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The capacity of blood pressure cuffs to act as vehicles of hospital infection has been recognised. We describe the microbial flora of in-use DINAMAP blood pressure cuffs used in the operating theatres and one recovery room in a teaching hospital. Our results show significant microbial contamination of in-use blood pressure cuffs.
Sixteen extremely obese patients were anaesthetized for intestinal short circuiting operations. Severe obesity may cause pathological cardio-pulmonary changes. Cardiovascular alterations include increased systemic, pulmonary artery and pulmonary capillary venous pressure. Cardiac output, total blood volume and left ventricular work increase. Expiratory reserve volume and consequently functional residual capacity decrease with gross obesity. Functional residual capacity falls below closing volume and inspired gas may be distributed to non-dependent lung zones, resulting in decreased ventilation/perfusion ratios and arterial hypoxaemia. Low total respiratory compliance increases the oxygen cost of the work of breathing. Obesity may change the dose requirements for regional anaesthesia and long-acting muscle relaxants. General anaesthesia may also reduce functional residual capacity. We used a technique of anaesthesia which consisted of epidural analgesia with intra-operative mechanical ventilation and which specifically avoided volatile inhalation agents and long-acting muscle relaxants. All patients were extubated immediately after operation and returned to the recovery room for an average duration of 26 hours. Post-operative treatment included humidified oxygen, chest physiotherapy and elevation of the head of the bed to 45 degrees. Each patient's respiratory progress was monitored by repeated determinations of arterial blood gases and vital capacity and by serial chest X-rays. None of the patients in this group required post-operative tracheal intubation and mechanical ventilation.
The coagulation-fibrinolysis system was studied during Ethrane anaesthesia and gynaecological operations in 20 patients. No particular change was noted in the platelet counts, which remained within the normal range. In the coagulation system, no appreciable change was observed except for the partial thromboplastin time (P.T.T.) which was significantly short-ended, both 30 minutes after the start of operation and in the recovery room when the patient had completely awakened from the anaesthesia. In the fibrinolytic system, the plasminogen level and the fibrinogen level declined significantly. It is considered that the fibrinolytic system is prominently accelerated under Ethrane anaesthesia, but the haemostatic mechanism works in such a manner that bleeding is controlled. However, Ethrane anaesthesia should be avoided or pre-operative administration of an antiplasmic agent recommended for patients with an abnormal haemostatic mechanism.
We have described our technique of caudal anaesthesia in children. This technique was used for relief of post-operative pain in 120 patients. Relief of pain was complete. Post-operative recovery was quiet and comfortable, with no side effects. The surgeons, the parents and recovery room personnel were satisfied. There were no surgical or anaesthetic complications.
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The effectiveness of 10 mg IV prochlorperazine in preventing postoperative nausea and vomiting was compared with placebo when given perioperatively to 100 patients in a prospective double-blind randomized trial. The occurrence of nausea and vomiting was assessed in the recovery room prior to and after narcotic administration for pain relief. No statistically significant difference in the frequency of postoperative nausea and vomiting was found between the treatment and control groups.
A randomized, prospective, comparative study was performed to evaluate induction characteristics, haemodynamic changes and recovery in 60 ASA I-II patients undergoing mainly gynaecological laparotomies with either propofol or thiopentone-enflurane anaesthesia. The propofol group (n = 30) received 2 mg.kg-1 propofol for induction of anaesthesia followed by propofol infusion. The thiopentone-enflurane group (n = 30) received thiopentone 4 mg.kg-1 for induction followed by enflurane (0.5-2 per cent). All patients received nitrous oxide (66 per cent] in oxygen begun one minute after tracheal intubation, and fentanyl (1.5 micrograms.kg-1) four minutes prior to induction. Other drugs administered during or after anaesthesia were similar among the groups. Haemodynamic measurements were similar between propofol and enflurane groups except after tracheal intubation when the mean arterial pressure was lower in the propofol group (P less than 0.05). The propofol group had significantly less (P less than 0.01) emesis in the recovery room than the enflurane group. The propofol group experienced significantly less (P less than 0.05) dizziness, depression/sadness and hunger than the enflurane group in the postoperative period as assessed with a visual analogue questionnaire. We conclude that propofol provided better outcome than enflurane in terms of these nonvital but annoying outcome measures after relatively long intra-abdominal operations.
Several cases of recurrent respiratory depression progressing to apnoea and unconsciousness after apparent recovery from sufentanil have been reported recently. Alfentanil has the shortest elimination half-time of the narcotics used in anaesthesia, suggesting that it should be the least likely to cause postoperative respiratory depression. A case of recurrent unconsciousness and respiratory arrest after apparent recovery from alfentanil-isoflurane-nitrous oxide anaesthesia is reported. A total dose of 137 micrograms.kg-1 alfentanil was given over a 3.25-hr period to a 45-year-old female undergoing partial gastrectomy. Naloxone, 0.16 mg IV, rapidly restored spontaneous ventilation and consciousness. This case demonstrates that apnoea and unconsciousness can also recur after apparent recovery from alfentanil. Recovery room personnel should be aware of this phenomenon. Earlier detection may permit treatment before apnoea occurs. Patients given narcotic-supplemented anaesthesia should be monitored by capnography and/or pulse oximetry in the early postoperative period.
Five hours following an uneventful coronary artery bypass graft operation, an otherwise healthy 54-yr-old man developed a pneumothorax while his lungs were being ventilated in the recovery room. Neither arterial blood gas analysis, ventilatory variables, nor clinical examination had suggested this diagnosis, which was made subsequent to a chest radiograph taken as part of the assessment of hypotension. At the same time, the waveform of the pressure tracing from his pulmonary artery catheter changed inexplicably while attempting balloon inflation as part of the assessment of the hypotensive episode. In retrospect, the changes in the pressure tracing most likely were due to alterations in the pulmonary vasculature associated with the pneumothorax. These changes can be explained in terms of a well-known physiological model. If such changes are encountered in similar circumstances, a tension pneumothorax should be suspected.
Two doses (10-15 micrograms.kg-1, Group I, and 15-20 micrograms.kg-1, Group II) of oral transmucosal fentanyl citrate (OTFC) plus a placebo (Group III) were evaluated for premedication in 105 healthy children, aged 2 to 13 yr, undergoing short (less than 1 hr) operations in the hospital short-stay unit. The study was randomized and double-blinded and 91 of the 105 children also received droperidol, 25 micrograms.kg-1 IV, after induction of anaesthesia with halothane and N2O in oxygen. Both doses of OTFC produced significantly greater sedation (first present at 20 min) and anxiolysis (first present in Group I at 40 min) than the placebo. Recovery times were similar in the three groups and analgesic requirements in the recovery room were significantly lower in Group I than Group III. Both OTFC groups took longer to tolerate oral fluids in the postoperative discharge unit than the placebo group and this caused patients in Group I to have a delayed discharge from the hospital compared to Group III. Preoperative pruritus occurred significantly more frequently in Groups I and II (58 and 76 per cent, respectively) than Group III (23 per cent). Although the incidences of nausea and vomiting tended to be slightly higher in the OTFC groups in the preoperative holding and postoperative discharge units, the differences among the groups were not statistically significant. Likewise droperidol did not reduce the incidence of postoperative nausea or vomiting. The data indicate that OTFC may be a safe and effective premedicant in paediatric patients having short operations but delays discharge from the hospital (by 30-50 min) by delaying the time patients tolerate fluids early after operation.
Physostigmine salicylate has proved to be a very useful agent for use in the recovery room. All but two of our first 110 patients receiving it were returned to full consciousness, whether they had been comatose or agitated. In our hands it has been used to reverse the adverse central effects of tranquilizers, antihistamines and belladonna alkaloids.
Nalbuphine (EN2234A) is an agonist-antagonist analgesic. It is structurally related to the narcotic analgesic oxymorphone and to the narcotic antagonist naloxone. A double blind study was carried out in 400 children in ASA classification I, ranging from 10 months to 14 years of age, to compare nalbuphine, pentazocine and placebo for paediatric premedication. Our results showed that nalbuphine is comparable to pentazocine as a premedicating agent and superior to placebo, in the doses used, and that premedication is an important adjunct to anaesthesia in children. Following premedication with nalbuphine or pentazocine, there were fewer apprehensive children at the time of induction of anaesthesia and in the recovery room when compared to those receiving placebo injections.
The activity of the renin-angiotensin system was measured before, during, and after infrarenal aortic cross-clamping in 13 patients. Five of the patients studied were taking propranolol preoperatively and formed a subgroup. Intraoperative blood loss, volume of crystalloid and colloid infused, haemodynamic parameters and urine output were similar for the two groups. In eight patients who were not taking propranolol mean plasma renin activity was 2.24 ng . ml-1 . hr-1 prior to induction, 3.78 ng . ml-1 . hr-1 during surgery prior to cross-clamping and 4.42 ng X ml-1 X hr-1 15 minutes after the aorta was cross-clamped (increases not statistically significant). Mean plasma renin activity measured ten minutes prior to release of the cross-clamp (5.02 ng X ml-1 . hr-1), 15 minutes after clamp release (5.47 ng X ml-1 X hr-1), and 30 minutes after reaching the recovery room (5.84 ng X ml-1 X hr-1) were significantly greater than preinduction levels. Four patients developed postoperative hypertension (mean blood pressure greater than 120 mmHg); there was not a correlation between the elevated plasma renin activity observed postoperatively and the occurrence of postoperative hypertension. The five patients taking propranolol had a markedly attenuated renin activity response during and after surgery; the mean plasma renin activity was less than 1.5 ng X ml-1 X hr-1 at all sampling times. Two of these five patients did develop postoperative hypertension. It is concluded that surgery involving infrarenal aortic cross-clamping is associated with increased plasma renin activity with peak levels occurring postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)
This prospective, randomized, double-blind trial evaluated the efficacy of rectal indomethacin as an adjunct to morphine for controlling postoperative pain. Fifty healthy patients undergoing elective hip arthroplasty were investigated. Group 1 (n = 25) received placebo suppositories, Group 2(n = 25) received indomethacin suppositories, 100 mg q8hr for five doses, starting at the end of the procedure. Both groups received morphine via a PCA pump, which recorded the amount of morphine delivered each hour. After a standardized general anaesthetic, PCA was begun in the recovery room. Pain was measured with a standard 100 mm VAS at 2, 6, 20, 28, 42 hr after surgery and the morphine consumption recorded. Over the 42-hr study period, patients in Group 2 required less morphine than those in Group 1 (34.8 +/- 21.8 mg vs 89.6 +/- 43.7, P less than 0.01). Pain scores were lower in Group 2 at 20, 28, 42 hr postoperatively. The incidence of side-effects did not differ between groups and no patient had excessive postoperative bleeding. The combination of indomethacin and morphine provided superior pain relief to morphine alone even though the control group had liberal access to morphine. This synergistic effect would make indomethacin a useful adjunct to intramuscular or epidural narcotics.
We sought to determine the pharmacokinetic and pharmacodynamic behaviour of a continuous infusion of nifedipine given for prevention of myocardial ischaemia following coronary artery bypass graft (CABG) surgery. Patients scheduled for elective CABG, who had good left ventricular function, were included. Only normotensive patients who did not require treatment with vasoactive drugs and were bleeding less than 100 ml.hr-1 following surgery were included. The patients were randomly distributed into two groups: a control group not receiving any treatment and a treated group receiving a bolus (3 micrograms.kg-1.min-1 for 5 min) and maintenance (0.2 micrograms.kg-1.min-1) infusion of nifedipine, starting upon arrival in the recovery room and continuing for four hours. Patients given nifedipine were compared with control patients in order to determine the effects of nifedipine on haemodynamic function and on the postoperative incidence of hypotension, hypertension, myocardial ischaemia and infarction. Continuous 2-lead Holter monitoring was used to detect myocardial ischaemia. Infarction was diagnosed by 12-lead ECGs and by assessment of the MB-isoenzyme creatine kinase. The infusion of nifedipine rapidly achieved and maintained plasma concentrations between 30 and 40 ng.ml-1. The pharmacokinetic studies revealed a systemic clearance of nifedipine of 0.371 +/- 0.101 L.hr-1.kg-1, an apparent volume of distribution of 0.764 +/- 0.288 L.kg-1 and an elimination half-life of 1.4 +/- 0.6 hr. No correlation was found between plasma concentration of nifedipine and mean arterial pressure (MAP). The incidence of postoperative hypotension (MAP < 70 mmHg) and hypertension (MAP > 100 mmHg) was comparable between the groups. All haemodynamic variables were similar in both groups during the study period. Of 23 patients who received nifedipine, none showed evidence of ischaemia within six hours of starting the infusion. During the same period, five of 24 patients in the control group had ST-segment deviation suggestive of myocardial ischaemia (P = 0.05, Fisher's exact test). Three patients in the control group and none in the nifedipine group suffered perioperative myocardial infarction (P = NS). In conclusion, the continuous infusion of nifedipine used in this study is safe and reduces the incidence of myocardial ischaemia in normotensive patients with good left ventricular function following CABG. Further studies of larger number of patients are required to determine the role of calcium entry blockers following coronary artery surgery.
A case of respiratory depression which occurred following administration of epidural meperidine during Caesarean section is described. Epidural meperidine, 75 mg (10 mg.ml-1) was given after delivery of the infant to provide postoperative analgesia. Oxygen desaturation (SaO2 90%) and a decrease in respiratory rate (4.min-1) were noted 30 min after epidural meperidine was administered. Naloxone, 0.1 mg, was given iv which resulted in prompt improvement in both respiratory rate and oxygen saturation. Vascular absorption of meperidine from the epidural venous plexus is the most probable explanation for this case of early respiratory depression. We recommend a maximum bolus dose of 50 mg of epidural meperidine for pain management after Caesarean section. It is also important to monitor oxygen saturation continuously during the intraoperative period, and to monitor the patient closely in the recovery room for at least one hour for evidence of respiratory depression.
Thirty-four patients undergoing thoracotomy were entered into a randomized, double-blind, placebo-controlled study to compare the effects of patient-controlled, lumbar epidural (PCA-E) fentanyl with patient-controlled intravenous (PCA-i.v.) fentanyl with respect to drug requirements, analgesic efficacy and respiratory function. Prior to chest closure patients received fentanyl 2 micrograms.kg-1 by the epidural or i.v. route. In the recovery room further doses of epidural or i.v. fentanyl, 50 micrograms, were administered by the patients who controlled two PCA pumps. Background fentanyl infusion rates were increased by 10 micrograms.hr-1 each time the patient administered a drug bolus and were decreased by 10 micrograms.hr-1 whenever visual analogue scale (VAS) pain scores were less than 2 on a maximum 10 scale. Twenty-nine patients completed the study. Patients in the PCA-E group (n = 14) required less total fentanyl than those in the PCA-i.v. (n = 15) group (1857 +/- 693 micrograms vs 2573 +/- 890 micrograms respectively, P less than 0.05). Fentanyl infusion rates were lower in the PCA-E group at most measurement times. There were no differences between groups in respiratory rates, PaCO2, VAS pain scores or changes in pulmonary function as measured by FVC and FEV1. It is concluded that satisfactory patient-controlled analgesia can be achieved with both epidural and i.v. fentanyl after thoracotomy but that fentanyl requirements are less when given via the epidural route. This supports a direct spinal cord site of action for lumbar epidural fentanyl.
We report a case of a 70-yr-old white woman who underwent a revision of a total hip arthroplasty under general anaesthesia. The intraoperative course was stable without any complications and the estimated blood loss was 2500 ml. The patient received an autologous transfusion of blood from a wound drainage system in the recovery room. The transfusion was followed immediately by marked respiratory distress and upper airway oedema. She required emergency tracheal intubation and mechanical pulmonary ventilation. A coagulopathy also developed which was treated and resolved within 12 hr of the capillary leak phenomenon. The trachea was extubated on the first postoperative day and she had an uneventful course until discharge from the hospital two days later. We discuss the possible, aetiology of such a reaction to autologous blood including complement and platelet activation. It is suggested that reinfusion of nonwashed shed blood from a wound drainage system may present a hazard even though the fluid was autologous in origin.