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PubMed1995

Implications of chemical and physical properties of desflurane for longer surgery.

Increased duration of anaesthetic administration has implications for recovery from anaesthesia, has cardiovascular effects, and potential for toxicity through metabolism and breakdown of the anaesthetics. Recovery of function after desflurane or sevoflurane anaesthesia, because of the low blood gas and tissue solubilities of these agents, is more rapid than after halothane, isoflurane or enflurane, with recovery being most rapid after desflurane. Increased duration of anaesthesia amplifies the differences in rate of recovery because of the additional anaesthetic (greater with more soluble agents) dissolved in tissues. Increased duration of anaesthesia lessens the cardiovascular depression associated with most halogenated inhaled anaesthetics including desflurane, but not isoflurane. Increased duration of anaesthesia allows for greater metabolism of anaesthetics and greater exposure to metabolites and potentially toxic breakdown products. Desflurane is the least metabolised of the available anaesthetics and is stable in soda lime and Baralyme. Thus, it has exceedingly low potential for toxicity. Sevoflurane undergoes considerable metabolism, producing free fluoride ion, with plasma concentrations proportional to dose and duration of anaesthesia exceeding 50 microM in approximately 7% of patients. In rats, the effects of a toxic breakdown product of sevoflurane, CF2 = C(CF3)OCH2F (compound A), are also dose- and duration-dependent, with lower concentrations producing toxic effects as duration of exposure increases. The clinical importance of the metabolism and in vitro breakdown of sevoflurane has still to be adequately tested.

Anesthesia Recovery Period↗
PubMed2004

Reliability of radiographic measurement of small intestinal length.

OBJECTIVE: The capacity for absorption of nutrients after small intestinal resection is related to the remaining length of intestine, and short bowel syndrome has major implications. Accurate pre-operative determination of bowel length may be useful in conditions where further resection of small bowel is contemplated. The aim of this study is to evaluate the accuracy of small bowel length measured by barium follow-through (BaFT) examination. PATIENTS AND METHODS: Twenty-two patients underwent both intra-operative measurement of small bowel length, and BaFT examination where length was measured using an opisometer. RESULTS: The difference between operative and radiological measurement (mean +/- standard deviation: 15.7 +/- 16 9%) was least in those with the shorter small intestine (overall variation: r = 0.703, P < 0.01, regression coefficient: -0.118, intercept: 15.1). There was no difference in whether BaFT was performed pre or postoperatively. CONCLUSION: Assessment of small bowel length by BaFT radiography is accurate, particularly in those with shorter small bowel lengths.

Adult↗
PubMed1999

The use of electrophysiological monitoring in the intraoperative management of intracranial aneurysms.

OBJECTIVES: Somatosensory evoked potentials (SSEPs) and brainstem auditory evoked potentials (BAEPs) have been increasingly utilised during surgery for intracranial aneurysms to identify cerebral ischaemia. Between July 1994 and April 1996, we surgically treated 70 aneurysms in 49 consecutive patients (58 operations) with the aid of intraoperative evoked potential monitoring. This study sought to evaluate the usefulness of SSEP and BAEP monitoring during intracranial aneurysm surgery. METHODS: Mean patient age was 51.9 (range 18-79) years. The sizes of the aneurysms were 3-4 mm (15), 5-9 mm (26), 10-14 mm (11), 15-19 mm (seven), 20-24 mm (six), and >25 mm (five). SSEPs were monitored in 58 procedures (100%) and BAEPs in 15 (26%). The neurological status of the patients was evaluated before and after surgery. RESULTS: Thirteen of the 58 procedures (22%) monitored with SSEPs had SSEP changes (12 transient, one persistent); 45 (78%) had no SSEP changes. Three of 15 patients (20%) monitored with BAEPs had changes (two transient, one persistent); 12 (80%) had no BAEP changes. Of the 14 patients with transient SSEP or BAEP changes, these changes resolved with adjustment or removal of aneurysm clips (nine), elevating MAP (four), or retractor adjustment (one). Mean time from precipitating event to electrophysiological change was 8.9 minutes (range 3-32), and the mean time for recovery of potentials in patients with transient changes was 20.2 minutes (range 3-60). Clinical outcome was excellent in 39 patients, good in five, and poor in three (two patients died), and was largely related to pretreatment grade. CONCLUSIONS: SSEPs and BAEPs are useful in preventing clinical neurological injury during surgery for intracranial aneurysms and in predicting which patients will have unfavourable outcomes.

Adolescent↗
PubMed2005

Carotid endarterectomy without shunt: the role of cerebral metabolic protection.

BACKGROUND: The optimal method to protect the brain from hemodynamic ischemia during carotid endarterectomy (CEA) remains controversial. This study reports our experience with induced arterial hypertension and selective etomidate cerebral protection in a cohort of patients who underwent CEA without shunting and continuous electroencephalography (EEG) monitoring. METHODS: We reviewed retrospectively 102 consecutive CEAs performed in 102 patients with routine EEG monitoring and general anesthesia between March 1998 and October 2002. There were 65 (66%) symptomatic and 37 (34%) asymptomatic individuals. A protocol of induced arterial hypertension against EEG ischemic changes during carotid artery cross clamping was followed. Only patients with EEG changes refractory to induced hypertension went into etomidate-induced burst suppression. RESULTS: EEG changes were classified as mild, moderate and severe. Twenty patients (19.6%) developed asymmetric EEG changes, of which the great majority were mild and moderate (75%, p< 0.05). Seven patients with moderate (n=3) and severe (n=4) EEG changes needed etomidate cerebral protection. There were no mortalities and only one stroke (0.98%) is reported in the series. The morbidity rate was 6.8% and included transient cranial nerve palsies (n=5) and wound hematoma (n=1). CONCLUSIONS: Carotid endarterectomy can be safely performed with EEG monitoring and selective induced arterial hypertension and etomidate cerebral protection. Our results suggest that this method may be a good alternative for shunting and its inherent risks.

Adult↗
PubMed2005

Atrial fibrillation after cardiac surgery/cardiopulmonary bypass is associated with monocyte activation.

Atrial fibrillation (AF) contributes significantly to morbidity and mortality in as many as one-third of patients after cardiac surgery that requires cardiopulmonary bypass (CPB). Recent data suggest that inflammatory infiltration of the myocardium may predispose to AF. We conducted an exploratory pilot study to determine if there was an association between the perioperative leukocyte inflammatory response to cardiac surgery/CPB and postoperative AF. We enrolled 72 patients undergoing cardiac surgery with CPB; all patients were in sinus rhythm before surgery. Leukocyte activation (CD11b upregulation) was perioperatively measured in monocytes and neutrophils (PMN). Preoperative C-reactive protein (CRP) and perioperative neutrophil myeloperoxidase (MPO) were also monitored for inflammation, and troponin I was assayed for perioperative cardiac muscle damage. All markers were evaluated for differences between the subset of patients who developed AF versus those who remained in normal sinus rhythm after surgery. All 72 patients completed the study. Postoperative AF developed in 26 (36%) patients. Perioperative monocyte CD11b upregulation was significantly increased in patients who developed AF (P = 0.01), but increases in PMN CD11b were not significantly associated with AF (P = 0.057). The increase in both monocyte and PMN counts after aortic cross-clamp release was significantly associated with postoperative AF (P = 0.007 and P = 0.005, respectively). By contrast, preoperative CRP and perioperative MPO did not differ between AF and normal rhythm patients. Similarly, the peak value of troponin I did not differ between groups. In this pilot study of cardiac surgery/CPB patients, perioperative upregulation of the monocyte adhesion receptor, CD11b, and higher circulating monocyte and PMN numbers were associated with postoperative AF, suggesting that the induction of cellular inflammation during cardiac surgery/CPB may contribute to this pathophysiology.

Aged↗
PubMed2001

Arterial waves in humans during peripheral vascular surgery.

The purpose of this study was to investigate the effect of aortic clamping on arterial waves during peripheral vascular surgery. We measured pressure and velocity simultaneously in the ascending aorta, in ten patients (70+/-5 years) with aortic-iliac disease intra-operatively. Pressure was measured using a catheter tip manometer, and velocity was measured using Doppler ultrasound. Data were collected before aortic clamping, during aortic clamping and after unclamping. Hydraulic work in the aortic root was calculated from the measured data, the reflected waves were determined by wave-intensity analysis and wave speed was determined by the PU-loop (pressure-velocity-loop) method; a new technique based on the 'water-hammer' equation. The wave speed is approx. 32% (P<0.05) higher during clamping than before clamping. Although the peak intensity of the reflected wave does not alter with clamping, it arrives 30 ms (P<0.05) earlier and its duration is 25% (P<0.05) longer than before clamping. During clamping, left ventricule (LV) hydraulic systolic work and the energy carried by the reflected wave increased by 27% (P<0.05) and 20% (P<0.05) respectively, compared with before clamping. The higher wave speed during clamping explains the earlier arrival of the reflected waves suggesting an increase in the afterload, since the LV has to overcome earlier reflected compression waves. The longer duration of the reflected wave during clamping is associated with an increase in the total energy carried by the wave, which causes an increase in hydraulic work. Increased hydraulic work during clamping may increase LV oxygen consumption, provoke myocardial ischaemia and hence contribute to the intra-operative impairment of LV function known in patients with peripheral vascular disease.

Aged↗
PubMed2002

[Intraoperative hemodynamics in elderly patients during abdominal aortic aneurysm operations].

An association between hemodynamics and age was assessed in abdominal aortic aneurysm resection and graft replacement. Changes in blood pressures and heart rates before and after clamping the aorta as well as before and after its declamping were compared in 34 cases of elective abdominal aortic resection from 1998 to 1999. The results were analyzed retrospectively reviewing their charts. The patients were divided into two groups: age under 70 and 70 or above. In the first group, the decrease in heart rate following clamping of the aorta was greater than that in the second group. On the contrary, after the aorta was declamped, a greater increase in the heart rate after declamping the aorta correlated with aging (R = 0.34, P < 0.05). However, the changes in blood pressure and heart rate were independent of preoperative coronary diseases. Whereas the people aged 70 or above showed different hemodynamics from those under 70, intraoperative hemodynamics did not reflect preoperative coronary diseases.

Aged↗
PubMedDate not supplied

[Monitoring control of the visual evoked potentials during the surgical treatment of tumors of the chiasmal-sellar area].

Visual evoked potentials were recorded in different stages of the operation in 12 patients with tumors of the chiasmal-sellar region. A correlation was noted between the dynamics of the P100 latent period and the changes of visual functions after the operation. Intraoperative monitoring of visual evoked potentials makes it possible to appraise the functional condition of the optic nerves objectively and correct the techniques and tactics of the operative intervention.

Adenoma↗
PubMed1989

Cecal diverticulitis.

Cecal diverticulitis is an uncommon entity. Its operative treatment represents 0.2% of procedures performed for an acute abdomen. The clinical presentation is often indistinguishable from acute appendicitis. At operation, it may be confused with cecal carcinoma. The surgeon must be aware of this condition and be prepared to choose the most appropriate treatment. Local excision has been advocated as the treatment of choice. The authors review 18 cases seen over a 10-year period. In no case was the correct diagnosis made preoperatively. Intraoperatively, a correct diagnosis was made in 12 of the 18. Carcinoma was the next most frequent intraoperative diagnosis (four cases). Twelve of the 18 patients were treated by standard or limited right hemicolectomy. One patient died early in the series of sepsis caused by a perforated diverticulum and one patient had a life-threatening complication. Right hemicolectomy appears to be a safe and effective treatment option for cecal diverticulitis.

Acute Disease↗
PubMedDate not supplied

[Anesthesia during radical surgery for esophageal cancer].

The paper summarizes the experience with 245 anesthesias made in 1983 to 2002 during operations for malignant esophageal neoplasms and cardioesophageal cancer. The specific features of the perioperative period, monitoring of the function of vital viscera, the technical features of transhiatal esophagectomy, risk factors of postoperative complications and principles of their prevention are considered. The ways of optimizing anesthesiological protection during radical esophageal operations are discussed.

Adult↗
PubMed2002

Perioperative monitoring of indocyanine green clearance and plasma disappearance rate in patients undergoing liver transplantation.

INTRODUCTION: Indocyanine green (ICG) elimination tests have been repeatedly suggested as an early predictor of graft function in patients with liver transplantation. Conventionally, ICG clearance (ClICG) is measured by a series of blood samples with subsequent laboratory analysis. More recently bedside techniques have become available to measure ICG concentrations in vivo and in addition to ClICG, the plasma disappearance rate of ICG (PDRICG) is increasingly being used. The aim of this study was to assess and to compare the normal time courses of ClICG and PDRICG in liver transplant recipients. METHODS: ClICG and PDRICG were measured perioperatively and at various times up to 24 h after liver transplantation. The bedside transpulmonary indicator dilution technique with an arterial fiberoptic-thermistor catheter was used to assess the ICG concentration time curve together with total circulating blood volume (Vd circ). RESULTS: Similar patterns of the time courses of ClICG and PDRICG with a fast recovery of ICG elimination in the early reperfusion period were observed. Compared to healthy subjects, ClICG was supranormal and PDRICG was slightly subnormal. In this study, Vd circ was increased at baseline and remained increased during surgery. CONCLUSIONS: PDRICG and ClICG are well suited to monitor onset and maintenance of graft function in patients undergoing liver transplantation. The PDRICG values measured tend to be relatively lower than ClICG because of an increased blood volume in these patients. By knowing these differences it is justified to monitor liver function in a very simple manner with PDRICG.

Adult↗
PubMed2001

Intraoperative mild hypothermia does not increase the plasma concentration of stress hormones during neurosurgery.

PURPOSE: To determine how mild hypothermia (34 degrees C) affects the hemodynamic and the stress hormonal responses intraoperatively and during extubation in patients undergoing cerebral aneurysm surgery. METHODS: After induction, anesthesia was maintained with 1.2% isoflurane and 50% nitrous oxide. For the normothermia and the hypothermia groups, the body temperature was maintained at 36.9 +/- 0.3 degrees C and 34.2 +/- 0.2 degrees C respectively up to the recovery room. Hemodynamic changes were recorded continuously. Stress hormones comprising epinephrine, norepinephrine, ADH, ACTH, and cortisol were measured at the awake control, intraoperative, and extubation periods. RESULTS: Vital signs of the intraoperative and postextubation time periods were not significantly different between the normothermia and hypothermia groups except for a statistically lower pulse rate intraoperatively in the hypothermia group (P <0.05). In the control awake state, all five hormonal concentrations were similar between the two groups. Intraoperatively, all of the hormonal levels tended to be lower in the hypothermia group compared to the normothermia group, but only the epinephrine level decreased sufficiently to reach statistical significance (P <0.05). During extubation, all stress hormone concentrations, except norepinephrine, were lower in the hypothermia group (epinephrine: P <0.05; ADH: P <0.05; ACTH: P <0.05; cortisol: P <0.05). CONCLUSIONS: Our data suggest that intraoperative mild hypothermia neither significantly affects the blood pressure response nor increases the concentrations of stress hormones intraoperatively. Furthermore, mild hypothermia significantly decreased the plasma concentrations of stress hormones during the extubation period.

Adrenocorticotropic Hormone↗
PubMed2002

[Inhaled nitric oxide in the peroperative period and recovery].

OBJECTIVE: To analyse the current knowledge concerning use of inhaled NO (iNO) in anaesthesia and intensive care. DATA SOURCE: References were obtained from Medline, recent review articles, the library of the department and personal files. STUDY SELECTION: All categories of articles on this topic have been selected. DATA EXTRACTION: Articles have been analysed for history, biochemistry, pharmacology, toxicity and clinical use of iNO. DATA SYNTHESIS: Nitric oxide (NO) is a potent endothelium-dependent vasodilator. Because of its selective action on pulmonary circulation and the lack of effect on the systemic circulation due to its inactivation by haemoglobin, iNO has been presented as a new therapeutic agent in most diseases with pulmonary hypertension. During heart transplantation or surgical correction of congenital heart disease, iNO decreases pulmonary hypertension and improves altered right ventricular function. Studies included however small numbers of patients. Preliminary pharmacological studies demonstrated that iNO was able to decrease pulmonary hypertension and improve systemic oxygenation in adult respiratory distress syndrome. To date, none of the three multicentric studies performed was able to show any significant effect on duration of mechanical ventilation, morbidity or mortality. Finally, the sole demonstrated indication for iNO which remains is the persistent pulmonary hypertension of the newborn. Two multicentric studies have evidenced an improvement in systemic oxygenation and a reduced need for extracorporeal membrane oxygenation. In these two studies global mortality was however unchanged. CONCLUSION: Persistent pulmonary hypertension is the sole demonstrated indication for iNO. Inhaled nitric oxide may be efficient in pulmonary hypertension, right ventricular dysfunction and severe hypoxemia. Inhaled nitric oxide must be considered as a rescue therapy or needs to be part of research protocols.

Administration, Inhalation↗
PubMed2006

The utility of intraoperative blood flow measurement during aneurysm surgery using an ultrasonic perivascular flow probe.

OBJECTIVE: Inadvertent vessel compromise is one major cause of unfavorable outcome from aneurysm surgery. Existing strategies for intraoperative assessment of this complication have potential limitations and disadvantages. We assessed the utility of quantitative intraoperative flow measurements using the Transonic ultrasonic flow probe (Transonic Systems, Inc., Ithaca, NY) during aneurysm surgery. METHODS: Of all aneurysms treated surgically at our institution from 1998 to 2003, 103 patients with 106 aneurysms were identified in whom intraoperative flow measurements were available for analysis. We assessed the frequency of flow compromise and clip repositioning and correlated these with postoperative angiography and stroke. RESULTS: Significant (>25%) reduction in flow rate was apparent in 33 (31.1%) cases, and resulted in clip repositioning in 27 (25.5%), with return to baseline flow except for two cases with vessel thrombosis/dissection. In the other six cases, flow reduction was owing to spasm resolving with papaverine (n = 3) or responded to retractor repositioning (n = 3). In another six (5.7%) cases, unnecessary clip repositioning was avoided (n = 3) or safe occlusion of the parent vessel for trapping of the aneurysm was allowed by confirming adequate distal flow (n = 3). Aneurysms of the basilar, middle cerebral, anterior communicating, or carotid terminus were more likely to be associated with flow compromise (odds ratio, 4.3; P = 0.03). Postoperative angiography corroborated vessel patency in all cases, and no unexpected large vessel occlusions or strokes were evident. CONCLUSION: Use of the ultrasonic flow probe provides real-time immediate feedback concerning vessel patency. Vessel compromise is easier to interpret than with Doppler, and faster/less invasive than intraoperative angiography. Intraoperative flow measurement is a valuable adjunct for enhancing the safety of aneurysm surgery.

Adult↗