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PubMed1980

Effects of butorphanol, fentanyl and morphine on the intrabiliary pressure of guinea pigs.

Alleged injury to the liver by halogenated hydrocarbon anesthetic agents has led to greater use of balanced anesthesia with analgesics, tranquilizers and nitrous oxide and oxygen. Reports of high intrabiliary pressures and bizarre cholangiograms for patients under such anesthesia led us to investigate the specific effects on intrabiliary pressure of morphine sulfate, fentanyl and butorphanol tartrate, each at two different dosage levels. After control measurements were taken, all of the guinea pigs, an animal with a biliary tract much like that of man, were injected with a different drug, dosage level or with 0.9 per cent saline solution, and changes in intrabiliary pressure were recorded every five minutes. Both high and low dosages of morphine and fentanyl produced marked and statistically significant increases in the intrabiliary pressure. In contrast, equianalgesic dosage of butorphanol produced little or no increase. Since two of these drugs can elevate intrabiliary pressure significantly above pretreatment values, it is recommended that dilations of the biliary tract occurring during operative cholangiograms be interpreted with caution.

Animals↗
PubMedDate not supplied

[Physiopathologic implications of the anesthesiologic management of pediatric laparoscopic surgery].

We study gas exchange and hemodynamic repercussions during pediatric laparoscopic surgery. We provided balanced anesthesia with muscle relaxation while ventilation was maintained with FiO2 at 0.4 and flow volume between 10-15 ml/kg-1 during abdominal laparoscopic procedures performed in 10 ASA I-II children (4-14 years). Pneumoperitoneum was produced with CO2 insufflated up to a pressure of 15 mmHg. Airways pressure (PIP), PaO2, PaCO2, heart rate (HR), systolic arterial pressure (SAP) and diastolic arterial pressure (DAP) were measured before insufflation and 5, 30 and 60 minutes afterwards. We calculated the ratio of dead space to flow volume (VD/VT), thoracic distensibility and metabolic production of CO2 (VCO2). Insufflation caused an immediate reduction (29-33%) in dynamic thoracic distensibility (p = 0.0004), but no hypoventilation or increases in VD/VT. The decrease in PaO2 was small (5-6%) but statistically significant (p = 0.0188). Hypercapnia (14-21%) was due to an increase in VCO2 caused by gradual peritoneal absorption of CO2 (24-32%, p = 0.0013). We also found increases in SAP (10%, p = 0.02) and DAP (32%, p = 0.0001) at 5 min, along with an increase in HR (8%, p = 0.0163) at 60 min. Arterial CO2 levels were held within physiological limits by compensatory hyperventilation (+25% of physiological VT). Capnography proved to be an excellent guide. Any clinical repercussion of hemodynamic effects was blocked by a dose of atropine given before insufflation and by the excess loading volume (10 ml/kg of crystalloids). Laparascopic surgery in children diminishes thoracic distensibility and causes hypercapnia, making it necessary to measure PefCO2 to regulate ventilation.

Adolescent↗
PubMedDate not supplied

[Anesthesiological support during reconstructive surgery of the upper lip and palate in children].

Two thousand cases of anesthesiological support during reconstructive facial surgery in children aged from 1 to 15 have been reviewed. Gas exchange, heart rate, hemodynamics and neurological status have been assessed. The most frequent and severe complications have been outlined. A most safe variant of balanced anesthesia using ketamine combined with controlled lung ventilation with positive end expiratory pressure has been suggested for intraoperative and postoperative periods.

Adolescent↗
PubMed1994

[An emergency operation for a patient in hypercalcemic crisis--a case report].

Hypercalcemic crisis due to hyperparathyroidism which is resistant to medical treatment, is a rare clinical condition which requires prompt surgical intervention. This 78 year-old woman was hospitalized because of hypercalcemic crisis. Conservative treatment including hemodialysis was not successful. A progressive mental disorder was noted. The maximum preoperative calcium value was 18.5 mg.dl-1, and an emergency surgery was scheduled. Anesthetic management for the hypercalcemic state includes (1) good hydration, (2) protection of the cardiac function, and (3) consideration of specific pathological features like renal failure. Balanced anesthesia with analgesics, vecuronium bromide and calcium blocker (diltiazem 0.5 microgram.kg-1.min-1) had been advocated to maintain the stable circulatory state. Postoperatively, this patient went into hypocalcemic seizures and treatment was necessary for a long period of time.

Aged↗
PubMed1994

Anesthetic management of pheochromocytoma in a long term hemodialysed patient.

The anesthetic management of a hemodialyzed patient with a dopamine producing pheochromocytoma is described. A 56-years old man underwent surgical procedure the day after hemodialysis. Prior to intervention adrenal cortex hormones were normal as well as other endocrine variables (T3-T4-TSH-cortisol-ACTH-parathyroid hormone); epinephrine and norepinephrine, were in a normal range while dopamine was elevated (185 pg/ml). Preoperatively the patient was alpha-blocked with oral phenoxybenzamine (20 mg/day). A balanced anesthesia was performed (isoflurane and fentanyl). Plasma catecholamines were determined. During the induction of anesthesia and before tracheal intubation phentolamine and labetalol were injected till 3.4 mg and 50 mg total dose respectively. During surgical manipulation a nitroglycerin infusion was started (1.5 gamma/kg/min) and after tumor resection dopamine was given till 15 gamma/kg/min. Hormonal values increased in presence of unchanged hemodynamic parameters, likely due to alpha and/or beta blockade. In this case report our problem was especially fluid replacement after tumor resection, because of renal failure. On the basis of CVP and PCWP values, fluid treatment and dopamine infusion allowed to achieve an adequate preload. A sufficient level of analgesia and an efficient alpha blockade may assure hemodynamic stability also in a so compromised patient status.

Adrenal Gland Neoplasms↗
PubMed1998

[Characterization of dose profile of remifentanil with computer simulation: comparative study with fentanyl and alfentanyl].

OBJECTIVES: To estimate the optimum dosing regimen and delivery system for remifentanil, a new opioid, using computer simulations based on information from pharmacokinetic and pharmacodynamic models available for fentanyl, alfentanil and remifentanil, as well as from clinical trials of fentanyl and alfentanil. PATIENTS AND METHODS: We estimated the site concentration ranges likely to be needed to blunt response to anesthetic or surgical stimuli and to recover from spontaneous ventilation. Dosing guidelines for remifentanil, fentanyl and alfentanil were estimated for three methods of administration (bolus, bolus + variable continuous infusion or constant continuous infusion). To that end, the time course of opioid concentration was simulated for hypothetical balanced anesthesia lasting 60 min. We then studied the number of boluses, the number of infusion rate steps, time taken to reach the terapeutic threshold, and time from turning off the infusion until reaching a concentration compatible with spontaneous ventilation. RESULTS: The estimated "effect site" concentration ranges for remifentanil were 6 to 10 ng.ml-1 during intubation; 4 to 6 ng.ml-1 during cutaneous incision; 4 to 7 ng.ml-1 for maintenance; and less than 2.5 ng.ml-1 for recovery of spontaneous ventilation. Simulated bolus administration indicated that 21 boluses of remifentanil, 4 boluses of fentanyl and 7 boluses of alfentanil were needed during one hour. The therapeutic threshold was reached within the first minute with remifentanil, within 2 minutes with fentanyl and within 1 min with alfentanil. Time until recovery of spontaneous ventilation was 7 min with remifentanil, 22 min with fentanyl and 14 min with alfentanil. In the simulation of bolus plus variable infusion, the initial bolus of remifentanil was 100 micrograms, the infusion rate for induction and maintenance was 25 micrograms.min-1 and the maintenance rate was 15 micrograms.min-1. The initial bolus of fentanyl was 300 micrograms, the infusion rate for induction and maintenance was 5 micrograms.min-1. The initial bolus of alfentanil was 2,000 micrograms, the infusion rate for induction was 200 micrograms.min-1 and the maintenance rates were 75 and 25 micrograms.min-1. The therapeutic threshold was reached in 1 min with remifentanil, in 2 min with fentanyl and within 1 min with alfentanil. Spontaneous ventilation was recovered 4 min after turning off the infusion of remifentanil, 4 min afterwards with fentanyl and 6 min afterwards with alfentanil. The simulated constant infusion rate for remifentanil of 15 micrograms.min1 (8 micrograms.min-1 for fentanyl and 75 micrograms.min-1 for alfentanil) allowed the therapeutic threshold to be reached in 10 min with remifentanil, in 22 min with fentanyl and in 17 min with alfentanil. Recovery of spontaneous ventilation occurred 5 min after closure of the infusion pump with remifentanil (24 min with fentanyl and 17 min with alfentanil). CONCLUSIONS: Information from pharmacokinetic and pharmacodynamic models allows us to establish the effect site concentration ranges for remifentanil and determine the ideal administration technique for this drug. The simulation also allows us to compare the properties of remifentanil to those of other common opioids such as fentanyl and alfentanil. The results are fairly consistent with clinical evidence, demonstrating the power of pharmacokinetic and pharmacodynamic models for rationally establishing opioid dosing guidelines.

Adult↗
PubMed1987

Experimental meningitis in the rabbit. I. Arterial blood pressure and acid-base balance during halothane anesthesia and in situ freezing of the brain.

Effects of halothane/N2O anesthesia and in situ freezing of the brain on mean arterial blood pressure (MABP), pH, pCO2 and pO2 were evaluated in rabbits with either Streptococcus pneumoniae or Escherichia coli meningitis. Prior to anesthesia infected rabbits had, compared to controls, significantly lower values for MABP and pCO2, either with a compensated (S. pneumoniae group) or decompensated (E. coli group) metabolic acidosis. In most animals a slight additional decrease in MABP was observed during anesthesia. With maintained pre-anesthetic hypocapnia no further disturbance in acid-base balance occurred during anesthesia. After one minute of freezing MABP increased towards preanesthetic levels. We conclude that the technique for in situ freezing of the brain under halothane/N2O anesthesia may be applied for studies of cerebral metabolism in rabbit with experimental meningitis.

Acid-Base Equilibrium↗
PubMed1994

Onset and duration of action and hemodynamic effects of rocuronium bromide under balanced and volatile anesthesia.

The onset and duration of action, and hemodynamic effects of rocuronium bromide 0.6 or 0.9 mg kg-1 were studied in 4 groups of 10 patients each during anesthesia with nitrous oxide in oxygen and fentanyl or halothane. Neuromuscular block was monitored using mechanomyography and train-of-four (TOF) stimulation. The mean time to onset of complete neuromuscular block was 55 s with the 0.6 mg kg-1 dose during both anesthetic techniques. The times to recovery of T1 (first response in the TOF stimulation) to 25 and 90% of control and to the recovery of the TOF ratio to 0.7 were 36, 45 and 54 min respectively during narcotic anesthesia, and 35, 54 and 58 min during halothane anesthesia. Complete block with the 0.9 mg kg-1 dose occurred in 50, and 52 s respectively in the fentanyl and halothane groups. The recovery of T1 to 25% occurred in 49 and 52 min, to 90% in 66 and 71 min and to TOF ratio of 0.7 in 72 and 79 min respectively during balanced and halothane anesthesia. There were no significant changes in heart rate or mean arterial pressure during the 5 min following administration of either dose of rocuronium during balanced or halothane anesthesia. A separate group of 10 patients received 0.9 mg kg-1 of rocuronium during anesthesia with nitrous oxide, oxygen and isoflurane. Complete block occurred in an average time of 45 s in these patients with 25% recovery of T1 in 53 min.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1989

[The alterations of serum colloid osmotic pressure, serum protein and water balance during prolonged anesthesia].

The changes of serum colloid osmotic pressure (COPm), serum protein and water balance were examined in 9 patients during and for 2 weeks after operation which required prolonged anesthesia. The values of serum total protein (TP), serum albumin (Alb) and COPm decreased by about 17% three hours after the start of anesthesia and by 15%, 20% and 24%, respectively, after 18 hours. These values returned to each preoperative value about one week after the operation. The correlation coefficients (the values in parentheses were calculated using data obtained during anesthesia) comparing COPm to TP, Alb and calculated colloid osmotic pressure (Landis' equation) were 0.661 (0.710), 0.480 (0.649) and 0.666 (0.727). There was no correlation between COPm and water balance. When COPm was 17.5mmHg or lower, calculated colloid osmotic pressure value was higher than COPm as the Alb/TP ratio decreased. Decreases in the values of COPm and serum protein during operation were considered to have been caused mainly by increased capillary permeability.

Anesthesia↗
PubMed1995

[Qualitative comparison of modified neurolept-, balanced and intravenous anesthesia. 2. Results of a clinical study, 1992].

The safety and tolerance of neuroleptanaesthesia (NLA), balanced anaesthesia (BAL), and intravenous anaesthesia with propofol (IVA) were analysed for the first time in a prospective, randomised clinical trial. METHODS. In all, 1318 surgical patients received either NLA, BAL, or IVA. Patients who had regional anaesthesia, were aged under 18 years, or were non-cooperative or vitally threatened (ASA class i.v. to V) did not participate in the study. Premedication and anaesthetic course were set up at a standard of 30% oxygen and 70% nitrous oxide. Incidents, events, and complications due to anaesthesia were obtained (IEC key of the German Society of Anaesthesia and Critical Care Medicine, DGAI). Furthermore, postanaesthetic alertness based on specific recovery tests and the quality of anaesthesia from the patient's viewpoint, rated by patient questionnaires from the DGAI were evaluated. All parameters were calculated and checked for statistical significance using the chi-square test. RESULTS AND DISCUSSION. The groups were broadly comparable with respect to age (P = 0.91), ASA class (P = 0.42), preoperative blood pressure (P = 0.36), and length of anaesthesia (P = 0.82). The anaesthesia, which averaged 103 min, comprised the following regimens: (1) NLA: 7.1 mg droperidol and 0.008 mg/kg body weight fentanyl, (2) IVA: 493.4 mg propofol and 0.004 mg/kg body weight fentanyl, and (3) BAL: 2.6 mg droperidol and 0.004 mg/kg body weight fentanyl with 0.4 vol.% isoflurane. With respect to anaesthetic risk, the following reactions were observed: the use of NLA led to a high incidence of tachycardia (P = 0.001), arrhythmias (P = 0.05), and hypertensive reactions (P = 0.001), whereas in the IVA group only hypotension (P = 0.0001) occurred. However, after the use of BAL none of the aforementioned complications were detectable to any considerable degree. Similarly, patients who had cardiac disease showed greater IEC changes after the use of NLA than after BAL or IVA (P = 0.02) (Tables 1 and 2). The heart rates and blood pressures during BAL and IVA were extremely stable, and therefore, vasoactive therapy was required considerably less in comparison to NLA (P = 0.001) (Table 4). Recovery after the use of IVA was strikingly rapid: the patient's responsiveness, orientation, and ability to concentrate was significantly better than after the other anaesthetic regimen (P = 0.01) (Table 5). With regard to the typical discomforts after anaesthesia, IVA was highly superior to BAL and NLA: nausea (P = 0.0003) and retching (P = 0.03) hardly ever occurred (Table 6). Due to the tolerable manner of waking up and rapid return of orientation and the ability to concentrate, IVA was highly favoured by the patients (P = < 0.01) (Table 7). CONCLUSION. The present results show clear clinical advantages of BAL and IVA in contrast to neuroleptanaesthesia. Due to the very low incidence of side effects such as nausea and vomiting IVA was highly recommended by the patients, at least in part because of the rapid recovery time.

Adult↗
PubMed1993

Continuous intravenous infusion of rocuronium (ORG 9426) in patients receiving balanced, enflurane, or isoflurane anesthesia.

BACKGROUND: Rocuronium (ORG 9426) is a new nondepolarizing neuromuscular blocking agent with a rapid onset and an intermediate duration of action. This study obtains the infusion requirements of rocuronium in 30 patients in whom anesthesia was maintained with barbiturate-nitrous oxide-opioid, nitrous oxide and enflurane, or nitrous oxide and isoflurane. METHODS: For all 30 patients, anesthesia was induced with intravenous thiopental and fentanyl, followed by 0.45 mg/kg rocuronium. Patients were randomly allocated to receive either: 1) nitrous oxide in 40% oxygen supplemented with fentanyl, thiopental, and droperidol (balanced anesthesia), 2) 1.25 MAC enflurane-nitrous oxide, or 3) 1.25 MAC isoflurane-nitrous oxide. Once blockade had recovered to 95% depression of twitch height, muscle relaxation was maintained by continuous infusion of rocuronium, adjusted to maintain mechanical twitch response at 95% depression. RESULTS: At 90 and 120 min, the enflurane and isoflurane groups had lower infusion requirements than those receiving barbiturate-nitrous oxide-opioid anesthesia (P < 0.02), but these did not differ significantly between the two volatile agents. Final infusion requirements (mean +/- SD) were 9.8 +/- 3.7, 5.9 +/- 3.1, and 6.1 +/- 2.7 micrograms.kg-1.min-1 for the groups receiving barbiturate-nitrous oxide-opioid, enflurane, and isoflurane anesthesia, respectively. Spontaneous recovery began soon after termination of the infusion; in all patients, twitch tension equaled 10% of control within 5 min. CONCLUSIONS: The infusion requirements to maintain 95% twitch depression approximated 10 micrograms.kg-1.min-1 during barbiturate-nitrous oxide-opioid anesthesia. These requirements were reduced by 40% during anesthesia involving enflurane or isoflurane.

Adult↗
PubMed1995

[Quality comparison of modified neurolept-, balanced and intravenous anesthesia. 1. Study design and patient analysis of the Krefelder study 1992].

The choice of appropriate anaesthesia in a more or less seriously ill patient requires detailed information on the risk and tolerance of each specific anaesthetic regimen. The objective of this prospective, randomised clinical trial was to test the hypothesis that three regimens of general anaesthesia--neurolept-(NLA), balanced (BAL), and intravenous propofol anaesthesia (IVA)--differ with regard to safety and comfort. The criteria for the intraoperative safety and postoperative comfort of the patients were the incidents, events and complications (IEC) that required medical treatment as well as the evaluation of postoperative complaints by the patients according to the IEC list and patient questionnaires of the German Society of Anaesthesia and Critical Care Medicine (DGAI). METHODS. The study duration was about 4 months, from January to April 1992. During this period the patients of all nine operative departments of the hospital received strictly randomised NLA, BAL, or IVA. Patients who had regional anaesthesia or were not capable of understanding the German language, were nonco-operative, or were seriously ill (ASA class IV to V) as well as children under 18 years of age did not participate in the study. All eligible patients provided their informed consent. ANAESTHESIA. For premedication 10 mg chlorazepate was administered the night before and on the day of surgery. Anaesthesia was conducted under normoventilation using a mixture of 70% nitrous oxide and 30% oxygen. NLA patients were induced intravenously with 0.2 mg/kg body weight etomidate and received 0.005 mg/kg fentanyl and 0.07 mg/kg droperidol before the start of surgery. The repetition dose was 0.2 mg fentanyl and 2.5 mg droperidol. In the BAL patients the dose of fentanyl and droperidol was reduced to 50% due to the addition of isoflurane up to 1 vol. %. IVA patients received 2 mg/kg propofol over 3 min followed by an infusion of 3-5 mg/kg per hour together with 0.2 mg fentanyl/h. Neuromuscular blockade was accomplished with vecuronium 0.1 mg/kg. If the blood pressure and heart rate increased by more than 20% of preoperative values, analgesia was reinforced by an additional fentanyl dose. Anaesthesia was subsequently enhanced by increasing the neurolept/propofol/isoflurane dose by up to 50%. DATA COLLECTION. The following parameters were registered: patients' personal data and physical condition according to ASA classification; the grade of risk according to the Munich risk checklist; the frequency of IEC during surgery; the patients' permanent medications; postanaesthetic vigilance and recovery; the acceptance of the assigned anaesthetic by the physician; the cost of the anaesthetic used; and pre- and post-operative complaints as well as the assessment of anaesthesia by the patient. The statistical evaluation was performed using the chi-square test. RESULTS. A total of 1,346 patients were enrolled in the study; 28 (2%) were excluded because the treatment protocol was changed by the anaesthesiologist. Seventy per cent were recruited from general, gynaecologic, or otorhinolaryngologic surgery. The three anaesthetic regimens (NLA, BAL, and IVA) were used in other departments with the same frequency with the exception of ophthalmology and urology (P > 0.1) (Fig. 1). Of the 1,318 eligible patients, 443 received NLA, 443 BAL, and 432 IVA (P = 0.8). The distribution of the various parameters was surprisingly similar among the three groups: the average age was 50 years (P = 0.91), body weight 71 kg (P = 0.33), reference or initial blood pressure 130/80 mm Hg (P = 0.36), average time of anaesthesia 103 min (P = 0.82), and all had the same risk score (P = 0.42). Sixty per cent were female. An average of 85% of the 18- to 89-year-old patients were considered to be healthy according to the ASA risk classification (P = 0.42). However, on applying the Munich risk checklist the average number of healthy individuals was 5% to 10% lower than that of the ASA risk classification.

Adolescent↗
PubMed1996

[Does the difference in anesthetic methods influence postoperative nitrogen balance?].

To evaluate the influence of anesthesia on postoperative nitrogen balance after upper abdominal surgery, twenty-seven patients undergoing the surgery were investigated. They were allocated randomly to three groups receiving different anesthetic methods, i.e., epidural anesthesia, general anesthesia or balanced anesthesia. In the epidural anesthesia group, anesthesia was maintained with 0.5% isoflurane, nitrous oxide and oxygen supplemented with epidural analgesia extending from Th 1 to L 3. In general anesthesia group, anesthesia was maintained with isoflurane, nitrous oxide and oxygen. In balanced anesthesia group, anesthesia was maintained with 0.5% isoflurane, nitrous oxide, oxygen and intravenous fentanyl. Epidural fentanyl was used for postoperative analgesia in all groups. There was no significant difference in the cumulative nitrogen balance for three days among the three groups. Postoperative values of IL-6 and CRP also did not differ significantly among the three groups. Postoperative WBC was significantly higher in the balanced anesthesia group than in other two groups. The results suggest that the difference in anesthetic methods does not influence postoperative nitrogen balance.

Abdomen↗