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PubMed1987

Selective neuromuscular blockade for intraoperative electrocorticography.

Local anesthesia is advocated for cortical mapping in certain neurological procedures. Occasionally, however, a modified general anesthetic is necessary. We describe a technique of balanced anesthesia in which the arm opposite to the craniotomy is selectively isolated from the effect of the neuromuscular blocking agent and hence preserves its motor response to cortical stimulation. The technique secures complete immobility of the patient during mapping of the brain, shortens the stimulation time, facilitates the localization of the motor cortex, precludes the development of full-blown seizures, increases safety and is well tolerated.

Adolescent↗
PubMedDate not supplied

[Effect of changes in cardiac output on oxygenation and intrapulmonary short circuit (Qs/Qt) under inhalation anesthesia].

OBJECTIVES: To assess the relation between changes in pulmonary shunt and minute volume induced by blood loss, using an animal model with anesthetic maintenance by isoflurane CAM 1. MATERIAL AND METHODS: Eight dogs were given balanced anesthesia with pancuronium and isoflurane. Variables monitored were systemic and pulmonary arterial pressures, central venous and pulmonary capillary pressures and minute volume. Arterial and mixed venous blood gas measurements were taken from the pulmonary artery catheter, and blood samples were analyzed for hemoglobin in order to calculate pulmonary shunt (Qs/Qt). Two levels or stages of hypovolemia were studied: a) level I = loss of 20% blood volume and b) level II = loss of 30%. RESULTS: A significant decrease of 35% (139 +/- 43 to 90 +/- 24 ml/min-1/kg-1; p < 0.001) in minute volume was observed at the first level of hypovolemia; a 52% (139 +/- 43 to 69 +/- 23 ml/min-1/kg-1; p < 0.001) decrease was found at the second. This decrease was accompanied by similar drops in Qs/Qt of 34% (18.2 +/- 5% to 12.1 +/- 5%; p < 0.01) and 47% (18.2 +/- 5% to 9.2 +/- 5%; p < 0.01) at the first and second levels, respectively. Linear regression analysis showed a direct relation between changes in Qs/Qt with changes in minute volume. CONCLUSIONS: The data reported in this study indicate that changes in Qs/Qt are directly related to those of minute volume in the presence of isoflurane.

Anesthesia, Inhalation↗
PubMedDate not supplied

[Functional state of the right and left heart at different stages of anesthesia in patients with ischemic heart disease during myocardial revascularization surgery].

57 ischemic heart disease (IHD) patients entered the study of right and left heart function at different stages of anesthesia and operation to reveal possible reasons of myocardial dysfunction and to propose effective prevention of this dysfunction. All the patients were operated on under multicomponent balanced anesthesia (relanium, fentanyl, arduan, nitric oxide with oxygen 1:1). Left ventricular function was assessed at Doppler echocardiography, right ventricular function--at catheterization of the lung artery with a Swan-Ganz catheter with low time constant. Hemodynamic monitoring was made with a domestic MX-04 monitor. It was found that in the preperfusion period diastolic function of the right and left ventricles is impaired much more than the systolic one. The conditions of anesthesia and operation affect right ventricular function more than the left one. Diastolic and systolic right ventricular dysfunctions were observed at all stages and three stages of the operation, respectively. Diastolic and systolic left ventricular dysfunction was observed at four and one stages, respectively. Basic causes of the above systolic and diastolic disorders in the preperfusion period may be tachycardia, arterial hypertension, reduction of the preloading and increased postloading (for the right ventricle) in artificial lung ventilation.

Anesthesia↗
PubMed1995

Epidemiology of the adverse hemodynamic events occurring during "clonidine anesthesia": a prospective open trial of intraoperative intravenous clonidine.

STUDY OBJECTIVE: Determine the hemodynamic consequences of intraoperative clonidine during major abdominal surgery. DESIGN: Prospective open trial. SETTING: Teaching hospital. PATIENTS: 402 consecutive patients scheduled for major abdominal surgery. INTERVENTIONS: 350 consecutive patients received intravenous (IV) clonidine (loading dose of 4 micrograms/kg in 20 minutes at anesthesia induction, followed by a continuous infusion of 2 micrograms/kg/h until the end of surgery). Fifty-two additional patients served as controls. Anesthetic technique consisted of balanced anesthesia (isoflurane, fentanyl, atracurium). ECG, invasive arterial blood pressure (BP), expiratory PCO2 and pulse oximetry were continuously recorded. Hemodynamic events (HEs) were defined as moderate for a 20% reduction of the baseline systolic blood pressure (SBP) or a heart rate (HR) decreasing between 50 beats per minute (bpm) and 40 bpm. A 30% reduction of the baseline SBP or a HR below 40 bpm was considered an important HE. The rate and duration of these events were recorded from induction to recovery. HEs requiring a specific treatment were noted. Central venous pressure, volume of fluid infused, and urinary output were also recorded. MEASUREMENTS AND MAIN RESULTS: 21% of control patients and 31% of clonidine patients had no adverse HEs. A moderate reduction of the baseline BP was the most common episode in both groups. The incidence of the HEs (moderate and important) was similar in both groups but the duration HEs was significantly longer in the clonidine patients (p < 0.05). 40% of the control patients and 13% of the clonidine patients required specific management for their HEs (p < 0.05), the most common of which was hypotension without bradycardia. Neither coexisting pathology nor preoperative medications influenced the incidence of HEs. CONCLUSION: IV clonidine can be used routinely during anesthesia for major abdominal surgery.

Abdomen↗
PubMed2004

The effect of epidural bupivacaine on induction and maintenance doses of propofol (evaluated by bispectral index) and maintenance doses of fentanyl and vecuronium.

The growing interest in combining local and general anesthesia has led to studies investigating possible interactions between general anesthesia and local anesthetics administered via spinal, epidural, IV, or IM routes. However, no study has evaluated the effect of local anesthetics on all three components of balanced anesthesia, i.e., hypnosis, analgesia, and muscle relaxation. In this prospective, randomized, double-blind study, we investigated the effect of epidural bupivacaine on the dose requirement of propofol (as evaluated by using the bispectral index [BIS]), fentanyl, and vecuronium for general anesthesia. This study consisted of 30 adults, ASA physical status I and II, undergoing Whipple's pancreaticoduodenectomy for periampullary carcinoma lasting >4 h. An epidural catheter was placed between T9-10. Depending on the group allocation, 10 mL of the study drug was administered as a bolus followed by an infusion at 6 mL/h via the epidural catheter. Patients were divided into 2 groups of 15 each. Patients in the control group received epidural normal saline whereas those in the bupivacaine group received epidural bupivacaine 0.1%. Induction of anesthesia was performed with IV fentanyl 2 mug/kg and propofol titrated to achieve BIS between 40-50. Endotracheal intubation was facilitated by the IV administration of vecuronium 0.1 mg/kg and patient's lungs were ventilated with 66% nitrous oxide in oxygen. After intubation, infusion of propofol 1% was titrated to maintain BIS between 40-50. Inadequate analgesia was defined as an increase in systolic blood pressure and/or heart rate by >20% of baseline values in response to surgical stimulus and was treated with bolus fentanyl 0.5 mug/kg. Neuromuscular monitoring was used to assess the need for additional doses of vecuronium. Data were analyzed by using the Student's t-test and P </= 0.05 was considered significant. The requirement of propofol for induction and maintenance of anesthesia in the bupivacaine group was 1.3 +/- 0.3 mg/kg and 2.4 +/- 0.9 mg . kg(-1) . h(-1), respectively, compared with 2.4 +/- 0.6 mg/kg and 4.4 +/- 1.6 mg . kg(-1) . h(-1) observed in the control group (P < 0.05). Significant reduction was also observed in the requirement of vecuronium and fentanyl during maintenance in the bupivacaine group (P < 0.05). We conclude that epidural bupivacaine given before induction of anesthesia reduces the requirement of propofol, fentanyl, and vecuronium during general anesthesia.

Adult↗
PubMedDate not supplied

[Hemodynamic disorders in liver transplantation and their correction].

To study the pre- and intraoperative causes of hemodynamic disorders at the basic stages of liver transplantation in adult recipients, case histories and anesthesia protocols were analyzed in detail in 15 recipients of the cadaveric liver (Group 1) and 60 recipients of a liver portion taken from a living relative donor (Group 2). The patients' preoperative status, the etiology of the disease, the pattern and scope of preoperative preparation and examination, the cause of anesthesia, the volume, pattern, and rate of infusion were studied. Particular emphasis was placed on the presence of pathophysiological prerequisites and various intraoperative factors, which are causes of hemodynamic disorders. Orthotopic transplantation of the liver was performed under generalized balanced anesthesia whose major components were the inhalational anesthetics isoflurane and sevoflurane (89.3%) or total intravenous anesthesia based on neuroleptic anesthetics (10.7%). The main causes of hemodynamic disorders were the patients' severe baseline condition, anemia, ascitis, intoxication, encephalopathy, and the specific features of a surgical intervention, blood loss, heavy plasma and perspiration losses, water-electrolyte balance impairments, vein-vein shunt and reperfusion syndrome. Operations of extraordinary duration (longer than 15-20 hours) required higher plasma compensation volumes (36-52 ml/kg). Severest hemodynamic disorders were observed in patients admitted to hospital for emergency transplantation of the cadaveric liver. These patients who are to undergo transplantation are outside hospital in most cases, which is why any operation should be regarded in them as an emergency one made in patients who are in a very severe state (ASA IV-VE).

Adult↗
PubMed1996

Postoperative alpha 2-adrenergic stimulation attenuates protein catabolism.

The metabolic effects of continuous intravenous (IV) application of the alpha 2 agonist clonidine were evaluated by assessment of nitrogen economy and postaggression endocrine patterns. Twenty-four patients undergoing abdominothoracic esophageal cancer resection were studied. Thirteen of these patients with alcohol abuse were treated postoperatively with IV clonidine for prevention of alcohol withdrawal syndrome. Eleven patients who were not treated with clonidine served as controls. All patients were treated in a standardized manner in regard to surgical technique, balanced anesthesia, and postoperative intensive care treatment, including thoracic epidural analgesia with bupivacaine and fentanyl. Isonitrogenous and isocaloric nutrition was comparable in all patients. A significantly improved cumulated 6-day nitrogen balance was found in clonidine-treated patients (-1.5 +/- 4.9 g nitrogen) compared to the control group (-17.6 +/- 4.2 g nitrogen) (P < 0.05). The main reason for improved nitrogen economy may be clonidine-induced growth hormone (GH) release. The pattern of insulin-like growth factor I (IGF-I) and insulin-like growth factor binding protein 3 (IGFBP-3) concentrations could support this hypothesis.

Adrenergic alpha-Agonists↗
PubMedDate not supplied

[A case of malignant hyperthermia: anesthesia and recovery].

We report the case of a 29-years-old woman with Menière's syndrome undergoing surgery to drain the endolymphatic sack. After anesthetic induction trismus developed but tubes were inserted without difficulty. Tachycardia began 15 min after start of balanced anesthesia with isoflurane, as arterial oxygen saturation and CO2 pressure decreased and temperature increased. These symptoms responded favorably to immediate treatment with dantrolene sodium, which was continued for 30 h in the ward for postoperative intensive care. Blood chemistry reports showed high enzyme levels that peaked at 24 h. We stress the importance of monitoring end tidal CO2 pressure and of rapidly starting specific treatment with dantrolene for correction of the clinical picture described.

Adult↗
PubMed2002

Hypothermic circulatory arrest and retrograde cerebral perfusion for aortic surgery at Siriraj Hospital: a preliminary review of anesthetic management.

OBJECTIVE: To evaluate the anesthetic management in patients undergoing aortic surgery cerebral perfusion; with particular emphasis on under hypothemic circulatory arrest and retrograde intraoperative brain protection, blood salvage and postoperative outcomes. MATERIAL AND METHOD: Retrospective case series. Data on medical conditions, anesthesia, surgery and postoperative care from patients who underwent operation between June 1993 and December 1999 were analyzed. RESULTS: There were 53 patients involved in this study. They all received general balanced anesthesia; 70.6 per cent had single-lumen endotracheal intubation, while the remaining required double-lumen endotracheal intubation. The duration of the anesthetic procedure, aortic cross-clamping and circulatory arrest, were 365.58 +/- 89.21, 126.35 +/- 34.64 and 48.35 +/- 19.47 min respectively. The lowest nasopharyngeal and rectal temperature were 17.42 +/- 1.40 degrees C and 21.26 +/- 2.80 degrees C respectively. Thiopental 804.68 +/- 353.93 mg and dexamethasone 14.41 +/- 7.88 mg were administered for brain protection, in addition to retrograde cerebral perfusion; 82.35 per cent received 785.71 +/- 273.86 mg of tranexamic acid and only 23.52 per cent received aprotinin in order to reduce blood loss. However, massive blood replacement therapy was always necessary. In the postoperative period, the patients were ventilated for 39.18 +/- 59.53 h, the length of hospital stay was 14.58 +/- 5.83 d, and the mortality was 13.2 per cent. CONCLUSION: This preliminary data indicate that hypothermic circulatory arrest in aortic surgery is associated with a high mortality rate, despite attempts to provide adequate cerebral protection as well as intraoperative blood salvage.

Adult↗
PubMed2005

[Perioperative management of a patient with subarachnoid hemorrhage complicated with descending aortic dissection].

A 62-year-old man with descending aortic dissection received general anesthesia for clipping of aneurysm of the cerebral artery. We chose a surgical operation for the aneurysm of the cerebral artery, and conservative therapy for the dissection of the aorta. We gave balanced anesthesia with blood pressure control using calcium channel blocker. Anesthesia was induced with propofol, fentanyl, and vecuronium, and maintained with isoflurane, fentanyl, nitrous oxide and oxygen. Transesophageal echocardiography was useful for checking dissection of the aorta. Perioperative course was uneventful.

Anesthesia, General↗
PubMed1989

[Difficult intubation and anesthesia in Pfaundler-Hurler disease].

Because of increasing dyspnea, adenoidectomy and tonsillectomy were indicated in a 6-year-old girl with Pfaundler-Hurler disease. The main symptoms were cardiac insufficiency and chronic bronchitis. Because of the large skull with hypoplastic cervical spine, anomalies of facial bones, larynx and jawbone normal intubation was impossible. We therefore performed intubation during spontaneous breathing under inhalation anesthesia and topical anesthesia of the larynx. After exploratory laryngoscopy a preformed Woodbridge tube was inserted into the trachea blind and by ear during of inspiration. The patient's cardiac insufficiency and chronic bronchitis made a balanced anesthesia with reduced dosage of rapifen and halothane necessary. In spite of the poor general prognosis, after the operation a considerable relief of the patient's suffering was noted, because she was able to breathe freely.

Adjuvants, Anesthesia↗
PubMed2004

Correlation of bispectral index and Guedel's stages of ether anesthesia.

UNLABELLED: Bispectral index (BIS) analysis is a method of electroencephalograph (EEG) analysis based on the interfrequency phase relationships of the EEG, designed to quantify anesthetic hypnosis. The BIS was created after concurrent collection of EEG and clinical data from a large number of patients anesthetized with various drugs over a prolonged period and then performing a Fourier analysis followed by a bispectral calculation. The clinical stages of anesthetic depth are very well demonstrated in etherized patients. In this study, we studied the BIS changes during various stages of ether anesthesia and quantified the hypnotic depth during the surgical stage of ether anesthesia. The values for BIS under various stages and planes of ether anesthesia were recorded in 21 patients listed for short surgical procedures. During diethyl ether anesthesia, BIS initially increased and subsequently decreased. During surgical anesthesia, a BIS value of 30 was observed. IMPLICATIONS: For the first time, bispectral index (BIS) has been studied in patients being anesthetized solely with ether. Ether both causes an increase and decrease in BIS during induction and emergence. The index observed during the surgical stage of ether anesthesia is probably the correct value for the depth of hypnosis because no other volatile anesthetic can produce the true anesthetic state when used alone. This value could be taken as the value to be attained when balanced anesthesia is being practiced.

Adult↗
PubMed1999

Anesthesia with sevoflurane in bariatric surgery.

BACKGROUND: Sevoflurane is a good halogen agent for bariatric surgery anesthesia because of its physical and chemical characteristics and its repartition coefficient (blood/gas = 0.65). METHOD: From November 1997 to April 1998, 98 bariatric surgery procedures with sevoflurane anesthesia were done: 17 lipectomies, 71 vertical gastroplasties, and 10 biliopancreatic diversions in 71 women and 27 men, average age 30.3+/-8.3 years, with body mass index 43.9+/-5.7. The average operating time was 50+/-15 minutes for vertical gastroplasty, 160+/-20 minutes for biliopancreatic diversion, and 80+/-12 minutes for lipectomy. The technique of anesthesia was as follows: preanesthesia with atropine sulfate 0.01 mg/kg (dosage refers to ideal weight), ranitidine 50 mg, fentanyl 0.1 mg, ketorolac 60 mg; induction with propofol 0.5-1 mg/kg, succinylcholine 1 mg/kg; orotracheal intubation; maintenance with O2-N2O 50%, sevoflurane 1% to 1.5%, actracurium 0.5 mg/kg (dosage refers to ideal weight); awakening and decurarization with atropine sulfate 1 mg and prostigmine 2 mg. RESULTS: This method permitted correct control of the anesthesia, a quick awakening with a low incidence of nausea and vomiting, a prompt regain of physical and psychological functioning, an early discharge from the hospital, and a larger turnover of patients with lower costs. CONCLUSION: Sevoflurane balanced anesthesia seems to be the best anesthesiologic method for bariatric surgery.

Adult↗
PubMedDate not supplied

[General intravenous anesthesia with spontaneous respiration for noncavitary interventions in cancer].

Two new variants of total intravenous anesthesia with spontaneous respiration were used in 307 female patients subjected to noncavitary interventions for cancer and gynecological cancer. The patients were divided into 2 groups: 1) total anesthesia with midasolam, fentanyl, and calipsol and 2) the same + propofol. Preventive analgesia by preoperative injections of peripheral analgesics was carried out in both groups. Both methods proved to be effective, ensuring good protection from traumatic noncavitary oncological operations. Balanced anesthesia with two hypnotics midasolam and propofol should be preferred, as they mutually potentiate their effects and therefore can be used in the minimum doses, thus preventing the probable side effects, minimizing the use of central analgesics, and ruling out the probability of respiration depression.

Adult↗
PubMed2005

Use of a remifentanil and propofol combination in outpatients to facilitate rapid discharge home.

The goal of our study was to evaluate whether the combination of remifentanil and propofol facilitated shorter recovery time and decreased charges compared with conventional balanced anesthesia. We studied 49 patients, aged 13 to 75 years, who underwent elective outpatient surgery. All data were analyzed using the Pearson chi2 and the Student t test; results were considered statistically significant at a P value of.05 or less. Group 1 received a remifentanil-propofol combination and group 2, a conventional balanced anesthetic. Group 1 had decreased mean operating room (dollar 280.83 vs dollar 337.42; P = .05) and operating room plus postanesthesia care unit (PACU) (dollar 442.67 vs dollar 544.62) charges (P = .02). Group 1 had less PACU time (48.26 vs 59.62 minutes) and 2 group 1 patients bypassed the PACU. We conclude that a remifentanil-propofol combination is more cost effective than conventional balanced anesthetics and enables some patients to bypass the PACU, resulting in quicker discharge. Our findings have important implications for ambulatory surgery centers and office-based practices.

Adolescent↗
PubMed2002

Remifentanil infusion for cardiac catheterization in children with congenital heart disease.

BACKGROUND: Cardiac catheterization of children with congenital heart disease is increasingly being performed under general anesthesia. Haemodynamic stability during anesthesia and fast and adequate recovery after the procedure is crucial in these patients. We performed a pilot study to evaluate hemodynamic stability when using remifentanil for anesthesia during cardiac catheterization. We also evaluated extubation times and recovery characteristics. METHODS: In a randomized, prospective, double-blind study 30 children (aged 1.5-20 months) received a continuous infusion of either 0.2 (group 0.2) or 0.3 microg/kg/min remifentanil (group 0.3) as part of a balanced anesthesia with 0.6 MAC sevoflurane. Heart rate, noninvasive arterial blood pressure, end tidal CO2 and pulse oxymetry were monitored throughout the procedure. Extubation times were noted, and recovery from anesthesia was evaluated using Aldrete scores. RESULTS: : Haemodynamic response to intubation was well blunted in both groups. No significant changes in hemodynamic variables were noted from induction of anesthesia until 10 min after intubation. From then on there was a decrease in HR and systolic arterial pressure, which remained significant throughout the procedure in both groups. Extubation times were similar in both groups: 7.3 min (2,1) in group 0.2 vs. 6.6 min (2,1) in group 0.3 (NS). The number of patients with an Aldrete score of nine or more was 14 (group 0.2) vs. 15 (group 0.3), 10 min after extubation (NS). CONCLUSION: Both dose regimens of remifentanil provided stable hemodynamic conditions during anesthesia for cardiac catheterization of children with congenital heart disease and allowed for rapid and adequate recovery.

Adjuvants, Anesthesia↗
PubMed1990

[Peridural anesthesia and narcosis with propofol in thoracic surgery].

Twelve patients undergoing elective thoracic surgery because of lung cancer, have been studied. The anesthetic management included: continuous epidural anesthesia with bupivacaine (T6-T7), continuous infusion of propofol and vecuronium, mechanical ventilation with an oxygen/air mixture. We evaluated the perioperative analgesia and the cardiovascular side effects of two groups of patients differing for the position (supine or lateral) selected to administer the local anesthetic. We also analysed the most important characteristics of the recovery from anesthesia (degree of analgesia and consciousness, respiratory function and cooperation with physiotherapeutic manoeuvres). The authors conclude that, although the number of patients studied is limited, there are no significant differences between the two groups for intraoperative analgesia and hemodynamic imbalance; the anesthetic technique employed is a reliable alternative to classic balanced anesthesia, because seems to reply very well to the mayor purposes of thoracic surgery. Moreover it makes the operative room free from pollution caused by volatile anesthetics.

Analgesia, Epidural↗
PubMed1988

[Neurophysiological monitoring (electroencephalogram, evoked potentials) and the effects of benzodiazepines].

Since the introduction of diazepam, flunitrazepam and midazolam into clinical practice benzodiazepines have been increasingly used for premedication, induction of anesthesia, and long-term sedation in the intensive care unit utilizing their anxiolytic and sedative components. Intraoperative monitoring of central nervous structures has to take into account the effects of benzodiazepines on the electroencephalogram (EEG) and evoked potentials (EP) before their contribution to alterations in brain electrical activity during balanced anesthesia with combination of different drugs can be evaluated. EEG reflects the spontaneous brain electrical activity whereas EP are the averaged time-locked electrical responses to external stimulation. They are thus able to assess the functional integrity of afferent neuronal pathways from peripheral nerves to cortical areas. The specific benzodiazepine antagonist flumazenil binds competitively to benzodiazepine receptors and is able to induce a change in pharmacodynamic parameters, which i.e. can be measured by EEG- and EP-recordings. Characteristical changes in the EEG after benzodiazepine medication consist in an activation of higher EEG-frequencies simultaneous to a decrease in alpha-activity. A facultative increase in delta-activity seems to be dependent on the absolute dose administered and on the speed for intravenous injection. Benzodiazepine-induced EEG-alterations can be reversed by flumazenil almost completely but in the time course will change again in correspondence to the plasma levels of the benzodiazepines and the half-time of flumazenil. Cortical EP-components are suppressed by benzodiazepines whereas subcortical generated potentials are not altered.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia↗