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In an open study, buprenorphine was used as the sole analgesic agent in sixty patients undergoing orthopedic or abdominal surgery. The average dose used was 5 micrograms.kg-1. The level of peroperative analgesia was of good quality and was maintained during the recovery period in the majority of cases. The occurrence of side effects such as nausea, vomiting, respiratory depression was low.
A system is presented which in connection with monitors commonly used affords high resolution control of pulmonary mechanics, respiratory and haemodynamic parameters during surgery. Extent of monitoring as well as choice of the parameters to be monitored is not determined by the system but by the physician concerned. The essential part of the system is a microprocessor in control of all monitors connected, which can store the accumulated data for a 24 hour period. On application in over 200 anaesthetics acceptance by the user was good. Because of the still rather complicated technical procedure use of the system during minor surgery proved to be difficult.
BACKGROUND: We have previously reported an alternative technique for treatment of choledocholithiasis found at laparoscopic cholecystectomy (LC) that can be considered with selected patients. This study was undertaken to update our experience with this alternative technique, which makes serial postoperative cholangiograms possible and facilitates stone extraction by assuring access to the common bile duct so that a guidewire-assisted endoscopic retrograde sphincterotomy can be performed. METHODS: In the period between 1989 and 1997, prospective data were maintained on 1043 consecutive patients who underwent LC by a single surgeon. Fifty-two patients with abnormal cholangiograms were managed with a percutaneously placed double-lumen catheter threaded through the cystic duct and advanced into the duodenum. RESULTS: Five attempts failed, 3 because of failure to pass the catheter and 2 because of catheter dislodgement. Of the 47 remaining patients, 2 underwent intraoperative endoscopic sphincterotomies using this alternative technique and 45 had cholangiograms repeated at 10 to 14 days. Twenty-three had negative cholangiograms, thus avoiding further procedures or unnecessary sphincterotomies because of spontaneous stone passage or initial false-positive cholangiograms. The remaining 22 had positive cholangiograms. Eighteen ultimately underwent sphincterotomies with stone extraction using a guidewire placed through the catheter. The other 4 had negative cholangiograms after serial follow-up, presumably because of spontaneous stone passage. CONCLUSIONS: The use of a transcystic double-lumen catheter passed through the ampulla of Vater is an effective and safe alternative for the management of choledocholithiasis discovered during LC.
Use of morphine by titration in the post-anaesthesia care unit (PACU) is often the first step in postoperative pain management. This approach provides rapid analgesia but shows a wide inter-individual variability in morphine requirements and may prolong patient stay in the PACU. The aim of this study was to identify the patient characteristics, surgical, anaesthetic, and postoperative factors predictive of early morphine requirements. The study included 149 patients undergoing various non-cardiac surgical procedures under general anaesthesia. In the multiple regression analysis of nine variables, only ethnicity (Caucasian), emergency surgery, major surgery, surgery exceeding 100 min, and pain score on arrival in PACU were predictive factors of morphine requirements. This observational study identifies for the first time independent predictive factors of morphine requirements in the early postoperative period. Future studies are warranted to evaluate the impact of intervention on these factors and any resulting improvement in postoperative pain treatment.
UNLABELLED: We compared the efficacy of granisetron plus dexamethasone with that of granisetron alone for preventing nausea and vomiting in parturients undergoing cesarean section under spinal anesthesia. In a randomized, double-blinded manner, 120 patients received either granisetron 3 mg (Group I, n = 60) or granisetron 3 mg plus dexamethasone 8 mg (Group II, n = 60) IV immediately after clamping of the fetal umbilical cord. A complete response, defined as no emetic symptoms and no need for another rescue antiemetic medication in the intraoperative, postdelivery period was 83% in Group I and 98% in Group II (P = 0.008); the corresponding rates during the first 24 h after surgery was 85% and 98% (P = 0.016). No clinically serious adverse events were observed in any of the groups. In conclusion, the prophylactic use of a granisetron/dexamethasone combination is more effective than granisetron alone for reducing nausea and vomiting in patients during and after spinal anesthesia for cesarean section. IMPLICATIONS: Intraoperative, postdelivery, and postoperative nausea and vomiting are distressing to patients undergoing cesarean section under spinal anesthesia. The combination of granisetron plus dexamethasone was evaluated and found to be effective for preventing these emetic symptoms.
BACKGROUND: A significant number of patients undergoing coronary artery surgery have severe carotid artery disease. It is also true that up to half of the patients undergoing carotid endarterectomy (CEA) have severe treatable coronary lesions. This study aims to review data regarding 82 patients of combined approach in 8 years; the second half consists of 44 patients whose CEA was performed under local anesthesia. It compares results of the conventional and the modified approaches to simultaneous surgery. METHODS: All 82 patients who planned to have a concomitant procedure were recorded prospectively between 1995 and 2003. From 1998, the surgical technique has been modified to switch to local anesthesia for CEA, rather than perform under a single general anesthetic period. All pre-and perioperative data as well as in-hospital and outpatient control (mid- to long-term) data were recorded. A P-value of less than .05 was considered as significant. Analysis of survival was performed by using the Kaplan-Meier method and the log-rank test. RESULTS: The 30-day follow-up was 100% complete for all patients. All patients were followed for 59.59 to 114 months) months postoperatively. Three patients (6.8%) in the modified and 2 (5.2%) in the standard group had intraluminal shunting (P > .05). In the standard group, 3 patients expired and 3 had perioperative stroke; only 1 patient had a stroke in the modified group and two expired (P > .05). Mean survival time according to Kaplan-Meier test was 109.97, SE 2.84, 95% CI (104.41-115.52) months for the former group, whereas it was 62.79, SE 1.20, 95% CI (60.4565.13) months for the latter. Actuarial estimates of survival during ten-year follow up were 94.44% SE 3.83 in ten-year follow-ups and 97.67% SE 2.30 in 5-year follow-ups for the modified group (P > .05). CONCLUSIONS: Avoidance from extended periods of general anesthesia and cardiopulmonary bypass periods as well as immediate recognition of impaired cerebral flow during CEA and the time it provides to take preventive measures are the most important benefits of the modified technique without significantly changing hospital and long-term mortality and stroke. It may also reduce the cost and the waiting period for the suffering patient.
AIM OF THE STUDY: The authors present their first experience with the application of esophageal manometry during the operation on achalasia of esophagus. The completeness of performed myotomy is evaluated on the basis of decreased pressure in the region of lower esophageal sphincter (LES). METHODS: Stationary pull-through four-channel manometry was performed twice during the operation: before the application of capnoperitoneum to localize LES with evaluation of its length and tonus and after the myotomy was performed after capnoperitoneum was abolished to verify sufficient extent of myotomy. The subsequent endoscopic control was used to exclude damage of esophagus mucous membrane. RESULTS: In the period of one year during 2002/2003 the authors operated on four patients with achalasia, when manometry was used for peroperative localization of LES and evaluation of the extent of myotomy. The peroperation manometry demonstrated decreased tonus of LES (the mean 42.06 mmHg before myotomia and the mean 20.03 mmHg after myotomia) and in one case the finding resulted in necessary extension of myotomia. CONCLUSIONS: Based on our preliminary experience with peroperation manometry in operations on achalasia of esophagus it may be stated that it is a useful method for objectivization of the completeness of myotomy, which does not significantly prolong the period of operation. It contrast, it makes it possible to respond to lasting hypertonic area in LES subjected to myotomy, which may be the cause of lasting complaints of patients after the operation.
OBJECTIVE: To evaluate the effects of coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (CPB) on inflammatory response and myocardial injury. METHODS: Sixty patients undergoing elective CABG were randomly divided into CABG with CPB group (CCABG, 30 cases) and CABG without CPB group (OPCABG, 30 cases). Blood samples were collected from central vein to assay interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor-alpha (TNF-alpha), MB isoenzyme of creatine kinase (CK-MB) and troponin I (cTnI) before operation and 2, 8, 24, as well as 48 hours after operation, and all clinical data of the patients were recorded accordingly. RESULTS: After operation, the contents of IL-6, IL-8, TNF-alpha, CK-MB and cTnI were significantly higher in CCABG group than those before operation and those in OPCABG group, while most of these parameters showed little change in OPCABG group both in operative or postoperative period. CONCLUSION: The results suggest that OPCABG may provide better myocardial protection and less systemic inflammatory response than CCABG.
The levels of doxorubicin (DOX) and epirubicin (epi-DOX) in serum, tumors, and normal tissues were assayed by high-performance liquid chromatography after peroperative administration of test doses (10 mg) to 14 patients with gastrointestinal cancer. Large interindividual variations were found. The drug levels also varied markedly between tissues from the same patient, with normal liver consistently having the highest drug concentration, followed by tumors and striated muscle, which had similar levels. In serum, a rapid initial distribution phase, with a half-life of about 5 minutes for DOX and 4 minutes for epi-DOX, was followed by a slower decrease in the drug levels. The concentration versus time curves were not influenced by the presence of liver metastases. No metabolites of DOX or epi-DOX were found during the time period studied, in most cases 2 hours after drug administration. Our pharmacokinetic results give no explanation for the claimed superiority of epi-DOX in the treatment of gastrointestinal cancer.
In the experience of the Universitary Surgical Clinic of Amiens, anaesthesia of more than 8 hours duration appears for 3 p. thousand of the total amount (9/3 000 on 1978). The authors distinguish between them "provided" very long duration operations and the "involuntary" ones (complex multitrauma, unexpected difficulties, etc.); that distinction is justified by many reasons among which one must consider mostly the team work setting up. The authors briefly report V. L. D. A. events in their own experience as in that reported in the medical literature. Also the practical difficulties resulting of V. L. D. A. in the intra-operative or post-operative periods are appraised. Then the authors propose some means able to reduce the number of V. L. D. A. and to assure a better proceeding of very long duration operations.
A case report is presented describing the clinical usefulness of transcutaneous oxygen (PtcO2) monitoring in an infant undergoing tracheoesophageal fistula repair. Its use allowed early and precise recognition of hypoxaemia during periods of surgical manipulation. During periods of hypoxaemia, there were no associated cardiovascular changes or changes in routine monitoring modalities. Clinical use of PtcO2 may detect early hypoxaemia and thus allow for correction before the appearance of changes in vital signs.
Plasma ionized calcium has been measured in eighteen patients undergoing open heart surgery. No change in ionized calcium concentration was found during the period of cardiopulmonary bypass. In the early postbypass period, a wide range of ionized calcium concentrations was found, but this did not obviously affect myocardial performance. Factors influencing the ionized calcium concentration under these circumstances are discussed.
OBJECTIVE: To observe the dynamic changes of tumor necrosis factor-alpha(TNF-alpha) and endothelin (ET-1) during perioperative period in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) and to investigate their pathological significance so as to bring up feasible measure to increase therapeutic effect. METHODS: Blood samples of 32 patients undergoing CABG with CPB were drawn before operation, induction period of anaesthesia, after aortic crossclamping and declamping, by the end of surgery, and 2 hours, 8 hours, and 24 hours after surgery. The plasma TNF-alpha and ET-1 were measured by radioimmunoassay (RIA). RESULTS: (1) The plasma TNF-alpha level increased markedly after aortic crossclamping (18.3 ng/L +/- 3.4 ng/L vs 12.1 ng/L +/- 2.0 ng/L, P < 0.05) and went up to the peak value(22.4 ng/L +/- 3.6 ng/L) after aortic declamping, and then decreased. However, till 24 hours after operation, the TNF-alpha concentration maintained at a level higher than that before surgery (18.5 ng/L +/- 4.1 ng/L vs 12.1 ng/L +/- 2.0 ng/L, P < 0.05. After aortic declamping, during reperfusion of the lungs the TNF-alpha level was significantly higher than that after aortic crossclamping and before declamping (22.4 ng/L +/- 3.6 ng/L vs 18.3 ng/L +/- 3.4 ng/L P < 0.05). (2) The plasma ET-1 increased significantly after aortic crossclamping (146 ng/L +/- 20 ng/L vs 97 ng/L +/- 14 ng/L, P < 0.05) and went down after aortic declamping. Two hours after surgery, the plasma ET-1 increased again and reached the second height (134 ng/L +/- 19 ng/L), and then went down again and decreased to 92 ng/L +/- 18 ng/L 24 h after operation. CONCLUSION: (1) Attenuation of inflammatory reactions mediated by TNF-alpha should be considered an important strategy for myocardial and lung protection. (2) During the perioperative period of CABG the plasma ET-1 level shows two peaks, occurring respectively after aortic crossclamping and 2 h after surgery, which may result from operation itself and ischemia-reperfusion injury.
301 patients underwent thyroid surgery in 1998 by using the intraoperative neuromonitoring. The documentation was done prospectively. The system of intraoperative neuromonitoring consists of a stimulation circuit and an electromyographic record. We placed the deriving electrode transligamentally through the cricothyroid membrane. By relaxometry we investigated the influence of the relaxation level on the electromyographic record of the vocal muscle. Using a standardized operative technique we found a side-related rate of primary palsy of 2.3% (n = 13), from which 61.5% (n = 8) showed to be only temporary during a postoperative follow-up period. The intraoperative neuromonitoring with the purpose of identification of the recurrent laryngeal nerve is a safe and reliable method.
The influence of neuroleptanalgesia and halothane-N2O-anaesthesia on the activity of the sympathetic nervous system was studied continuously in the intra- and postoperative period in 2 groups of 10 patients undergoing abdominal operations. In the neuroleptanalgesia-group the noradrenaline level in plasma rose continuously during the course of the operation and this increase was highly significant. The adrenaline level in plasma increased as well, however this increase did not depend on the duration of the operation. In the halothane-N2O-group only a small increase of both adrenaline and noradrenaline in plasma could be demonstrated intraoperatively. One hour after the end of the operation the plasma levels of adrenaline and noradrenaline were elevated in both groups. The noradrenaline level was even higher after neuroleptanalgesia. Four hours after the end of surgery the levels of adrenaline and noradrenaline started to decrease, but were still above the preanaesthetic level. The increase of the concentration of catecholamines in plasma indicating an activation of the sympathetic nervous system was not associated with a corresponding increase in heart rate and blood pressure intra- as well as postoperatively in either group. Only in the neuroleptanalgesia-group was there a small, but insignificant increase of the systolic and diastolic pressure postoperatively.
The influence of cardiopulmonary bypass on fibrinolytic activity was assessed by a sensitive clot lysis assay in eight patients undergoing coronary artery bypass operations. Fibrinolytic activity increased immediately after cardiopulmonary bypass was begun and remained elevated throughout the period of extracorporeal circulation. At the conclusion of the operative procedure, fibrinolytic activity returned to the normal range in all patients, and no subject had postoperative bleeding.
The effect on intra-operative heart rate of two nondepolarising muscle relaxants, rocuronium and vecuronium, was compared in 116 fit out-patients undergoing gynaecological laparoscopic procedures. Both groups received an anaesthetic technique which differed only in the choice of muscle relaxant. Intra-operatively it was noted that patients given rocuronium (20 mg) had significantly fewer episodes of bradycardia (heart rate < 50 beat.min-1) than patients given vecuronium 4 mg (p < 0.05). Profound bradycardias (heart rate < 30 beat.min-1) did not occur in any of the patients in the rocuronium study group, whereas 5% of patients receiving vecuronium had a period of transient asystole. We conclude that, at the doses stated, rocuronium results in significantly fewer episodes of bradycardia than vecuronium when used as a muscle relaxant for laparoscopic gynaecological procedures.
Abdominal aortic surgery may produce significant haemodynamic instability (from a combination of factors: hypovolaemia, acid-base disturbances, vasoactive metabolite release from ischaemic tissues and hypocalcaemia). Calcium is often given after aortic unclamping to attenuate this instability. We studied 20 patients undergoing elective abdominal aortic surgery and observed a triphasic change in ionized calcium concentrations and acid-base status. Initially, during the cross-clamp period (when patients were cardiovascularly stable), ionized calcium concentrations decreased significantly (mean 1.06 (SD 0.08) to 0.91 (0.13) mmol litre-1; P < 0.01), while a significant metabolic acidosis developed (pH 7.38 (0.05) to 7.30 (0.05); P < 0.05). Second, release of the aortic cross-clamp resulted in further acidosis (pH 7.27 (0.05) (P < 0.05) mixed respiratory and metabolic) with a decrease in mean arterial pressure, with no change in ionized calcium concentrations. The third phase was associated with spontaneous restoration of acid-base status and ionized calcium concentrations to normal over 2 h. There was no correlation between units of blood given, volume of blood lost, fluid volume given or duration of aortic cross-clamping and degree of ionized hypocalcaemia. We conclude that ionized hypocalcaemia occurred during the cross-clamp period of aortic surgery, was unrelated to the volume of blood given and did not appear to be responsible for the changes in arterial pressure during surgery.