noninvasive cardiac output (CO) and systemic vascular resistance (SVR) were determined while the patient was awake, immediately before intubation, and at 5 and 10 minutes after intubation. Following intubation, the concentration of desflurane or isoflurane was lowered until the end-tidal concentration reached 0.65 MAC (low-MAC group), 1.25 MAC (high-MAC group), or 0 MAC (control group). Pancuronium bromide in 0.005 mg/kg doses was administered incrementally until T1 (first twitch of train-of-four) was depressed more than 90%. ED50 and ED95 for pancuronium with balanced anesthesia and for desflurane or isoflurane in low and high MACs, as well as speed of recovery, were determined. The time to responsiveness and awakening also was determined. MEASUREMENTS AND MAIN RESULTS: There was no significant difference between desflurane and isoflurane in intubating conditions or in BP or HR response to tracheal intubation. Both anesthetics increased HR significantly during induction. BP rose with desflurane at the preintubation point; other points showed no difference. A hyperdynamic response of increased HR and BP above 20% of baseline values was seen more frequently with desflurane (n = 7) than with isoflurane (n = 1). CO was elevated at all times after induction for low and high concentrations of both drugs, while SVR decreased over the same time with no significant difference between drugs. ED50 and ED95 for pancuronium were similar under desflurane and isoflurane at both low and high MAC, but they were significantly lower than under balanced anesthesia. Awakening times were similar for desflurane and isoflurane. CONCLUSIONS: Desflurane is similar to isoflurane in providing anesthesia for intubation and maintenance. Desflurane tends to increase HR and occasionally causes a hyperdynamic response during rapid deepening of anesthesia. It is very similar to isoflurane in its interaction with pancuronium.
Adult↗
[Effect of thoracic epidural analgesia on the early postoperative phase after interventions on the gastrointestinal tract].
INTRODUCTION: Thoracic epidural anesthesia is increasingly being used in visceral surgery as an adjuvant to general anesthesia and, in addition, as a postoperative method of thoracic epidural analgesia (TEA). This method interrupts specifically nociceptive reflexes, increases the blood supply by blocking sympathetic activation, improves pulmonary function, and has a beneficial effect on gastrointestinal (GI) motility. METHODS: A retrospective study was conducted on 175 patients with a primary GI carcinoma operated between January 1, 1999 and December 31, 1999; 78 operations were performed on the upper GI tract (UGI, gastrectomy), and 97 on the lower GI tract (LGI, anterior rectum resection). The postoperative course in patients with and without TEA was compared. For intraoperative and postoperative catheter analgesia, bupivacaine (intraoperative: 0.25%; postoperative: 0.125%) and fentanyl were used. General anesthesia was administered as balanced anesthesia. RESULTS: A total of 102 patients received combined anesthesia with TEA (UGI n = 61/LGI n = 41) and 73 patients were given general anesthesia with continuous postoperative, intravenous pain therapy or a patient-controlled analgesia (PCA) pump (UGI n = 17/LGI n = 56). There was no difference between the groups with and without TEA in terms of initial demographic details, such as age distribution, tumor stage or ASA classification. Under TEA, the length of stay in the intensive care unit (P < 0.01), the administration of antibiotics (P < 0.001), days without oral nutrition (p < 0.05) and the rate of anastomosis insufficiencies (P < 0.001) was significantly reduced after operations on the upper GI tract. After surgery on the lower GI tract, the use of TEA led to less frequent vomiting and earlier resumption of GI motility (P < 0.01). However, these positive effects did not have a significant beneficial impact on overall hospitalization. CONCLUSION: The combination of TEA and general anesthesia has been shown to offer advantages after operations on both the upper and the lower GI tract. The positive effects of the TEA in the postoperative period should be used for the early enteric nutrition and mobilization of patients.
Aged↗
Anesthetic management of a patient with beta-thalassemia intermedia undergoing splenectomy: a case report.
A 37-year-old man with beta-thalassemia intermedia (betaTI), a rare disease caused by partial or complete deficiency of beta-globin chain synthesis, fell into a hemolytic crisis. Severe anemia persisted despite frequent transfusions. Therefore, he was scheduled for splenectomy to alleviate the anemia. The preoperative laboratory data showed marked anemia and liver dysfunction. Echocardiography revealed hyperkinetic left ventricular motion and increased cardiac index (CI), indicating a compensatory hyperdynamic circulation induced by persistent, severe anemia. Our strategy during general anesthesia was to keep the hyperkinetic cardiovascular system steady. Hence, the hemodynamic parameters including the CI were measured using a Swan-Ganz catheter, and other physiological parameters were monitored perioperatively. Anesthesia was maintained with balanced anesthesia: isoflurane at low concentrations and fentanyl to avoid cardiovascular depression. Throughout the operation, vital signs were kept stable and the lactate/pyruvate ratio was unchanged, indicating that anaerobic metabolism did not increase. We report successful anesthetic management with attention to hemodynamic changes in a patient with betaTI.
Adult↗
Acid base balance and anesthesia.
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Acid-Base Equilibrium↗
Minimizing emergence phenomena: subdissociative dosage of ketamine in balanced surgical anesthesia.
Three hundred twelve patients, ranging in age from 14 to 89 years and undergoing various major and minor surgical procedures, were anesthetized by oxygen, nitrous oxide, and ketamine in sequence. Anesthesia was induced with thiopental (5.8 mg./kg.). The first 212 patients received an initial dose of ketamine of 1.6 mg./kg. lean body mass; 100 other patients, an initial (subdissociative) dose of ketamine of 0.4 mg./kg. body weight. Subsequent doses of ketamine, one-half the initial dose, were given 20 to 40 minutes apart, as needed. Postoperative subjective reactions were limited to slight confusion on emergence, with some disorientation to time, and occurred in 10 patients (5 percent) in the first group and 4 (4 percent) in the latter group. No psychotomimetic reactions were noted in either group. The latter group unanimously found the anesthetic technic acceptable for future use.
Adolescent↗
[Convulsions after balanced general anesthesia in a newborn infant].
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Anesthesia, General↗
[Preoperative clonidine comedication within the scope of balanced inhalation anesthesia with sevoflurane in oral surgery procedures].
Both clonidine and sevoflurane are interesting drugs for anaesthesia in maxillo-facial surgery. The present study was performed to discover how far it is possible to combine the benefits of sevoflurane (fast modulation of depth of anaesthesia, rapid emergence and recovery) and clonidine (reduction of perioperative stress response, prophylaxis of postoperative shivering, analgetic, antiemetic and anaesthetic-saving effect) without compromising the pharmacokinetic of sevoflurane. Twenty-eight patients were included in the present double-blinded prospective study. These patients were randomly treated with an infusion of 4 micrograms kg-1 clonidine (group 1) or a placebo (group 2) preoperatively. For anaesthesia a standardized procedure with fentanyl, propofol, rocuronium, N2O/O2/sevoflurane and an antiemetic prophylaxis with DHB was performed. The depth of anaesthesia was controlled by using spectral edge frequency (target--SEF90 = 10 Hz). Perioperative stress response was assessed by noting the effects on haemodynamic parameters (MAP, heart rate), and emergence and recovery were assessed by using established standardized tests. We confirmed the anaesthetic-saving property of clonidine only for fentanyl (-20%). On the other hand, there was no difference in MAC-sevoflurane values between the groups in keeping a steady target--SEF90 (1.62 +/- 0.26 versus 1.65 +/- 0.24 vol.%). The time until emergence and recovery was not significantly different. Even the occurrence of PONV, the VAS level or the postoperative analgesic requirement did not differ in the two groups. However, the incidence of postoperative shivering was significantly higher in the placebo group. The stress response to intubation or extubation was lower in the clonidine group. The haemodynamic parameters in the clonidine group were intraoperatively always below the baseline, in some cases by more than 20%, making therapy for hypotension or bradycardia frequently necessary. Postoperatively, the majority of the patients showed similar changes in these parameters, but did not reach the 20% mark. Preoperative clonidine comedication seems to complicate the management of anaesthesia. On the other hand, it is beneficial during the early postoperative period (e.g. stability in haemodynamics, prophylaxis of shivering) without compromising emergence and recovery. Our results show that therapy with clonidine should be better placed at the end of anaesthesia.
Adult↗