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Buprenorphine was administered for the balanced general anaesthesia in 300 patients during several operations. The results obtained, the good features of analgesia, morphine-like, the absence of cardiovascular and respiratory side effects are presented.
Clinical pharmacology of pipecuronium; a comparative study of its duration of action between balanced (propofol/fentanyl) and isoflurane anesthesia. Pipecuronium duration of action has been compared between patients under balanced (propofol/fentanyl) or 0.8-1 Mac isoflurane anesthesia. T1/TC 10-25-50-75-90% (T1/TC, 10, T1/TC, 25, T1/TC, 50 TOF, 75T1/TC 90) and TOF 10-25-50-75% (TOF 10%, TOF 25%, TOF 50%, TOF 75%) ratios were studied; T1/TC 10-75% (T1/TC 10/75) and TOF 10-75% (TOF 10-75%) recovery times were also derived. The muscle relaxant has been utilized in 55 patients divided into groups according to the method of its administration: in group I (33 patients) the drug was injected in small divided doses until ED95% was reached, according to the cumulative dosage method; in group II (8 patients) and III (12) the drug was injected at 0.35 micrograms/kg and 50 micrograms/kg respectively. Neuromuscular function was monitored by isometric force transduction, stimulating the adductor pollicis by tof every 12 sec. Pipecuronium duration of action (min) following single doses was longer than following the cumulative dosage method (TOF 25% vs 61%, TOF 50% 103 vs 76, TOF 75% 136 vs 102). The presence of isoflurane significantly prolonged recovery times (TOF 10%, from 55 to 70, TOF 25% from 61 to 88, TOF 50% from 75 to 120) in group I (cumulative doses) patients. Recovery times were dose related, while age did influence recovery only at the earlier intervals (T1/TC 10 and 25%). Keeping in mind the limited range of age and dosages, advantages and disadvantages of the drug are discussed, comparing the experimental results with those derived from the literature.
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The concept of balanced anaesthesia aims at an anaesthetic method for high risk patients by combination of different anaesthetic drugs. The anaesthetics and muscle-relaxants have to work in a way as to potentiate their effects and to reduce the side effects as well as the applied dosage. With this sensible regime the circulation and the metabolic energy should be less burdened. For the introduction of balanced anaesthesia, a combination of benzodiazepines (relaxing and sedative), morphine (analgetic and sedative) and quickly metabolizing hypnotics of the imidazol group (hypnotic and relaxing) is used. A fentanyl-drip-infusion continues and deepens the analgesia. After endotracheal intubation with the help of the carrier-gas nitrous oxide (weakly analgetic) and oxygen (2:1) a low concentration of volatile inhalation anaesthetics (weakly hypnotic) is added. Under artificial respiration low doses of competitive antidepolarizing neuromuscular blockers help to potentiate and reduce drug amounts of other anaesthetics especially of that for inhalation. At the end of balanced anaesthesia an antagonization of benzodiazepines, morphines and competitive neuromuscular blockers is recommended for emergency situations only because of possibly occurring changes of cardiovascular parameters.
During balanced anaesthesia sufentanil may be difficult to use, as the required doses change over time depending on the patient and the noxious stimuli. Patient adjustment may be improved by using pharmacokinetic simulations that predict the concentration achieved in the body. In the first case report, sufentanil was given manually as repeated boluses, then by infusion. As haemodynamic status remained unstable, a simulation of the sufentanil concentration time course was started during the case. It showed that instability had pharmacokinetic explanation and allowed to determine the adequate sufentanil concentrations (0.30-0.40 ng.mL-1 + N2O + isoflurane 0.8-1 vol% for abdominal surgery). However, adjusting the doses manually required numerous human actions. In the second case, sufentanil was given as a computer-controlled infusion. The adequate concentrations were determined (0.15-0.20 ng.mL-1 + N2O + isoflurane 0.4 vol% for peripheral surgery in an aged cardiac patient). They were maintained with a limited number of human actions and resulted in satisfactory haemodynamic stability.
The Authors compare the results of general balanced anaesthesia and propofol in the anaesthetic management of closed-chest ablation of A-V junction. The best results were obtained with propofol because of the lower incidence of cardiovascular complications. Therefore propofol is a suitable agent in the anaesthetic management of closed-chest ablation of the A-V junction.
Thumb adductor twitch response to train-of-four (2 Hz for 2 seconds) stimulation of the ulnar nerve was used to assess the clinical characteristics of long-term neuromuscular blockade induced with continuous infusion of succinylcholine during balanced (N2O-O2-narcotic-thiopental) anesthesia. Twitch depression of 80 to 90% was maintained for 86 to 365 minutes by continuous infusion of succinylcholine at 86 +/- 5(SEM) micrograms/kg/min. Of 32 patients, 24 developed phase II block, defined as a train-of-four ratio of less than 50%. There was a large degree of individual variability in sensitivity to development of phase II block. This precluded defining a narrow dose range where transition from phase I to phase II occurred. Tachyphylaxis occurred in 25% of patients and was independent of the type of block. Neither dose nor duration of infusion was predictive of spontaneous recovery rate from phase II block. Of 24 patients who developed phase II block, 50% recovered spontaneously at a rate comparable to the recovery rate from a phase I block. The other 50% manifested prolonged recovery of neuromuscular function. After observing spontaneous recovery in these patients for 31 +/- 5(SEM) minutes, successful antagonism of residual phase II block with anticholinesterase agents was achieved.
We did a retrospective study to compare butorphanol with morphine for use in a balanced anesthetic technique with nitrous oxide, oxygen, and neuromuscular relaxants. Patient records were reviewed for preoperative, intraoperative, and postoperative arterial blood gas values and vital signs; postoperative analgesia, nausea, vomiting, hallucinations, and dysphoria; and patient recall of the procedure. Patients in the butorphanol group proved to have less postoperative respiratory depression as determined by arterial carbon dioxide tension on arrival in the recovery room (42.8 mm Hg vs 51.1 mm Hg). The patients who received butorphanol also had less nausea (8.3% vs 44.4%) and less vomiting (8.3% vs 33.3%) than those given morphine. Neither group had any recall of procedure, hallucination, or dysphoria as determined by postoperative interview.
The alterations of hydrocortisone concentration in the blood serum have been studied in 29 gynecological patients. Epidural anesthesia combined with sodium hydroxybutyrate surface anesthesia prevents an unnecessary activation of the hypothalamo-pituitary-adrenal system. A sedative effect of sodium hydroxybutyrate favours the elimination of emotional stress in patients. The preservation of an adequate and not excessive adrenocortical response to the surgical trauma has been noted as well.
OBJECTIVE: This study was designed to investigate the differences between TIVA with propofol/remifentanil (P/R) and balanced anaesthesia with sevoflurane/fentanyl (S/F) in gynaecological laparoscopic surgery. Emphasis was put on haemodynamic reaction, recovery profile, postoperative side effects and patient satisfaction. METHODS: Sixty patients were randomly assigned to receive either total intravenous anaesthesia with propofol/remifentanil or anaesthesia with sevoflurane/fentanyl. After premedication (midazolam) and induction of anesthesia (propofol, atracurium) in both groups, either 1 microgram/kg fentanyl (S/F) or 1 microgram/kg remifentanil (P/R) was injected. Anaesthesia was maintained with 0.5 microgram/kg/min remifentanil (reduced to 50% after 5 min) and 0.06 microgram/kg/min propofol (P/R) or 1.7 vol % sevoflurane (S/F). Both groups were mechanically ventilated with 30% oxygen in air. The administration of sevoflurane and the infusion of the anaesthetics were adjusted to maintain a surgical depth of anaesthesia. For postoperative analgesia 1 g paracetamol was administered rectally prior to surgery. After recovery 20 mg/kg metamizol was given intravenously. At the end of surgery the anaesthetics were discontinued and haemodynamics, early emergence from anaesthesia, pain level, frequency of analgesic demand, incidence of PONV, shivering and patient satisfaction were assessed. Parameters were recorded for 24 h postoperatively. RESULTS: Recovery time after propofol-remifentanil anaesthesia was significantly shorter than after administration of sevoflurane and fentanyl (spontaneous ventilation 4.1 vs. 6.3 min, extubation 4.3 vs. 9.3 min, eye opening 4.4 vs 8.2 min, stating name 5.3 vs. 13.2 min, stating date of birth 5.4 vs. 13.3 min). There were no significant differences between the groups in shivering, pain score, analgesic demand and PONV. The S/F group responded to tracheal intubation with significantly higher blood pressure than the P/R group. During maintenance of anaesthesia heart rate in patients with S/F was significantly higher (P/R:HR max +16/-10; S/F:HR max +24/-0.). Measured on a scale (S/F 62%). CONCLUSION: Compared with patients given balanced anaesthesia with sevoflurane and fentanyl, TIVA with propofol and remifentanil proved to be particularly suited for gynaecological laparoscopic surgery. Its major advantages are haemodynamic stability, significantly shorter times of emergence, and the exceptional acceptance by the patients.
BACKGROUND: The aim of this investigation was to compare routine balanced anaesthesia with different inhalation agents to intravenous anaesthesia (IVA) using an Anaesthesia-Information-Management-System (AIMS) with regard to time of recovery from anaesthesia, the time of discharge from the postanaesthesia care unit (PACU) and postoperative nausea as well as postoperative therapy with analgesics. METHODS: In 1997 and 1998 all relevant data of each anaesthesia procedure have been recorded using the online documentation Software NarkoData. These data sets have been stored into a relational database during each anaesthesia procedure. For evaluation the information has been exported from the database to a statistics program via 'Structured Query Langvage' (SOL). Balanced anaesthesia has been performed using isoflurane, halothane, and sevoflurane, respectively, supplemented with or without nitrous Oxide (N2O). The intravenous based anaesthesia-groups included propofol-fentanyl or propofol-remifentanil. RESULTS: The fastest recovery was seen in patients of the isoflurane group (11.2 +/- 7.7 minutes), and the longest time for extubation was observed in patients wich halothane anaesthesia (12.8 +/- 9.3 minutes); the overall mean difference was 1.7 minutes. The earliest patient admitted to the PACU had received sevoflurane (7.0 +/- 6.3 minutes) and propofol-remifentanil (7.0 +/- 7.4 minutes) whereas patients of the halothane group (9.5 +/- 7.5 minutes) took more. The shortest stay in PACU was seen in patients of the sevoflurane and isoflurane groups (105.13 +/- 35.7 and 108.4 +/- 60.5 minutes), whereas propofol-remifentanil (126.2 +/- 89.1 minutes) and halothan (120.0 +/- 86.1 minutes) anaesthetised patients had the longest stay in PACU. No difference was noted in the incidence of postoperative nausea and vomiting nor in the amount of postoperatively given analgesics. CONCLUSION: Results achieved in routine correspond only in part to results from studies. In our investigation balanced anaesthesia with isoflurane and sevoflurane correspond with the shortest stay in PACU compared to balanced anaesthesia with halothane and IVAs with propofol-fentanyl or propofol-remifentanil. One reason for this could be the intraoperatively administered opioide piritramide in IVAs. Furthermore we conclude that an AIMS may provide additional information about overall costs-effectiveness. However this information depends largely on local factors, e.g. patient case mix, staffing, policy of discharge from the PACU etc.
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Since the first case report by Winter-bottom [106], the problem of intraoperative awareness or recall has received increasing attention from patients, anaesthesiologists and, more recently, even law courts [4, 20, 21, 78]. Our own interest in awareness derives from a study with the opiate agonist tramadol as a supplement to balanced anaesthesia, which revealed an unexpectedly high incidence of about 65% of patients who could recall intraoperative music [55]. It was the aim of the present randomized double-blind study to evaluate, under identical experimental conditions, what the incidence would be with other analgesic supplements to balanced anaesthesia (fentanyl, pentazocine and ketamine). Because few reports on this subject are available in the German literature, it was felt that the result should be discussed within a comprehensive review. PATIENTS AND METHODS. A total of 60 patients (ASA I-II, age 27-66 years, weight 48-93 kg) undergoing elective gynaecological surgery of at least 90 min duration were each randomly assigned to one of three study groups (F, fentanyl; P, pentazocine; K, ketamine). Premedication was performed with diazepam 10 mg p.o. the evening before surgery and pethidine 1 mg/kg i.m.+promethazine 1.5 mg/kg i.m.+atropine 0.5 mg i.m. 60 min before anaesthesia. Induction was performed with alcuronium (2 + 8 mg), methohexital (1.5 mg/kg) and a bolus dose of the analgesic supplement (F, 5 micrograms/kg; P or K, 2 mg/kg), followed by continuous infusion (F, 2 micrograms kg-1 h-1, P or K 0.8 mg kg-1 h-1). Endotracheal intubation was performed with succinylcholine (1 mg/kg). Patients were ventilated to normocarbia using a Takaoka respirator (4 breaths/min, tidal volume 1600 ml, N2O/O2 75:25). If insufficient anaesthesia was suggested by increases in blood pressure or heart rate to more than 20% of preinduction values, excessive sweating or lacrimation, enflurane (0.5-2 vol.%) was added for short periods of time. At the end of surgery, patients were ventilated with 100% O2, and the neuromuscular block antagonized using atropine 0.5 mg and neostigmine 1 mg. Without prior announcement, tape-recorded music (Mantovani, 3 min followed by 3 min silence) was played to all patients via earphones throughout the time period between intubation and the end of nitrous oxide administration. Vegetative parameters, cumulative and relative enflurane application times and retrospective judgement of quality of anaesthesia by the anaesthesiologist were documented. Post-operative recovery and pain were monitored using verbal rating scales. Patients were interviewed immediately after extubation and on the day after surgery to determine the incidence of dreams and recollection of music. Patients were classified as amnestic if they could not recall the music, even with prompting, and partially amnestic if they remembered the music but were unable to define the time when they had heard it. No amnesia was assumed if patients recalled the intraoperative music spontaneously. Groups were statistically compared by means of analysis of variance, Mann-Wilcoxon rank sum test and chi-square test. RESULTS. Mean duration of anaesthesia was 129-134 min in the subgroups. The total analgesic supplement dose was F 614 +/- 129 micrograms, P 238 +/- 38 mg, and K 230 +/- 50 mg (mean +/- SD). Enflurane substitution was necessary in 45 patients, regardless of the type of analgesic supplement. Mean cumulative enflurane application time was 26-28% in the treatment groups, corresponding to about 20% of anaesthesia duration. The most important reasons for enflurane substitution were increases in blood pressure (mostly in groups F and P) or heart rate (K). Recovery was fastest with F, followed by P, and slowest with K. Retrospective judgement of the quality of anaesthesia by the anaesthesiologist did not differ significantly between the treatment groups. Most (93%) of the patients were satisfied with their anaesthesia; 2 patients each who received P and K were dis
The Authors have tried Althesin as a medicine for the induction and maintainement of the narcosis in the stomatological, maxillo-facial and extra and intra-oral surgery. They have deduced that CT 1341 does not constitute to the anaesthetics Ethrane and Fluothane because of the anaesthetic-level instability (restlessness of the patient and clonic movements of the limbs during the most painful operations in particular). The Authors, supporters of the balanced anaesthesia, suggest using Althesin in the narcosis induction, the maintaining of which is carried on by the N.L.A. type II medicine and by the Ethrane or Fluothane. The latest ones are to be given in very small, not dangerous quantities. The Authors have so obtained a remarkable oxygenation of the patient, a ready, calm and lucid awakening without any collateral and dangerous consequences.
The aim of this work was to assess which anaesthetic technique is more suitable to the performance of videolaparocholecystectomy (VLC), particularly seeking for a faster and more comfortable recovery, although saving the maximum safety of the patient. A comparative investigation between two different anaesthetic techniques was carried out in 40 patients scheduled for VLC; the procedure's average length was 110.3 +/- 32.8 minutes and pneu- moperitoneum was obtained with 12-15 mmHg of CO2. Patients (32 females and 8 males, average age 52.3 +/- 8 years and ASA class 1, 2, 3, were randomized in two groups. The first group was administered total intravenous anaesthesia (TIVA): propofol+ fentanyl+pancuronio bromide; the second one received balanced narcosis:TPS+ Isoflurane+Pancuronio bromide. The following parameters were monitored at set times: SAP, DAP, HR and EtCO2; statistical analysis was performed by analysis of variance. The quality of recovery was assessed by Steward's test and analyzed by Student's "t" test. The data obtained from analysis of the intraoperative parameters showed no significant differences between the two groups; on the contrary a statistically significant difference was found with regard to the quality of recovery (p > 0.5 at 5' from the extubation). Thus, the comparative study showed the efficacy and safety of both techniques, but TIVA allowed a faster and more comfortable awakening with shorter time to recovery of consciousness. This, together with the reduced requirements of analgesic drugs in the postoperative period and the lack of air pollution, seems to suggest that TIVA is to be preferred for laparoscopic surgery.
To appraise the clinical impact of combined spinal-epidural anaesthesia (CSE) in patients undergoing total extraperitoneal laparoscopic hernia repair (TEPP), we performed a prospective study in 40 patients. These patients were randomized to receive either CSE (n = 20) or a balanced general anaesthesia (BGA) with controlled ventilation (n = 20). The aim of the study was to determine the impact of the intraoperative gas insufflation on compensatory respiratory reactions during regional anaesthesia. Therefore, blood gas samples were drawn and additional parameters were assessed as follows: noninvasive haemodynamic, lactate and glucose levels, differential blood count, and the patients' level of comfort during the perioperative setting, which was determined by a questionnaire. In our study it was clarified that the respiratory compensation of extraperitoneal gas insufflation is not decreased by regional anaesthesia. The haemodynamic state of the patients was stabilized by early interventions. In addition--there was no evidence that the anaesthesia regime used had any influence on the so called stress-parameters. Most of the patients with regional anaesthesia showed severe agitation often accompanied by chest pain. Hence, regional anaesthesia is not recommended in this setting.