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PubMed2004

[Anesthesia and concomitant pathologies: anesthesia in the elderly patient].

With the increase in the average age of the population, more and more older persons undergo surgery. Major surgery, cardiovascular, orthopaedic and abdominal interventions expose the elderly patient to a significant risk for postoperative morbidity and mortality. This is not only related to the advanced age of these subjects, which is a recognized independent risk factor, but also to the aging process itself and to the greater prevalence of heart and lung diseases affecting this population segment. An important role is also played by the so-called physiologic modification found in subjects without recognized illnesses. Reduced organ function reserve requires accurate preoperative assessment that takes into account cardiovascular reserve and physiologic and pathologic alterations in the respiratory system that may predispose the patient to hypoxemia and favour the development of postoperative infection. Moreover, alterations in pharmacokinetics and pharmacodynamics require individualized drug dosing. Particular attention should also be directed at the prevention of postoperative cognitive disorders that favour the development of complications and negatively affect postoperative recovery of body function.

Age Factors↗
PubMed1992

[General anesthesia vs. retrobulbar anesthesia in cataract surgery. A randomized comparison of patients at risk].

Several studies comparing retrobulbar block (RB) and general anaesthesia (GA) for cataract surgery in the elderly have been published. Most of them were retrospective. Our prospective study was designed in order to determine the benefits or disadvantages using RB or GA. Arterial blood gases (ABG) and cardiovascular stability were explored in high-risk patients undergoing elective unilateral cataract extraction. METHODS. Forty patients over 65 years of age and with other co-existing diseases (ASA III-IV) were allocated randomly to receive either GA or RB. No premedication was given to either group of patients. On arrival in the anaesthetic room, a radial artery was cannulated for collection of blood samples and direct monitoring of the blood pressure. Pulse oximetry and ECG were continuously monitored in all patients, the end-expiratory CO2 (F(eexCO2)) only in the GA group. GA was induced with vecuronium 0.1 mg/kg and thiopentone 5 mg/kg; the lungs were ventilated with 100% oxygen. After intubation of the trachea controlled mechanical ventilation was continued with N2O/O2 (55:45) and enflurane 1%-2%. Only enflurane concentrations were varied to correct changes in mean arterial pressure (MAP) if these exceeded +/- 20%. Respiratory frequency and tidal volume were kept constant until completion of surgery. The patients were extubated when they were able to ventilate more than 5 1/min (pressure support 10 cmH2O; PEEP 5 cmH2O). After extubation no O2 was given. In the RB group neural block was undertaken with prilocaine 2% (3 ml) as a retrobulbar injection and prilocaine 1% (5 ml) to block the facial innervation of the orbicularis muscle (Van Lint, O'Brien). Oxygen 3 1/min was administered by nasal tube during the operation. Nine arterial samples for blood gas analysis were collected: (1) control; (2) before operation; (3) 5 min after beginning the operation; (4) 15 min after beginning the operation and before i.v. administration of 500 mg acetazolamide over 5 min; (5) after acetazolamide; (6 and 7) 10 and 20 min after acetazolamide; and (8 and 9) 15 and 30 min after operation (RB) or extubation (GA). RESULTS. The patient demography, including duration of anaesthesia and operation, was similar in both groups (Table 1). Four patients in the GA group (2 needed O2 after extubation because of hypoxaemia) and 2 in the RB group were excluded. No significant differences were seen in base excess (BE) and standard bicarbonate (SHCO3). Arterial O2 tension, arterial O2 saturation, and pulse-oximetric O2 saturation were higher in the RB group intra- and postoperatively (Figs. 1, 3, 4). Arterial CO2 tension (PaCO2) was significantly higher in the GA group during the pre- and postoperative period (Fig. 2), but not during the operation. The PaCO2- F(eexCO2) gradient ranged between 5 and 9 mmHg. Administration of acetazolamide did not influence this gradient by regressive analysis. The postoperative outcome of the patients was comparable in both groups. Nausea or vomiting did not occur. MAP was significantly higher in the RB group during the operation. No significant differences were seen in the pre- and postoperative period. Heart rate in the GA group was higher only after extubation, but was within physiological limits. DISCUSSION. Despite the differing results between the two groups, our study showed no important advantage related to either RB or GA. Changes in ABG, MAP, and heart rate during the investigation period were within physiological limits in elderly patients. Intravenous acetazolamide did not influence ABG in a significant manner. With regard to the preference of each patient, we recommend both RB and GA for cataract surgery in high-risk patients on the assumption of sufficient preoperative treatment of co-existing diseases. In conclusion, cardiovascular and ABG stability were maintained during both anaesthetic techniques.

Aged↗
PubMed1992

[The integration of thoracic epidural anesthesia into anesthesia for intra-abdominal surgery].

Upper abdominal and thoracic surgeries require efficient pain management. The complications of postoperative analgesia include respiratory depression and--when choosing the epidural route--possible damage to the spinal cord by infection, trauma, or bleeding. Therefore, thoracic epidural analgesia may appear to be too risky and is frequently cancelled although many studies have shown its excellent efficacy. Controlled studies comparing thoracic epidural analgesia to lumbar epidural analgesia or intravenous analgetic regimens with special regard to the patient's outcome are contradictory. To make the preoperative decision on the method of pain control more rational, we studied catheter-related complications from 2056 thoracic epidural catheters used for intra- and postoperative analgesia retrospectively (n = 1002) and prospectively (n = 1054) over a 5 1/2-year period. In all patients the thoracic epidural catheter was inserted preoperatively using local anaesthesia, in most cases by the paramedian approach between level T 5/6 and T 8/9. During the clinical course of all patients there were no clinical signs of any epidural bleeding or infection. Neurological complications caused by the epidural catheter did not occur. Seven patients (0.035%) experienced radicular pain that disappeared after removal of the catheter or interruption of the puncture, respectively. A primary perforation of the dura mater was noticed in 0.5% of cases retrospectively and 1.23% prospectively. Respiratory depression following epidural application of 0.3 mg buprenorphine was seen in 1 patient (0.05%). Continuous analgesia with local anaesthetics and/or opioids applied epidurally by a thoracic catheter was performed on the peripheral ward (n = 829, 40%) if close monitoring of the neurological status as well as rapid diagnosis of any painful paraesthesia or paraplegia was possible.

Abdomen↗
PubMed1992

[Total spinal anesthesia. A complication of lumbar catheter peridural anesthesia for postoperative analgesia].

A case of secondary subarachnoidal dislocation of a lumbar epidural catheter is reported. A 76-year-old female underwent resection of the sigmoid colon. In order to provide postoperative analgesia, an epidural catheter was inserted between the 3rd and 4th lumbar interspaces prior to induction of anaesthesia. Aspiration tests were negative twice and a test dose of 4 ml 0.5% bupivacaine produced no signs of anaesthesia. Thereafter, the operation was performed under balanced general anaesthesia. Prior to the end of surgery a total of 14 ml bupivacaine 0.5% was administered without significant cardiovascular depression. At the time of extubation the patient was awake and free of pain. There was no sign of respiratory depression or paralysis of the upper extremities. Three hours later in the recovery room the patient complained of pain. After a negative aspiration test 14 ml bupivacaine 0.25% was injected. Thirty minutes after injection apnea and cardiac arrest occurred. Resuscitation was immediately started, resulting in quick restoration of circulation and restitutio ad integrum. Aspiration at this time showed cerebrospinal fluid. The latency of the onset of total spinal anaesthesia and the rapid restoration of stable vital functions, was astonishing. It is essential to observe the common precautions such as an aspiration test without a filter, administration of a test dose, and titration of the injected amount each time the anaesthetic agent is applied via an epidural catheter.

Aged↗
PubMed1992

[The usefulness of the laryngeal mask in ambulatory anesthesia. An evaluation of 200 cases of ambulatory anesthesia].

We studied the value of Brain's laryngeal mask on 200 patients undergoing ambulatory operations under general anaesthesia using propofol and alfentanil. Continuous registration of maximal airway pressure and pulse oximetry were carried out. The operations were performed mainly in the following four specialities: urology, general surgery, gynaecology, and ophthalmology. The mean operation time was 39 min (6-82 min). All patients belonged to ASA groups I-III. No patient was premedicated. We encountered no difficulties in introducing the mask using the technique described by Brain except in one 6-year-old boy with hypertrophic tonsils in whom it was impossible. Insufficient sealing of the trachea occurred in a 29-year-old woman with thyroid hypertrophy. In most patients (70%) the oxygen saturation (spO2) could be maintained above 95%; only 6 (2%) showed an spO2 value of less than 90%. Peak inspiratory pressures--a measure of tight fitting of the mask--are shown in Table 2. Laryngospasm occurred in 2 children who had inhalation inductions with halothane. This complication was never seen after induction with propofol. The most important positive finding was that relaxant drugs became largely unnecessary after we started working with the mask, which reduced postoperative recovery time as well as costs. CONCLUSION. We consider the laryngeal mask to be not only an important new technique, but in combination with propofol and alfentanil the method of choice for ambulatory anaesthesia in day-case surgery.

Adolescent↗
PubMed1977

[Anesthesia with continuous infusion of alfatesine and phenoperidine. Uses in anesthesia of aged subjects in visceral surgery].

Anaesthesia was administered to one hundred and fifty eight patients by continuous infusion of a mixture of Alfatesine and phenoperidine. The patients were divided on two groups: group A consisted in 96 patients undergoing abdominal surgery and group B of 62 cases of various types of surgery, mainly orthopedics. The average age was 63 years (range 16-96). The operative risk scored 6 or more in 71 cases. The length of operation averaged 151 minutes (S.D. +/- 15). The mixture made of alfadione 25 ml and phenoperidine 5 mg in a glucose 5 per cent 250 ml solution was administered by mechanical pump. The induction dose was 50 ml of the mixture for patients under 50 years (rate 10 ml per minute), 40 ml per patients from 50 to 70 years (5 ml per minute), and 30 ml for patients over 70 years (5 ml per minute). The maintenance dose was adjusted to weight and age and ranged from 0,11 to 0,15 ml/kg/h for alfadione and from 0,022 to 0,030 mg/kg/h for phenoperidine. Routine tracheal intubation and artificial ventilation were performed in group A. The results are studied in relation to the effectiveness of the anaesthesia mixture, its side effects and influence on recovery. Generally, the results are good and emphasize the value of the technic in abdominal surgery for elderly patients. The methods of application are discussed in terms of medical background.

Adult↗
PubMed1990

[Anesthesia of horses with xylazine and ketamine. 2. Anesthesia in adult horses].

Xylazine and Ketamine were used for anaesthesia in 250 adult horses. This combination is useful both for induction and maintenance of anaesthesia. The induction with Xylazine and Ketamine has been successful not only with foals but also with high risk patients such as horses with colic. During the maintenance of anaesthesia Xylazine/Ketamine can be used with injectable anaesthetics as well as with volatile anaesthetics at the same time. A form of injection anaesthesia for short-time surgical procedures like castration and wound repair is presented. The maintenance of a Thiobarbiturate/Guaifenesin anaesthesia with Xylazine/Ketamine seems to be suitable for field conditions.

Age Factors↗