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PubMed2000

Intraoperative mild hypothermia ameliorates postoperative cerebral blood flow impairment in patients with aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Intraoperative mild hypothermia has been used during cerebral aneurysm surgery to reduce ischemic injury induced by temporary vessel occlusion and brain retraction. However, the clinical effects on cerebral hemodynamics are unclear. This study investigated the effects of intraoperative mild hypothermia on cerebral blood flow (CBF) after surgery to treat aneurysmal subarachnoid hemorrhage. METHODS: Twenty-four patients with ruptured internal carotid or middle cerebral artery aneurysms, of preoperative Hunt and Hess Grade II or III, underwent aneurysm clipping within 72 hours after the onset of subarachnoid hemorrhage. During surgery, patients were randomly assigned to either intraoperative mild hypothermia (33.5 degrees C, n = 12) or normothermia (37 degrees C, n = 12). Brain single photon emission computed tomography with 99mTc-hexamethylpropylenamine oxime or 99mTc-L,L-ethylcysteinate dimer was performed on Days 4, 7, and 14 after subarachnoid hemorrhage. Regional CBF was determined in the basal ganglia and cingulate, frontal, and frontoparietal cortices, using a semiquantitative method. RESULTS: CBF in the frontal cortex ipsilateral to the aneurysm was significantly higher in the hypothermia group than in the normothermia group on Day 4 (P<0.01) but not Day 7 or 14. There was a similar trend in the ipsilateral frontoparietal cortex, but it was not significant. There were no differences in regional CBF in the ipsilateral cingulate cortex or basal ganglia or in any contralateral region during the study period. CONCLUSION: Intraoperative mild hypothermia may reduce the severity of ischemia induced by intraoperative temporary vessel occlusion and brain retraction, thus ameliorating postoperative CBF impairment.

Adult↗
PubMed1994

Renal function during cardiopulmonary bypass: influence of pump flow and systemic blood pressure.

The influence of systemic blood flow (pump flow) and arterial blood pressure on renal function was studied during hypothermic cardiopulmonary bypass (CPB) in 14 male patients where the pump flow rate was varied between 1.45 and 2.20 l.min-1 m-2. Renal blood flow (RBF) was measured in the left renal vein with retrograde thermodilution technique and urinary flow and circulatory variables were measured with an on-line computer set-up. During CPB the RBF comprised 12-13% of the systemic blood flow and was positively related to systemic blood pressure (r = 0.71; P < 0.001) and pump flow rate (r = 0.69; P < 0.001). These findings indicate that the renal autoregulation was not operative during the hypothermic CPB period. According to multiple regression analysis, RBF was primarily determined by the pump flow rate and systemic blood pressure was of secondary importance. Urinary flow increased during hypothermic CPB and became closely related to blood pressure and pump flow. According to multiple regression analysis, urinary flow was primarily determined by systemic blood pressure.

Aged↗
PubMed1998

Effect of graft reperfusion on haemodynamics and gas exchange during liver transplantation.

We have documented the changes in gas exchange, haemodynamic state and associated physiological variables which occurred after graft reperfusion in 20 patients undergoing uncomplicated orthotopic liver transplantation. Gas exchange was measured during constant ventilation using a metabolic monitor. After reperfusion, there were increases in VO2 (mean increase 57 (SD 25) ml min-1) (P < 0.001), VCO2 (mean increase 38 (17) ml min-1) (P < 0.001) and PaCO2 (mean increase 0.88 (0.56) kPa) (P < 0.001). These were associated with increases in cardiac output (1.2 (1.0) litre min-1 m-2) (P < 0.001) and mean pulmonary artery pressure (9 (6) mm Hg) (P < 0.001). There was a decrease in standard bicarbonate concentration (0.96 (1.6) mmol litre-1) (P < 0.02) and increase in hydrogen ion concentration (8.15 (5.9) mmol litre-1) (P < 0.001) consistent with the release of an acid load from the graft and previously ischaemic tissues. The increases in PaCO2 and hydrogen ion concentration were significantly larger in patients in whom venovenous bypass was used during the anhepatic period compared with the "piggyback" surgical technique. We found correlations between the changes in PaCO2 and VCO2 (r2 = 0.25, P < 0.02), cardiac output and VCO2 (r2 = 0.34, P < 0.01), and cardiac output and VO2 (r2 = 0.34, P < 0.01). We conclude that major alterations in gas exchange occur after reperfusion which result from alterations in metabolic rate and haemodynamic changes. These may be clinically relevant, particularly in patients at risk of cerebral oedema.

Adult↗
PubMed1990

Fantasies during sedation with intravenous midazolam or diazepam.

Details are reported of 41 incidents where women reported fantasies during sedation with IV midazolam or diazepam: 27 of them had some sexual element and 20 were unpleasant experiences. The events occurred in a logical sequence and all were certain of their authenticity. Some led to litigation against the sedationist. Out of 25 verified reports made by patients of incidents occurring during sedation, 17 did not happen and in 9/13 clear descriptions there was some relation between the fantasy and something that really happened under sedation. All occurred with what are now considered large doses of the drugs. During or following sedation lady patients should not be treated or examined without the presence of a responsible third person. The use of the injectable benzodiazepines, diazepam and more recently midazolam, with their sedative, amnesic and relaxing properties have made unpleasant operative procedures, particularly those usually carried out under local analgesia, more acceptable to many patients. These include oral endoscopy and dental procedures and operations under spinal or epidural analgesia. These drugs also provide good sedation during ventilatory support and in the intensive care unit. Over a long period of time these benzodiazepines have proven to be, in appropriate doses, among the safest in medicine for short term use. There have however been a few cases of what can be described as "fantasies" occurring during sedation: events occurring in a logical sequence which are very real to the patient and yet, on the evidence of two or more independent witnesses, did not occur. Many of these have had an element of sexual trespass.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

[The effect of hemodilution on the indices of aerobic metabolism and water metabolism in children with congenital heart defects operated on under artificial circulation].

The majority of pediatric cardiosurgery centers make use of cardiopulmonary bypass (CPB) with low hematocrit, and therefore we deemed it interesting to investigate the pathological effects of hemodilution on patients. Specifically, we studied the effect of hemodilution on aerobic and water metabolism in children with congenital heart disease subjected to CPB. Two groups of patients were examined. In the studied group (n = 12, mean age 7.1 +/- 1.1 years) the blood-fluid ratio in primary filling of the CPB device was 1:6.2 +/- 0.7 and minimal hematocrit during myocardial ischemia 18 +/- 0.7%. Control group consisted of 7 patients aged 8.3 +/- 0.6 years, with the above values 1:2.8 +/- 0.4 and 22 +/- 1.6%, respectively. The groups were similar as regards the initial status of patients, level of hypothermia, and duration of myocardial ischemia. Gas content in venous blood was the criterion of aerobic metabolism. Fluid accumulation in the extravasal space during and after surgery was assessed by bioelectroimpedance measurements of the total extracellular extravasal fluid (EEF). Monitoring showed a decrease of hematocrit during CPB to 18 +/- 0.7%, saturation of venous blood with oxygen within 70-75%, and oxygen content 37-43 mm Hg. In the main group a manifest increase of EEF was observed as early as during the early postperfusion period; this increase is probably one of the main components in the detrimental effect of hemodilution. Redistribution of fluid after CPB leads to expressed interstitial edemas and impairs the function of vital organs. That is why signs of cardiorespiratory failure were observed in the main group. Thus, one of the main problems in CPB with low hematocrit is fluid accumulation in the extravasal space.

Aerobiosis↗
PubMed1997

Relationship between circulating secretory immunoglobulin A levels and portal blood cytokine levels during major abdominal surgery.

OBJECTIVE: To investigate whether circulating secretory immunoglobulin A (S-IgA) levels correlate with cytokine and endotoxin levels in the systemic or portal circulation during major abdominal surgery. METHODS: Twenty patients who underwent abdominal surgery for malignant carcinoma were included in this prospective study. Portal blood samples were taken for the measurement of cytokine and endotoxin levels during abdominal surgery. Systemic blood samples were simultaneously collected for the determination of cytokine, endotoxin, and S-IgA levels. After surgery, serum levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and S-IgA were measured on the 1st, 7th, and 14th, postoperative days. RESULTS: Circulating S-IgA levels correlated with interleukin-6 levels (r = 0.48, P < .05), but not with interleukin-1 or endotoxin levels in the portal circulation. In the postoperative period, the best correlation between serum S-IgA and other biochemical parameters was found with alkaline phosphatase (r = 0.87, P < .01), followed by alanine aminotransferase (r = 0.70, P < .01). CONCLUSIONS: Interleukin-6 in the portal blood might stimulate synthesis and/or regurgitation from bile into the systemic circulation of S-IgA. Circulating levels of S-IgA appeared as a sensitive marker for postoperative cholestatic liver damage.

Abdominal Neoplasms↗
PubMed2004

Laparoscopic partial nephrectomy in patients with neoplasia in a solitary kidney.

OBJECTIVES: To assess the renal function and describe our operative experience with laparoscopic partial nephrectomy (LPN) in patients with solitary kidneys. METHODS: The medical records were analyzed to find patients with a solitary kidney and renal neoplasms who underwent LPN. Demographic, operative, pathologic, and follow-up data were obtained. RESULTS: Four patients were identified with solitary kidneys who had undergone LPN. The mean operative time was 251 minutes, mean warm ischemic time 15 minutes, mean estimated blood loss 395 mL, and mean hospitalization stay 3 days. The mean preoperative creatinine was 1.5 mg/dL and the mean peak creatinine 2.0 mg/dL. All patients returned to their baseline creatinine levels in the follow-up period. The final pathologic finding was Stage pT1 in 1, pT3a in 2, and angiomyolipoma in 1 patient. All surgical margins were negative. No cancer recurrence developed in the patients, with a mean follow-up of 17 months (range 3 to 35). CONCLUSIONS: LPN in patients with a solitary kidney is feasible and a reasonable treatment alternative to open partial nephrectomy.

Blood Loss, Surgical↗
PubMed1988

The case for selective cholangiography.

Seven hundred sixty-five patients were operated on in two hospitals in 1979 and 1980, 190 of whom were submitted to operative cholangiography, 41 to primary common duct exploration, and 534 to neither. The incidence of common duct stones was 4 percent in the minimal indications group, 21 percent in the moderate indications group, and 91 percent in the maximal indications group. Follow-up of 5 years revealed 1 recurrence in the minimal group subjected to cholangiography and none among the 534 in whom no cholangiogram was obtained. In the period from 1981 through 1985, eight patients returned with common duct stones, having had no common duct stones at the primary operation. In the same period, 1,722 of 2,533 patients were operated on without cholangiography. The ratio of recurrences to primary operations without cholangiography was 1:225 or 0.45 percent. From these findings, we conclude that on the basis of cost-effectiveness and insurance against subsequent disease and disability, cholangiography is only indicated in patients with moderate indications (minimal jaundice, moderately dilated common duct, pancreatitis, or an increased serum amylase level). Cholangiography is not indicated if there are no indications of obstruction of the common duct by stones (as a routine for small stones in the gallbladder, if the cystic duct is patent, or if there is an isolated increased serum alkaline phosphatase level). Cholangiography is also unnecessary, when the indications of common duct stones are maximal (deep jaundice, huge common duct, cholangitis, or palpable stone). In our geographic area, intraoperative cholangiography should be selected in 7 to 8 percent of patients.

Cholangiography↗
PubMed1983

Single aortic clamping for proximal and distal anastomoses in coronary operations: study of myocardial temperatures in nonvented hearts.

A prospective analysis of myocardial temperatures (septum, left and right atria, and right ventricle) in coronary operations was carried out in nonvented human hearts during a single period of aortic cross-clamping for construction of all anastomoses, proximal and distal. Also a comparison was made of normothermic versus hypothermic perfusion during cardiopulmonary bypass (CPB). Results indicate that (1) immediately after cross-clampling and infusion of the cardioplegic solution, the septal temperature was identical for hypothermic and normothermic perfusion; (2) at 20 minutes of clamping, however, hypothermic patients had lower septal temperatures than normothermic patients; and (3) at the end of the cross-clamping period, the septal temperature was lower in hypothermic hearts. The left and right atrial and right ventricular temperatures were lower throughout CPB in patients with hypothermic perfusion. It is concluded that if a single period of aortic cross-clamping under cardioplegic arrest is to be used for construction of all anastomoses in nonvented hearts during a coronary operation, core hypothermia is necessary and should be maintained until the aorta is unclamped. The surgeon cannot rely on cold slush and cardioplegia alone to cool the heart while the proximal anastomoses are being performed, since blood from the bronchial (left atrium) and systemic (right atrium) circulations warms the heart.

Aorta↗
PubMed2003

Superior septal approach for mitral valve surgery: a word of caution.

OBJECTIVE: Superior septal approach provides excellent exposure of the mitral valve and the subvalvular structures. The unavoidable section of the sinus node artery is in relationship with this technique. We have studied the electrical changes associated after using this approach. MATERIAL AND METHODS: We studied 247 cases of mitral valve surgery from 1996 to 2003. The patient population was divided into two comparative groups: group I (128 cases) was represented by the superior septal approach and group II (119 cases) composed the conventional right lateral approach through the left atrium. Preoperatively, 48 patients (37.5%) in group I and 46 (38.6%) in group II were in a normal sinus rhythm. Mean follow-up was 30.7 months in group I and 33.5 months in group II. RESULTS: There was no mortality in group I and eight cases (6.7%) in group II. A high incidence of changes as junctional rhythm was observed in group I, especially after weaning of cardiopulmonary bypass and on the first day after surgery (P>0.001). Postoperative P-R interval of the patients in sinus rhythm was 100+/-30 ms in group I and 148+/-24 ms in group II (P>0.05). P-R interval in group I was shorter than normal. P-wave morphology changed becoming inverted in leads II, III and aVF after surgery in these cases in group I. A full recuperation in P-R interval and the P-wave axis was seen in 52 cases (87.5%) in patients in group I after the third postoperative month. A definitive pacemaker implantation was need in two cases (1.5%) in group I and in six (5%) in group II (P>0.05). CONCLUSIONS: A superior septal approach is directly related with the loss of normal sinus rhythm because of the section of the sinus node artery. After a brief period of transient electrical changes, a new low atrial or coronary sinus rhythm slower than normal sinus rhythm appears. In consequence, a word of caution must be strongly considered in patients critically dependent on normal sinus rhythm, despite the low incidence of definitive electrical changes. Normal sinus rhythm appears again after the third postoperative month.

Adult↗
PubMed1994

Lipolysis during abdominal surgery.

Subcutaneous adipose tissue lipolysis has been monitored with microdialysis during elective cholecystectomy by laparotomy in otherwise healthy nonobese subjects. Eight of the subjects received saline and seven received glucose iv during the operation. In both groups the glycerol level in the microdialysate (lipolysis index) started to increase steadily from the start of the general anesthesia until the abdominal wall was closed. Thereafter it leveled off and remained elevated until after extubation. Plasma glycerol started to rise after the surgical incision. The levels of noradrenaline and adrenaline, but not of insulin, glucagon, and cortisol in plasma, changed in parallel with that of glycerol in the microdialysate. The glycerol response in adipose tissue in the group receiving iv glucose was three times more marked than in the saline group (P = 0.01) in spite of marked hyperinsulinemia, but there was no difference between the groups in plasma glycerol response. The plasma noradrenaline response was 50% higher (P = 0.03) in the glucose group than in the saline group, but there was no difference between the groups in the plasma adrenaline, glucagon, or cortisol responses. Adipose tissue blood flow was measured by the escape of ethanol from the dialysis solvent into the extracellular space. It was constant throughout the experimental period in both groups. In conclusion, the lipolysis rate is accelerated during general anesthesia and abdominal surgery because of increased catecholamine production. Perioperative glucose infusion is associated with a further acceleration of the lipolytic rate in subcutaneous adipose tissue due to an additional activation of the sympathetic nervous activity that overrides the antilipolytic effect of the glucose-induced hyperinsulinemia. Other adipose regions may be less sensitive to glucose infusions and anesthesia.

Adipose Tissue↗
PubMed1995

Paraplegia following surgical correction of scoliosis with Cotrel-Dubousset instrumentation.

Three patients with paraplegia following corrective surgery for idiopathic scoliosis, using the Cotrel-Dubousset (CD) instrumentation, were admitted to our department over a period of 22 months. They were operated on by three different surgeons and they were the first serious neurological complications in these surgeons' careers. The monitoring method was the "wake-up" test, applied at the end of the correction maneuver with the instrument. One patient presented paraplegia at the "wake-up" test and the other two were paraplegic shortly after ceasing anesthesia. Electrophysiological spinal cord monitoring during surgery may reduce the risks of complications.

Adolescent↗
PubMed1985

Anaesthetic carrier gases. Their effect on middle-ear pressure peri-operatively.

The effects of three different anaesthetic carrier gases on middle-ear pressure in the operative and postoperative periods was assessed. Patients receiving oxygen and oxygen-enriched air did not have significant changes in middle-ear pressure. The changes associated with the use of nitrous oxide as the carrier gas were reversed with return of pharyngeal reflexes or after prolonged inhalation of 100% oxygen. In patients undergoing middle-ear surgery or those with pre-existing middle-ear disease, we suggest that oxygen-enriched air is the anaesthetic carrier gas of choice.

Adult↗
PubMed1985

The serum and urinary cortisol response to operative trauma.

Serum and urinary cortisol levels were monitored throughout the perioperative period in eight patients who underwent elective extensive general surgical procedures. Significant elevations of serum cortisol levels occurred four and eight hours after anesthetic induction and were reflected by elevated urinary cortisol production on the day of operation. Cortisol serum levels and urinary production rapidly returned toward normal as all subsequent measurements were insignificantly different from preoperative values. Adrenal gland stimulation resulting from general surgical procedures is intense but short-lived.

Adrenal Glands↗
PubMed1984

[Electrostimulation anesthesia in comparison with enflurane-nitrous-oxide inhalation anesthesia during gynecologic operations. 2. Hormonal reactions in the pre-, intra- and postoperative course].

This study describes the secretion of cortisol, growth hormone, prolactin and catecholamines before, under, and following gynaecological surgery in electrostimulation anaesthesia combined with nitrous oxide (ESA). The hormonal stress reactions of ESA were compared to inhalation anaesthesia with enflurane-nitrous oxide ( EFL ). Twenty-two patients undergoing laparotomy were allocated evenly to one of these procedures. In both groups serum levels for cortisol, growth hormone, and prolactin increased during surgery. Growth hormone showed a considerably higher increase during ESA at the end of the operation, whereas prolactin was higher at all periods of surgery during EFL . Cortisol, however, was identical for both groups. Renal excretion rates of adrenaline and noradrenaline were not significantly different. During surgery more metanephrine and normetanephrine were excreted in the urine under ESA than under EFL . There is no advantage with ESA intra- or postoperatively as compared to other routine procedures of anaesthesia for abdominal gynaecological surgery with regard to the so-called stress hormones or sympathetic activity.

Anesthesia, Inhalation↗
PubMed1994

[Changes in the deglutition reflex during the perioperative period].

The swallowing reflex is one of the major mechanisms protecting the lungs against aspiration of foreign material. Its complex time course requires a perfect coordination with ventilation, as the aerodigestive crossroads are common for both functions. Physiological factors as ageing, as well as mechanical and pharmacological agents, may contribute to swallowing reflex alterations. Moreover, endotracheal intubation and most anaesthetic agents may impair the swallowing function and favour the occurrence of aspiration. This review discusses the normal swallowing process and its alterations by agents currently used in anaesthesia. Furthermore, the effect of intubation as well as changes related to co-existing diseases are considered.

Aged↗
PubMed1987

Pulmonary physiology in the postoperative period.

After upper abdominal or thoracic surgery, loss of lung volume, manifested most importantly by reduced FRC, and abnormal gas exchange, manifested by postoperative reduction in PaO2, are the rule rather than the exception. These physiologic alterations in lung function occur in the absence of superimposed complications such as pneumonia and/or lobar atelectasis; the usual physiologic alterations do, in fact, predispose to pulmonary complications (approximate 20 per cent incidence) which, when present, further compromise lung function. The mechanisms of postoperative impairment in lung function are multiple, interactive, and at the present, incompletely understood. An attempt to summarize the more important causes of impaired postoperative lung function is shown in Figure 6.

Humans↗
PubMed1993

Anxiety of elective surgical patients' family members. Relationship between anxiety levels, family characteristics.

Technological advances in the OR create new practices and procedures; however, humanistic and holistic approaches to nursing care remain the foundation of clinical practice. Perioperative nurses recognize that family members experience anxiety during surgery, especially during the time the patient is in the OR. Ironically, it is during this time period that little or no meaningful communication occurs between family members and health professionals. Patients continue to be discharged sooner, and in sicker condition, to be cared for by their family members. Families require information about how to provide postoperative care. Anxiety levels need to be decreased sufficiently to allow family members to use the information they are taught and ask appropriate questions. Interventions that reduce family members' anxiety need to be developed and tested so that family members can help patients after surgery. Using research findings as a basis for perioperative nursing practice may mean changing traditions and attitudes about family members of surgical patients. In the consumer-oriented climate of current health care, doing the "new" may make a difference in the market share. This "new" may be independent nursing interventions designed to reduce family members' anxiety during the intraoperative waiting period.

Adolescent↗