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PubMed1994

Monitoring for Laparoscopic Surgery.

Laparoscopy has come to be used for a large variety of surgical procedures. This has necessarily led to its use in patients who have a variety of interrelated diseases. While the postoperative course tends to be more benign than in traditional "open" procedures, the intraoperative period may be even more stressful to the patient from a physiological perspective. Use of sophisticated monitoring techniques in selected patients can help yield the optimal postoperative outcome.

Journal Article↗
PubMed1993

[Hereditary prolonged QT interval (Romano Ward syndrome) in obstetric management].

In the Romano-Ward syndrome, an inherited form of abnormally prolonged QT duration is a matter for concern. The frequency-corrected QTc value in the ECG amounts to more than 0.44 s. Persons suffering from Romano-Ward syndrome are vitally endangered by attacks of arrhythmia, syncope and cardiac arrest which are triggered or aggravated by stress or certain drugs. In obstetrical anaesthesia, attention should be paid to the foetus, which, due to the genetic dominance, will have a 50% probability of suffering from the disorder. A 28-year-old para I was admitted with cervical dilation on her predetermined date of delivery. Romano-Ward syndrome had been diagnosed 10 years earlier. The patient had been free of complaints and had received no treatment. Due to cephalopelvic disproportion and the cardiac syndrome, a primary Caesarean section was performed. The QTc values were pathologically prolonged (0.47 s; 0.48-0.63 s) during the pre- and intraoperative period. Haemodynamic irregularities did not occur in the perioperative period. The newborn was vital (3.830 g; 50 cm; Apgar scores 10/10/10; umbilical cord pH 7.29). Directly postpartum isolated supraventricular extra systoles occurred, and the QTc duration increased to 0.51 s.

Adult↗
PubMed1995

Does the addition of morphine to brachial plexus block improve analgesia after shoulder surgery?

We have studied 40 patients undergoing elective shoulder surgery for chronically painful conditions. Patients were allocated randomly to two groups and received interscalene brachial plexus block with 0.5% bupivacaine and adrenaline 1/200,000 40 ml either alone or with the addition of morphine 5 mg. All patients also received a general anaesthetic. The quality of the block, analgesic requirements and any complications or side effects were noted in the intraoperative period and during the 48 h after operation. No significant difference was seen in quality of analgesia or patient satisfaction between the two groups.

Adult↗
PubMed1996

Morphine consumption in patients receiving rectal paracetamol and diclofenac alone and in combination.

Paracetamol and diclofenac have different mechanisms of action, and the combination may be more effective than each drug used alone in treating postoperative pain. In a double-blind, controlled design, we studied 60 patients undergoing elective abdominal gynaecological surgery, who received suppositories of paracetamol 1.5 g, diclofenac 100 mg or a combination of the two before the start of surgery. Patients received morphine in the intraoperative period, and cumulative morphine use from a patient-controlled analgesia system was recorded to measure the analgesic effect of the suppositories. Morphine consumption was greatest in the group that received paracetamol alone and lowest in the group given the combination (P < 0.01). There was no difference in the incidence of morphine-related side effects between the groups. We conclude that a diclofenac-paracetamol combination reduced the amount of morphine used compared with paracetamol alone.

Acetaminophen↗
PubMed1996

A modification of sub-mental intubation.

In patients who have sustained base of skull fractures, the mode of intubation is controversial, with many anaesthetists arguing against nasal intubation. In several maxillofacial procedures temporary intermaxillary fixation (IMF) in the intraoperative period may be essential to achieve optimal results in fixation. For patients with combined facial and base of skull injury, tracheotomy may have to be performed. The submental approach to intubation allows IMF to be used without resort to nasal intubation or tracheotomy. We describe a modification of the original technique which is applicable to any reinforced tracheal tube and which does not compromise the airway.

Adult↗
PubMed2002

Effects of mild and moderate hypothermia on apoptosis in neuronal PC12 cells.

BACKGROUND: There is still a possibility that mild hypothermic therapy may be useful as a neuroprotective tool during the intraoperative period, although the mechanism of cerebral protection by mild hypothermia is not well understood. We hypothesized that mild hypothermia may be protective against cerebral ischaemia by inhibiting post-ischaemia apoptosis. In this study, we used serum-deprived PC12 cells as the neuronal apoptotic model and examined the direct effects of mild and moderate hypothermia. METHODS: Apoptosis was induced by depriving the cell culture medium of serum, which is one of the most representative methods to induce apoptosis, but not necrosis, in PC12 cells. Effects of mild (35 and 33 degrees C) and moderate (31 and 29 degrees C) hypothermia on apoptosis were evaluated. Cytotoxicity (lactate dehydrogenase leakage) and the percentage of apoptotic cells (calculated by flow cytometry with propidium iodide) were evaluated 4 days after induction of apoptosis. As a control, cells without induction of apoptosis were incubated under the same conditions as the apoptosis group. RESULTS: Without induction at 37 degrees C, cytotoxicity and the percentage of apoptotic cells were over 60 and 90%, respectively. At each temperature examined below 35 degrees C, significant decreases in cytotoxicity and the percentage of apoptotic cells were observed. Mean cytotoxicity at 31 and 29 degrees C was 50.2 (SD 4.2)% and 47.9 (4.4)%, respectively. The percentage of apoptotic cells at 31 and 29 degrees C was 42.5 (7.4)% and 36.5 (7.3)%, respectively. In the control group, cytotoxicity and the percentage of apoptotic cells were significantly higher at 29 degrees C than at 37 degrees C. CONCLUSIONS: Mild and moderate hypothermia (29-35 degrees C) inhibited apoptosis, although hypothermia below 30 degrees C may induce apoptosis in intact cells.

Animals↗
PubMed2005

Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children.

BACKGROUND: The ilioinguinal/iliohypogastric nerve block is a popular regional anaesthetic technique for children undergoing inguinal surgery. The success rate is only 70-80% and complications may occur. A prospective randomized double-blinded study was designed to compare the use of ultrasonography with the conventional ilioinguinal/iliohypogastric nerve block technique. METHODS: One hundred children (age range, 1 month-8 years) scheduled for inguinal hernia repair, orchidopexy or hydrocele repair were included in the study. Following induction of general anaesthesia, the children received an ilioinguinal/iliohypogastric block performed either under ultrasound guidance using levobupivacaine 0.25% until both nerves were surrounded by the local anaesthetic or by the conventional 'fascial click' method using levobupivacaine 0.25% (0.3 ml kg(-1)). Additional intra- and postoperative analgesic requirements were recorded. RESULTS: Ultrasonographic visualization of the ilioinguinal/iliohypogastric nerves was possible in all cases. The amount of local anaesthetic used in the ultrasound group was significantly lower than in the 'fascial click' group (0.19 (SD 0.05) ml kg(-1) vs 0.3 ml kg(-1), P<0.0001). During the intraoperative period 4% of the children in the ultrasound group received additional analgesics compared with 26% in the fascial click group (P=0.004). Only three children (6%) in the ultrasound-guided group needed postoperative rectal acetaminophen compared with 20 children (40%) in the fascial click group (P<0.0001). CONCLUSIONS: Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks can be achieved with significantly smaller volumes of local anaesthetics. The intra- and postoperative requirements for additional analgesia are significantly lower than with the conventional method.

Ambulatory Surgical Procedures↗
PubMed1995

Factors associated with postoperative pulmonary complications in patients with severe chronic obstructive pulmonary disease.

The purpose of this study was to determine the incidence of different postoperative pulmonary complications (PPCs) and their associated risk factors in patients with severe chronic obstructive pulmonary disease (COPD) (forced expiratory volume in 1 s [FEV1] < or = 1.2 L and FEV1/forced vital capacity (FVC) < 75%) undergoing noncardiothoracic operations. Thirty-nine of 105 patients (37%) had one or more PPCs (death, pneumonia, prolonged intubation, refractory bronchospasm, or prolonged intensive care unit (ICU) stay). Thirty-eight of 39 patients (97%) with a PPC had an anesthetic duration > 2 h. Our study patients had a 47% 2-yr mortality rate. We determined specific risk factors for each PPC by analyzing potential preoperative and intraoperative risk factors. Pulmonary factors alone do not predict the likelihood of PPCs in severe COPD patients. Multiple logistic regression identified composite scoring systems, such as the ASA physical status, as the best preoperative predictors of PPCs, probably because they include both pulmonary and nonpulmonary factors. During the intraoperative period, avoiding general anesthesia with tracheal intubation may decrease the risk of postoperative bronchospasm. Shortening the duration of surgery and anesthesia may decrease the risk of prolonged ICU stay.

Aged↗
PubMedDate not supplied

The role of the registered nurse-first assistant in the implantable left ventricular assist device program.

Successful support of patients using the implantable left ventricular assist device requires sustained and coordinated efforts by physicians and medical personnel. The authors describe the role of their registered nurse-first assistant (RNFA) as it has evolved through caring for 43 implantable pneumatic left ventricular assist device patients and 8 vented-electric left ventricular assist system patients during a 3 year period. Intraoperatively, the RNFA is responsible for pump assembly, including pre sealing all grafts and connecting areas of the pump using a combination of cryoprecipitate and thrombin. The RNFA assists with pump insertion during surgery. At device explantation, the RNFA dismantles the pump according to the FDA protocol for disassembly. Post operatively, the RNFA assesses and maintains patient hemodynamic stability and intervenes to manage hemodynamic and mechanical problems. Of the 51 patients, 13 are still on support, 9 died before transplantation (17.6%), and post transplant survival is 96.0%. In conclusion, an active left ventricular assist device program requires skilled personnel to manage complex problems and contributes to a successful patient outcome.

Heart Transplantation↗
PubMed1998

Tissue temperatures during ultrasound-assisted lipoplasty.

Removing excess subcutaneous fat with the assistance of ultrasonic energy has recently become a technique of interest in the United States after nearly a decade of use in Europe. There are a number of reported advantages of ultrasound-assisted lipoplasty over traditional liposuction, and there are also some theoretical concerns. Ultrasound-assisted lipoplasty involves the conversion of electrical energy to mechanical energy and transfer to the tissues through acoustic pressure waves, with the formation of heat as a by-product. Heat generated in this process dissipates through the body's own cooling mechanisms and conduction to the surrounding tissues, and it does not contribute to the clinical treatment of the adipose tissue. Reports of "burns" and ischemic skin injuries in the literature, and concerns for potential heat-related problems, prompted us to investigate whether significant temperature elevations occur in the clinical setting. Subcutaneous tissue temperature determinations during ultrasound-assisted lipoplasty were begun in February of 1996, and data were collected from 55 patients who had the procedure performed during a 6-month period. Intraoperatively, temperature measurements were made with a data-logging instrument and a needle microprobe inserted into the subcutaneous tissues. Temperatures were taken in the area of liposuction before the infusion of tumescent fluid, after tumescent fluid infusion, and at 5-minute intervals until the end of the procedure. The patient's core body temperature remained stable during the procedure within a narrow range (35.7 degrees C to 36.3 degrees C). There was a gradual increase in the temperature of the subcutaneous tissues over time during the application of ultrasonic energy; however, average subcutaneous temperatures remained below the core temperature (p < 0.05) at all time intervals. Room-temperature tumescent fluid further enhanced the thermal safety zone without lowering core body temperature. There were no temperature related complications in our study population and no untoward effects of performing temperature measurements. We conclude that there is no clinically significant elevation of subcutaneous temperatures during ultrasound-assisted lipoplasty. Reported ischemic skin complications are more likely the result of injury to the subdermal plexus rather than a temperature-induced thermal injury. Although heat is a natural by-product of the energy transfer involved in ultrasound-assisted lipoplasty, the risk of thermal injury is negligible when the procedure is performed by experienced operators. Complete understanding of the technique along with strict adherence to basic principles of flap vascularity will ensure safe and effective performance of ultrasound-assisted lipoplasty.

Adult↗
PubMed2002

Low-dose propofol infusion for sedation during local anesthesia.

The safety and efficacy of lose-dose propofol for sedation were investigated on 90 consenting patients who had undergone surgical procedures with local anesthesia. After being premedicated with intravenous midazolam 0.05 mg.kg(-1), all patients were randomly divided into two groups and received intravenously either a loading dose of propofol 0.8 mg.kg(-1) followed by a continuous infusion of propofol 30 microg.kg(-1)min(-1) (propofol group) or an equivalent volume of saline (placebo group) during operation. Study groups were compared with respect to the level of sedation, hemodynamic variables, oxygen saturation, and the incidence of intraoperative side effects. In addition, the discharge time and the satisfaction of both patients and surgeons with this sedative technique were assessed. Propofol reduced patients' discomfort and lowered their arterial pressure and heart rate during the infiltration of local anesthetics. It also promoted an adequate level of sedation without clinically significant oxygen desaturation in the intraoperative period. Surgeons and patients in the propofol group showed a higher level of satisfaction than those in the placebo group. There was no significant difference between the two groups with regard to the incidence of adverse effects and the discharge time. In conclusion, it was found that the use of low-dose propofol infusion was a safe and effective sedative technique for local anesthesia.

Adult↗
PubMed1987

Meckel's diverticulum in a femoral hernia: a Littre's hernia.

We have described a patient with strangulation of a Meckel's diverticulum in a femoral hernia. In the case of Littre's hernia, true diagnosis before surgical intervention is rare if not impossible. It is therefore important that the surgeon be well versed in the management of such cases, as well as in distinguishing a Littre's hernia from a Richter's hernia during the intraoperative period.

Aged↗
PubMed2004

Bradycardia and sinus arrest following saline irrigation of the brain during epilepsy surgery.

Adverse cardiac events during the intraoperative period are life-threatening. The authors report three episodes of severe bradycardia and sinus arrest that occurred in a patient undergoing anterior temporal lobectomy and amygdalo-hippocampectomy for the treatment of epilepsy. The first episode occurred during resection of the amygdala; the other two episodes were observed during subsequent irrigation of the exposed brain structures, most likely the brain stem structures, because of a rent that the surgeon had deliberately made into the basilar cistern for better anatomic appreciation of the structures to be excised. The patient responded well to treatment with no adverse outcomes. The probable mechanisms leading to this event are discussed; the authors excluded insular cortex stimulation, the effects of the anesthetic drugs used, and venous air embolism as a cause of bradycardia and sinus arrest. The amygdala resection was the most likely cause of the first episode of bradycardia; the second episode of bradycardia and sinus arrest occurred because of inadvertent stimulation of brain structures by the high temperature (42 degree C) of the saline used for irrigation. To counter its effects, saline irrigation at room temperature (20 degree C) was started, and this caused the third episode of bradycardia, most likely because of "temperature shock" of the exposed brain. Prompt communication with the surgical team and vigilance are crucial for the appropriate management of such an incident, which may pose a threat to life. Avoiding irrigation of the exposed brain with high-temperature saline may prevent such an incident.

Adolescent↗
PubMed2006

Advances in cardiac intensive care.

PURPOSE OF REVIEW: As surgical survival in children with congenital heart disease, particularly those with univentricular hearts, has improved in recent years, focus has shifted to reducing the morbidity of congenital cardiac malformations and their treatment. This review will focus on emerging therapies aimed at reducing these morbidities in the intensive care unit. RECENT FINDINGS: A protracted stay in the intensive care unit after cardiac surgery is a risk factor for developing various morbidities. Therapies or interventions that may hasten postoperative recovery and minimize the length of stay are thus important to evaluate. Fluid overload, renal dysfunction, low cardiac output and neurological dysfunction remain major contributors to morbidity after cardiac surgery. In addition, the treatment of these adverse states can potentially compound the injury. SUMMARY: The reduction in morbidity after cardiac surgery remains challenging. Recent insights have allowed us to recognize the impact of factors beyond the intraoperative period as significant contributors to morbidity. As our field continues to evolve, future studies should focus on emerging technologies and therapies that facilitate the prevention of physiological states that compound congenital morbidities.

Adrenal Cortex Hormones↗
PubMed1995

Fluid balance and pulmonary functions during and after coronary artery bypass surgery: Ringer's acetate compared with dextran, polygeline, or albumin.

The effects on fluid balance, pulmonary functions and economics were evaluated in a randomized comparison of one colloid free and three colloid containing fluid regimens, for 48 hours during and after coronary artery bypass (CAB) surgery. A standard regimen for anaesthesia, extracorporeal circulation and monitoring was used. Only Ringer's acetate (RAc) was used as priming solution for extracorporeal circulation. Forty patients were randomized to receive either RAc, polygeline 35 mg.ml-1 (Haemaccel), dextran 70 (Macrodex) 60 mg.ml-1, or albumin 40 mg.ml-1 in saline whenever fluid volume was needed to stabilize haemodynamics. At the end of the operation, fluid retention was significantly lower in patients receiving polygeline and dextran 70, compared with patients receiving RAc. At 48 hours, however, there were no differences in cumulative fluid balance. Patients in the colloid groups postoperatively had a higher serum colloid osmotic pressure (s-COP), but a higher net lung capillary filtration pressure (delta P) only on the second postoperative day than the RAc group. However, this did not adversely affect intrapulmonary venous admixture, arterial oxygen tension, or time on respirator in the RAc group compared with the colloid groups. The most expensive colloid fluid regimen (albumin) cost about 230 US$ more per patient than the RAc fluid regimen. We conclude that Ringer's acetate for volume replacement to stabilize haemodynamics during and after CAB surgery is associated with increased fluid retention only during the intraoperative period, compared with dextran 70 or polygeline, and with a lower serum colloid osmotic pressure and net lung capillary filtration pressure postoperatively, compared with all three colloid groups. This does not affect pulmonary functions adversely.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed2006

Retroperitoneoscopic pyeloplasty: using reconstructive methods based on intraoperative findings.

AIM: Reconstructive laparoscopic procedures have been recognized as a less invasive treatment than conventional open procedures. However, although the laparoscopic pyeloplasty has also been accepted as useful, few findings have been reported relevant to the retroperitoneal approach. To elucidate its effectiveness and safety, laparoscopic surgery via the retroperitoneal approach was examined in our institution. Furthermore, the importance of laparoscopic observation for ureteropelvic junction and urine passage ureteropelvic junction without indwelling ureteral stent. METHODS: Between July 1998 and December 2004, 13 men and 15 women underwent laparoscopic retroperitoneal surgery for ureteropelvic junction obstruction. The mean patient age was 33.6 years (range: 13-70 years). Methods of repair were determined by intraoperative findings for the relationship between the ureteropelvic junction and surrounding vessels. An indwelling ureteral stent was removed before initiating laparoscopic operation to observe the relationship between ureteropelvic junction and aberrant vessels more precisely. RESULTS: An aberrant renal vessel was found in 13 patients (46%). Dismembered pyeloplasty was carried out in 21 patients, Y-V plasty in five patients and Hellstrom technique in two patients. Ureteral transposition was not required in dismembered pyeloplasty cases. All patients achieved retroperitoneoscopic pyeloplasty without open conversion. The mean operative time was 272 min (range: 155-490 min). The mean estimated blood loss was 44 mL (range: 10-200 mL). No major complications were observed during the intraoperative period, but urinary tract infection occurred in two patients in the postoperative period. In all patients except one, obstruction was improved or resolved. CONCLUSIONS: Laparoscopic retroperitoneal surgery is not only able to repair ureteropelvic junction obstruction, but can also be done safety and less invasively. We believe that laparoscopic observation without indwelling stent will contribute to a more appropriate choice of pyeloplasty.

Adolescent↗
PubMed2007

Correlation of the myocardial performance index with conventional echocardiographic indices of systolic and diastolic function: a study in cardiac surgical patients.

BACKGROUND: The aim of this investigation was to compare the myocardial performance index (MPI), a Doppler-derived parameter of global ventricular function, with standard echocardiographic measures of systolic and diastolic function in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: Complete two-dimensional and Doppler examinations were performed on 46 CABG patients after induction of anesthesia (baseline), 15 minutes postcardiopulmonary bypass (CPB), and at the end of the surgical procedure. RESULTS: A strong inverse correlation between MPI and both fractional area change (adjusted r(2)= 0.588-0.802) and ejection fraction (adjusted r(2)= 0.576-0.656, both P < 0.001) of the left ventricle was observed throughout the intraoperative period. Following CPB, a weaker correlation was observed between MPI and overall diastolic heart function classification (adjusted r(2)= 0.224-0.268, P <0.001). Weak, though statistically significant, correlations were observed between MPI and deceleration time (P < 0.05), peak atrial reversal (AR) wave velocity (P < or =0.002), and duration of the AR wave (P < 0.05). CONCLUSION: Our data suggest that the MPI correlates well with standard echocardiographic measures of systolic function and modestly well with overall diastolic heart function classification. The MPI may be a useful, complementary marker of global left ventricular function in patients undergoing CABG surgery.

Aged↗
PubMed1999

Systemic hemodynamic changes in mansonic schistosomiasis with portal hypertension treated by azygoportal disconnection and splenectomy.

OBJECTIVE: The aim of this study was to assess systemic hemodynamic changes in patients with Manson's schistosomiasis and portal hypertension during azygoportal disconnection and splenectomy. METHODS: Sixteen patients with portal hypertension secondary to hepatosplenic schistosomiasis with indication for surgery were studied prospectively. All underwent invasive hemodynamic monitoring with pulmonary artery catheter. The first systemic hemodynamic assessment was performed preoperatively. In the intraoperative period new hemodynamic data were collected as follows: a) after laparotomy; b) 15-30 min after splenic artery ligature; c) 15-30 min after splenectomy; and d) after ligation of the collateral circulation. RESULTS: The results indicated preoperatively that the patients presented with an increased cardiac index (4.40 +/- 0.94 L/min/m2) together with a reduction in the systemic vascular resistance index (1692.25 +/- 434.91 dyne.s/cm5.m2). The stroke index (53.74 +/- 10.40 ml/beat/m2) and both left (5.71 +/- 1.50 kg.m/m2) and right heart work indexes (1.12 +/- 0.74 kg.m/m2) were also elevated. The mean pulmonary artery pressure was increased (17.81 +/- 9.00 mm Hg) and the pulmonary vascular resistance index decreased (164.31 +/- 138.69 dyne.s/cm5.m2). From the moment that the splenic artery was ligated until the end of the procedure, the cardiac index (3.45 +/- 0.90 L/min/m2) was reduced and the systemic vascular resistance index (2059.50 +/- 590.05 dyne.s/cm5.m5) increased. The systolic index (44.25 +/- 11.01 ml/beat/m2) and the left ventricle work index (4.33 +/- 1.29 kg.m/m2) also reduced. The mean pulmonary artery pressure (19.18 +/- 9.21 mm Hg) and the right ventricle work index (0.94 +/- 0.62 mm Hg) remained elevated after the surgical procedure. CONCLUSIONS: The data allowed us to conclude that hepatosplenic schistosomiasis induces a hyperdynamic circulatory state that was corrected after splenectomy and azygoportal disconnection, remaining a mild pulmonary hypertension. Therefore, these changes are correlated with the portosystemic collateral circulation, especially as a consequence of splanchnic hyperflow.

Adolescent↗