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PubMed1981

Elevated platelet norepinephrine concentration in patients with pheochromocytomas.

With a radioenzymatic method of analysis we determined the concentration of plasma and platelet norepinephrine in simultaneously drawn blood samples from six patients with pheochromocytomas. All six subjects had elevated platelet norepinephrine concentrations in the preoperative or intraoperative period. Three of the six patients had a normal plasma norepinephrine concentration in their sample. After resection of benign pheochromocytomas the platelet and plasma norepinephrine of five patients returned to normal. The platelet and plasma norepinephrine concentration of a patient with a malignant, non-resectable pheochromocytoma remained elevated. Eight of 30 patients (27%) with hypertension, not thought to be due to pheochromocytoma, had elevated platelet norepinephrine concentrations, All 8 of these patients had diastolic blood pressures of 120 mm Hg or greater at the time the blood samples were drawn. In contrast, the six patients with pheochromocytomas had elevated platelet norepinephrine concentrations while normotensive. Only five of 60 "sick" patients (8%) without a history of hypertension had elevated platelet norepinephrine concentration. Platelet norepinephrine concentration is an excellent test to screen patients, with a history of spells of hypertension but presently normotensive, for pheochromocytomas. An elevated value should be followed up with measurement of vanillylmandelic acid (VMA) and/or catecholamines in a 24-h urine collection.

Adrenal Gland Neoplasms↗
PubMed1993

Neonatal pain: a comprehensive survey of attitudes and practices.

We surveyed 352 physicians board certified in neonatal-perinatal medicine on their attitudes and practices in the area of pain and pain management in neonates and infants. In contrast to earlier surveys of this type, almost all respondents indicated that even the youngest and most premature infants are able to perceive pain, and most reported that they always advocated anesthesia during the intraoperative period. The use of analgesic agents in the postoperative period, however, was more variable. Respondents who indicated that neonates perceived less pain than adults reported seeing fewer signs of pain and using less analgesia in the postoperative period. They were also more likely to believe that analgesics are too dangerous to use in neonates and that physiologic factors such as incomplete myelination of the pain pathways and neural/physical immaturity (factors now known not to play a role) contribute to diminished pain sensitivity. Conversely, respondents who indicated that neonates do not perceive less pain than adults, the majority of respondents, reported seeing more signs of pain and using more medication in the postoperative period. These physicians also believed that the physiologic stress associated with pain can be more dangerous than the analgesics. We conclude that attitudes and reported practices have changed in the area of neonatal pain and pain management. Furthermore, our data indicate that these attitudes significantly predict reported postoperative medicating practices.

Attitude of Health Personnel↗
PubMedDate not supplied

General versus epidural anesthesia for femoral-popliteal bypass surgery.

This study examines whether epidural anesthesia is more effective than general anesthesia using an inhalation agent in controlling cardiovascular responses during femoral-popliteal bypass surgery. Nineteen patients were randomized into two groups: general anesthesia (n = 10) and epidural anesthesia (n = 9). The patients who underwent general anesthesia received sodium pentothal and succinylcholine for induction of anesthesia and 60% N2O, 40% O2, and 1% to 1.5% isoflurane for maintenance. Fifteen minutes before extubation, the patients received morphine sulfate 0.05 mg/kg intravenously (IV). The group that underwent epidural anesthesia received anesthesia to T-10 (through a catheter placed in the L4-5 interspace using 3% 2-chloroprocaine). Thirty minutes after the last dose, 0.05 mg/kg IV was administered. Hemodynamic variables were recorded at selected intervals during the operation and for 60 minutes in the recovery room. In the general anesthesia group, mean arterial pressure (MAP) and rate pressure product (RPP) significantly decreased (p less than 0.05) during the operation as compared with preoperative values. Following intubation and skin incision, 5 minutes after extubation, and after 60 minutes in the recovery room, MAP, heart rate (HR), and RPP were significantly greater (p less than 0.05) as compared with intraoperative periods. In the epidural anesthesia group, there were clinically important decreases in MAP and RPP after reaching T-10 and skin incision. The general anesthesia patients showed higher MAP, HR, and RPP 5 minutes after extubation and after 60 minutes in the recovery room. Epidural anesthesia patients showed stable hemodynamic patterns throughout the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1991

Propofol and thiopentone for caesarean section revisited: maternal effects and neonatal outcome.

In 56 women undergoing elective caesarean section, general anaesthesia was induced with either propofol 1% or thiopentone 2.5% followed by 50% nitrous oxide in oxygen and isoflurane 0.75% until delivery. In the thiopentone group the arterial pressure rose following tracheal intubation and skin incision, while in the propofol group there was a significant tendency to hypotension immediately following induction of anaesthesia. There were differences in electroencephalogram (EEG) between the groups, while laryngoscopy, intubation and surgical stimulation had no effect on EEG pattern. Recovery after anaesthesia did not differ between groups. None of the patients had recall of the intraoperative period, but 53% of patients induced with propofol showed signs of light anaesthesia between induction and delivery. Neonates in the propofol group had lower Apgar scores 1 min after birth than those in the thiopentone group, but these differences were no longer significant at 5 min. No differences were noted in neurobehavioural status at 1, 4 and 24 h.

Journal Article↗
PubMed2005

Evaluation of the anterior cruciate ligament integrity and degenerative arthritic patterns in patients undergoing total knee arthroplasty.

We prospectively reviewed 107 consecutive primary total knee arthroplasties performed over a 1-year period. Intraoperatively, the integrity of the anterior cruciate ligament (ACL), the characteristics of the intercondylar notch, and the patterns of cartilage wear were evaluated. The ACL was found to be deficient in 41 knees (39%) at the time of surgery. The ACL-deficient knee had significantly narrower intercondylar notch widths compared with knees with an intact ACL (average, 9.75 vs 16 mm, P < .01). Furthermore, patients with ACL deficiency were found to have a higher percentage of Outerbridge grade IV changes at the lateral femoral condyle, lateral tibial plateau, and patellar surfaces when compared to the ACL-intact group. An intact ACL appeared to be protective against severe patellar degeneration. In conclusion, intercondylar notch narrowing from the arthritic process can lead to attrition and rupture of the ACL. An ACL deficiency appears to be associated increased wear of the lateral femorotibial and patellofemoral joints.

Adult↗
PubMed2005

Increased prothrombotic state lasting as long as one month after on-pump and off-pump coronary surgery.

OBJECTIVE: This study investigated whether the activation of coagulation, fibrinolysis, and endothelium occurring during the first postoperative month after on-pump coronary artery bypass surgery differs from that after off-pump coronary artery bypass grafting. METHODS: Thirty-five patients candidates to coronary surgery were randomized to undergo on-pump (n = 18) or off-pump (n = 17) coronary artery bypass grafting. Blood samples were collected before the intervention and to 1 month after surgery. RESULTS: Prothrombin fragment F1.2, thrombin-antithrombin complex, and D-dimer increased after surgery and were persistently higher than preoperative values as late as 30 postoperative days in both on- and off-pump groups; higher levels of these variables were detected after on-pump surgery relative to off-pump surgery only at the time point after termination of cardiopulmonary bypass (fragment F1.2 and thrombin-antithrombin complex) or from bypass end to 8 postoperative days (D-dimer). Fibrinogen levels decreased after surgery and then increased in parallel in both groups to 8 days after surgery. The von Willebrand factor level increased postoperatively in both groups and returned to baseline 30 days after surgery; it was higher after on-pump surgery from bypass end to 8 postoperative days. Soluble vascular cell adhesion molecule 1 was increased significantly from baseline in both groups 30 days after surgery, with no difference between groups. CONCLUSION: Patients undergoing off-pump surgery showed protection against activation of coagulation and fibrinolysis and against endothelial injury only during the intraoperative period; this was followed by the development of a prothrombotic pattern comparable to that of patients undergoing on-pump surgery lasting at least as late as 30 days after surgery.

Blood Coagulation↗
PubMed2006

Extrahepatic metabolism and renal effects of sevoflurane in a case of liver transplantation.

In a case of liver transplantation, sevoflurane metabolism was studied to investigate if sevoflurane has an extrahepatic metabolism or possible nephrotoxicity in the presence of chronic liver disease. Plasma blood urea nitrogen (BUN) and creatinine and urine levels of N-acetyl glycosaminidase (NAG) and beta2 microglobulin were assessed intraoperatively and for 11 days postoperatively. We observed a close relation between urine NAG excretion and urine inorganic fluoride levels in the intraoperative period and early postoperative days. The NAG levels were greater than normal despite the peak serum inorganic fluoride concentration of 18.94 micromol/L. No impairment was observed in serum BUN or creatinine levels in these periods.

Acetylglucosamine↗
PubMedDate not supplied

Hand-assisted laparoscopic nephrectomy in living donors.

Hand-assisted laparoscopic nephrectomy (HLN) in living donors is a minimally invasive surgical modality that uses classic laparoscopic techniques either combined or not with the use of the surgeon's hand as a support tool during renal dissection maneuvers. The purpose of this study was to describe the initial experience with HLN technique in renal donors. Among 58 hand-assisted laparoscopic nephrectomies, the left kidney was removed in 39 donors (67%) and the right in 19 (33%). Surgery time ranged from 55 to 270 minutes (mean 156.9 +/- 49.5). Warm ischemia time ranged from 2 to 11 minutes (mean 4.38 +/- 2.31 min), with an estimated mean blood loss during the intraoperative period of 268 mL. Conversion to open surgery was required for four (6.8%) patients due to a vascular lesion. Upon graft evaluation, we observed immediate diuresis in 56 (96.3%) cases, with a mean serum creatinine on postoperative day 7 of 1.74 +/- 1.61 mg/dL. Renal vein thrombosis requiring graft removal occurred in one (1.7%) patient. Lymphocele was observed in three recipients (5.1%), and urinary leakage due to ureteral necrosis in three cases (5.1%). HLN for living donors is a safe procedure and an effective alternative to open nephrectomy. In this series, the procedure displayed low morbidity after surgery, providing a good morphological and functional quality of the graft for the recipient.

Adult↗
PubMed1984

Anxiety in surgical patients' families.

The purpose of this field experimental study was to test these hypotheses. Videotaped preoperative information directed specifically toward surgical patients' families would reduce their state anxiety during the patients' hospitalization. Informative and supportive staff interaction with family members would increase their perception of support from the nursing staff. A combination of the above would reduce the family members' state anxiety and increase perceived support from the nurse more effectively than either of the above actions would singly. The subjects were 67 family members of 60 patients scheduled for major elective surgery. Anxiety was measured by the Spielberger State Anxiety Inventory, and perceived social support was measured by a modified version of Caplan's Social Support Index. The two experimental treatments were fully crossed in a 2 x 2 factorial design. Correlational methods were also used for data analysis. Findings in this study showed that videotaped preoperative information decreased state anxiety in family members of surgical patients, staff-family interaction had a positive effect on the family's perceived support from the nurse, and family member state anxiety scores were higher during the intraoperative period than during the postoperative period.

Adolescent↗
PubMed1994

External ear reconstruction. Use of a pivoting helix, porous polyethylene implant.

We have used the porous polyethylene, pivoting helix framework for ear reconstruction at RLAMC since 1989 with no major complications. Postoperatively, patients have an external ear that resembles a normal ear and is sturdy enough to support eye wear. The aesthetic results have been well received by the patients and their families (Fig 8). Most children are reluctant to undergo surgery; however, those patients with ear deformities often are eager for external ear reconstruction surgery, and the majority of our pediatric patients have been pleased with the postoperative results (Fig 9). The success of this procedure depends on a number of factors, including proper patient selection, suitable selection of materials for the reconstruction, the technical skills of the surgeon, and the surgical team's attention to detail in the intraoperative period. The perioperative nurse, functioning as the patient advocate, plays an integral role in the success or failure of this procedure.

Burns↗
PubMed1994

Hypothermia associated with percutaneous nephrolithotomy.

OBJECTIVES: To characterize the perioperative fall in core body temperature associated with percutaneous nephrolithotomy, and to identify patients at greater risk of hypothermia. METHODS: A retrospective review was undertaken of core body temperatures in 77 patients who underwent 95 percutaneous nephrolithotomy (PNL) procedures using room temperature irrigants over a 3 year period. Intraoperative temperature measurements were obtained via an esophageal thermistor probe. RESULTS: Mean core body temperature fell from 36.7 degrees C preoperatively to 35.8 degrees C after retrograde manipulations and subsequent patient positioning before commencing the renal puncture. The mean core temperature fell an additional mean 1.0 degrees C during the percutaneous nephrolithotomy. This additional temperature drop was proportional to the length of the procedure. Female patients had a significantly greater decline in intraoperative core body temperature than male patients (p < 0.01). Obese patients preserved their preoperative temperature more efficiently. Blood loss and advanced age had no impact on the occurrence of hypothermia. Mean preoperative temperature was regained on average within 3 hours postoperatively. CONCLUSIONS: Hypothermia occurs in the majority of patients undergoing PNL. Nearly an equivalent fall in temperature is seen during presurgical preparation, induction of anesthesia, and patient positioning as is seen during the surgical procedure itself. Efforts to preserve core body temperature both before and during the percutaneous procedure may reduce the degree of hypothermia and its potential complications.

Body Temperature↗
PubMed1989

Duration of amnesia associated with midazolam/fentanyl intravenous sedation.

The purpose of this study was to determine the duration of amnesia associated with the intravenous usage of midazolam and fentanyl. The midazolam was administered in three different dosages based on the patient's weight in kilograms. Patients were shown a series of pen-and-ink drawings at various times throughout the procedure and tested the next day for memory of the drawings using both free recall and match-to-sample paradigms. The results indicate that the low-dosage group (0.07 mg/kg) had insufficient amnesia, whereas the medium (0.10 mg/kg) and high (0.13 mg/kg) groups displayed adequate amnesia in the intraoperative period.

Adolescent↗
PubMed2002

[Antibiotic prophylaxis in cardiac surgery: practice patterns].

OBJECTIVE: To assess the prescription patterns in French and foreign centres for antibiotic prophylaxis in cardiac surgery. MATERIAL AND METHODS: Phone and written surveys concerned 64 French and 70 foreign centres. It focused on the first injection, the duration of treatment and the recommended agents. RESULTS: 87% of the French centres and 67% of the foreign centres answered the questionnaire. The first injection took place at anaesthesia induction in all French centres but during administration of premedication in 11% of foreign centres (p < 0.05). The duration of prophylaxis was restricted to the intraoperative period only in 20% and 15% of centres, respectively (ns), as specified by the recommendations. No French centres carried on the antibiotics more than 48 h versus 11% of foreign centres (p < 0.05). Cephalosporines of the second generation were prescribed in 84 and 49% of centres, respectively (p < 0.05). The combination of two antibiotics was less frequent in France than in foreign countries (5 versus 17%, p < 0.01). In absence of betalactamin allergy glycopeptides were not utilized in France versus 8% in foreign countries (p < 0.05). In case of allergy vancomycin was used in 66% of French and 42% of foreign centres. CONCLUSION: The French recommendations may have influenced favourably the antibiotic choice but the prophylaxis duration was too long in most of the non French European centres.

Antibiotic Prophylaxis↗
PubMedDate not supplied

Time-course changes of serum immunoglobulins (IgA, IgG, IgM) after liver transplantation for alcoholic cirrhosis.

BACKGROUND: Serum immunoglubulin increase is a hallmark of liver disease. Serum IgA is specifically increased in alcoholic liver disease, which has been considered an IgA-associated disorder. No previous studies have been focused on the time-course changes of serum immunoglobulins (IgG, IgA, IgM) after liver transplantation. AIM OF THE STUDY: To investigate the outcome of serum immunoglobulin levels in alcoholic cirrhosis after liver transplantation, with special focus on IgA values. PATIENTS AND METHODS: A total of 18 patients, liver transplanted in our center because of alcoholic cirrhosis were included in the study. Serum immunoglobulins were assayed by nephelometry before transplantation and at different intervals after the procedure from the intraoperative period to more than a year after transplantation. RESULTS: A rapid drop in IgA, IgG and IgM concentration was observed during the surgical procedure, particularly after donor liver reperfusion, and during the first days after transplantation. Mild transient hypogammaglobulinemia (IgG) was present. After a subsequent moderate re-increase, serum immunoglobulins (particularly IgA and IgG) remained stable within normal or near-normal limits during the following months after liver transplantation. CONCLUSIONS: Liver transplantation for alcoholic cirrhosis is followed by a decrease in serum IgA, IgG and IgM. In the short term, low IgG levels may be observed. In the long term, serum levels of IgA and IgG become normal or near-normal.

Adult↗
PubMedDate not supplied

Effect of postoperative epidural analgesia on morbidity and mortality after total hip replacement surgery in medicare patients.

BACKGROUND AND OBJECTIVES: The effect of postoperative epidural analgesia (vs. systemic analgesia) on patient outcomes is unclear. Available randomized controlled trials (RCTs) have focused on the intraoperative period and not properly examined the effect of postoperative epidural analgesia (EA) on outcomes. METHODS: A 5% nationally random sample of Medicare beneficiaries from 1994 to 1999 was analyzed to identify patients undergoing total hip arthroplasty (Common Procedural Terminology [CPT] code 27130, 27132, 27134, 27137, 27138). Patients were divided into 2 groups depending on the presence or absence of postoperative EA based on the CPT coding (01996). The rate of major morbidity (acute myocardial infarction, deep venous thrombosis, pulmonary embolism, angina, respiratory failure, heart failure, cardiac dysrhythmias, pneumonia, pulmonary edema, sepsis, acute renal failure, paralytic ileus, acute cerebrovascular event) and death at 7 and 30 days after the procedure were compared. Multivariate regression analysis was performed to determine if the presence of postoperative (EA) had an independent effect on mortality or major morbidity. Data were reported as an odds ratio with 95% confidence intervals (CI) when appropriate. RESULTS: The unadjusted 7- and 30-day death rate was significantly lower for EA versus no EA (1.9/1000 [95% CI: 0.2-3.6] vs. 3.9/1000 [95% CI: 3.0-6.2] at 7 days [P =.04] and 5.8/1000 [95% CI: 2.9-8.7] vs. 9.9/1000 [95% CI: 8.6-11.3] at 30 days [P = 0.01]). However, multivariate regression analysis revealed that there was no difference between the groups with regard to mortality or major morbidity with the exception of an increase in deep venous thrombosis in patients who received EA. CONCLUSIONS: The use of postoperative EA was not associated a lower incidence of mortality and major morbidity in Medicare patients undergoing total hip arthroplasty. However, the results should be interpreted with caution because of limitations in using the Medicare claims data for analysis. Further trials using other properly conducted and designed studies (e.g., RCTs) would be ideal to validate these results.

Aged↗
PubMed2005

Large bolus dose vs. continuous infusion of cisatracurium during hypothermic cardiopulmonary bypass surgery.

BACKGROUND AND OBJECTIVE: We investigated whether a high bolus dose of cisatracurium (8x ED95) given at induction can provide muscle relaxation for the major part of a cardiac procedure with hypothermic cardiopulmonary bypass, avoid important postoperative residual curarization and cause no waste of product. METHODS: Twenty patients were randomly assigned either to Group 1 (n = 10) or Group 2 (n = 10). Those in Group 1 were given cisatracurium in a high bolus dose (0.4 mg kg(-1)). Those in Group 2 received cisatracurium 0.1 mg kg(-1) at induction followed after 30 min by a continuous infusion of cisatracurium. As an escape medication in case of patient movement, a bolus dose of cisatracurium 0.03 mg kg(-1) was given. RESULTS: In Group 1 (large cisatracurium bolus dose), the clinical duration of effect (until T1/T0 = 25%) was 110 min. Six of 10 patients in Group 1 required additional boluses of cisatracurium intraoperatively. Four of these six had received an additional bolus near the end of surgery and had a train-of-four (TOF) ratio = 0 at the end. The other four patients in Group 1 had a final TOF ratio >0.9. In Group 2 (continuous cisatracurium infusion), only two patients had a TOF ratio >0.9 at the end of surgery, no patient moved and none received additional boluses. The total amount of cisatracurium used in the bolus and infusion Groups was 34.5 +/- 7.8 and 21.3 +/- 5.7 mg, respectively (P = 0.0004). CONCLUSIONS: For continued neuromuscular block during hypothermic cardiac surgery, a high bolus dose of cisatracurium appears to be safe, although it is not an alternative to a continuous infusion, as its neuromuscular blockade does not cover the intraoperative period and a high incidence of movements occurs. In the patients who received a high bolus dose of cisatracurium, postoperative residual curarization appeared after additional boluses had been given. The consumption of cisatracurium by high bolus was significantly greater than with continuous infusion.

Aged↗
PubMed2003

Perioperative ulnar neuropathies: a medicolegal review.

BACKGROUND: Perioperative ulnar neuropathies have long been attributed to inappropriate arm positioning and padding during operations and have resulted in many lawsuits. METHODS: A recent Canadian lawsuit is described and the literature regarding perioperative ulnar and other focal neuropathies reviewed. RESULTS: The evidence strongly suggests that ulnar nerve damage is usually sustained in the postoperative rather than the intraoperative period. There is no evidence that positioning or padding of the arm during the operation prevents perioperative ulnar neuropathies. CONCLUSIONS: There should generally be no basis for a claim against medical or nursing staff or hospitals when an ulnar neuropathy develops following anesthesia and surgery.

Aged↗
PubMed2001

A revised consideration on the use of very aged donors for liver transplantation.

The upper age limit for organ donation for liver transplantation has increased over the past few years. A retrospective case control study was carried out to evaluate the outcome of 36 liver transplants (group A) performed with grafts procured from donors over 70 years old in the period 1996 to April 2000, matched with 36 transplants (group B) chronologically performed thereafter with organs procured from donors below the age of 40 yr. The groups were comparable as regards main clinical characteristics. Mean follow-up was 14.5 months. Clinical and laboratory parameters of the donors, cold ischemia period, intraoperative blood transfusions, 30-d mortality, incidence of primary graft nonfunction, acute rejection episodes, arterial complications and long-term survival of recipients were considered. The main postoperative biochemical parameters were also collected and compared. A liver biopsy was obtained in 20/36 old donors, revealing less than 25% of steatosis in all but one, which showed steatosis involving 70% of the hepatocytes. There were two postoperative deaths (5.6%) in group A and one (2.8%) in group B (p = NS). Seven postoperative arterial complications (19.4%) occurred in group A, leading to the patient's death because of rupture of the hepatic artery in one case, to successful surgical revascularization in three cases and to retransplantation in three cases. Only one patient in group B (2.8%) experienced hepatic artery thrombosis (p = 0.055). One-year patient survival rates were 77.4% for group A and 88.8% for group B (p = NS); 1-yr graft survival rates were 73.3% for group A and 85.7% for group B (p = NS). In conclusion, donors over 70 should not be excluded a priori for liver transplantation in elective settings. Great attention should be paid to the pathological conditions of arterial vessels caused by atherosclerosis, i.e. the presence of calcified plaques on the hepatic artery, which might represent the source of severe complications.

Adult↗