Anesthetic management for coronary bypass patients on hemodialysis: report of 4 patients.

We reported our own experience in four patients with chronic renal failure on maintenance hemodialysis undergoing coronary artery bypass graft surgery (CABGS). A balanced general anesthesia with endotracheal intubation was successfully achieved by using midazolam, atracurium, fentanyl, pentothal, nitrous oxide in oxygen and isoflurane. All patients were hemodialyzed within 24 hours before operation. One patient started peritoneal dialysis 10 hours after surgery. Three other patients were managed by hemodialysis the day after surgery. There was no hospital mortality. Many aspects of management of these patients which differ from those of routine cardiac surgical patients are outlined and discussed.

Chromosomal analysis of "failed-fertilized" human oocytes resulting from in-vitro fertilization and intracytoplasmic sperm injection.

To evaluate the incidence of chromosomal abnormalities in "failed-fertilized" oocytes derived from in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) procedure, a cytogenetic analysis was performed on 164 IVF and 64 ICSI oocytes. One hundred and eleven (67.7%) of the IVF and 56 (87.5%) of the ICSI oocytes were successfully karyotyped. Of 111 IVF oocytes, 73 (65.8%) exhibited normal haploid and 38 (34.2%) were abnormal. The abnormalities included 25 aneuploid (22.5%) (7 hyperhaploid and 18 hypohaploid), 11 diploid (9.9%) and 2 structural anomalies (1.8%). Of 56 ICSI oocytes, 52 (92.8%) were normal haploid and only 4 (7.2%) were aneuploid, with 2 hyperhaploid and 2 hypohaploid. The sperm nuclei were observed in 43 IVF oocytes (38.7%), composed of 38 (34.2%) premature chromosome condensation (PCC) and 5 (4.5%) decondensed sperm heads. Evidence of successful sperm delivery was found in all 56 ICSI oocytes; 25.0 per cent (14/56) showed PCC, 17.9 per cent (10/56) showed decondensed sperm heads, and 57.1 per cent (32/56) showed intact sperm heads. This study suggested that about one-third of unfertilized oocytes exhibited chromosomal abnormalities. The difference of aneuploidy between IVF and ICSI oocytes needs further studies analysing a larger number of oocytes.

A multicenter randomized double-blind comparison of remifentanil and alfentanil during total intravenous anaesthesia for out-patient laparoscopic gynaecological procedures.

We compared Remifentanil, an esterase-metabolized opioid, with Alfentanil as part of the total intravenous anesthesia with propofol and atracurium for out-patient laparoscopic gynaecological procedures in a multicenter randomized, double-blind study. We chose Remifentanil 1 mg./kg.for bolus injection and a continuous infusion of 0.25-0.5 microg./kg./min, compared to Alfentanil 20 microg./kg. For bolus injection and a continuous infusion of 0.5-1 microg./kg./min. Fifty-nine patients received Remifentanil, and sixty-three received Alfentanil. Patients who received Remifetanil experienced significantly fewer stress responses to surgical stimuli (p < 0.05) and required fewer additional boluses of study drugs and propofol (p < 0.05) than Alfentanil during the intraoperative period. Response time to verbal commands, spontaneous respiration, adequate respiration and tracheal extubation, were not significantly different between these two opioids. Remifentanil patients, required more fentanyl for post operative pain control, 40 from 59 cases in the Remifentanil group and 22 from 63 cases in the Alfentanil group (p < 0.05) but still showed significantly better recovery of psychomotor function by Aldrete score of ten at 50 and 60 min (p < 0.05) than Alfentanil patients. The incidence of intraoperative bradycardia was significantly higher with Remifentanil. Other incidences of nausea, emesis, urinary retention and postural hypotension were similar. All patients were ready to be discharged from the hospital within two hours after extubation except for one patient in the Alfentanil group who needed five hours of hospital stay because of urinary retention, nausea and severe emesis.

Epidural analgesia for pain relief in thoracic surgery.

The effectiveness and adverse effects of continuous epidural analgesia was studied in 104 patients undergoing thoracic operations at Siriraj Hospital. Patients were divided into 3 groups according to the type of surgical approach and the technique of epidural analgesia. Group 1 patients (n = 72) received thoracic epidural block using bupivacaine and morphine combined with light general anesthesia for exploratory thoracotomy; group 2 patients (n = 21) received the identical anesthetic technique, the operation was achieved through median sternotomy; group 3 patients (n = 11) had a similar type of operation to group 1, the anesthetic technique was lumbar epidural block using morphine and combined with light general anesthesia. Continuous epidural morphine infusion was given 0.1-0.4 mg/h during postoperation in all patients for providing adequate pain relief. The results revealed that a 10 cm visual analogue scale (VAS) pain scores were satisfactory and comparable in all groups. Lumbar epidural patients consumed a significantly larger dose of morphine than thoracic epidural groups (P < 0.01). Intraoperative hypotension occurred 43.05 per cent and 19.05 per cent in group 1 and 2, but none was found in group 3 (P < 0.05). Postoperative respiratory depression was found 54.16 per cent in group 1, 33.33 per cent in group 2 and 9.09 per cent in group 3 (P < 0.05), and was mostly mild to moderate, except three patients in group 1 and one in group 2 who needed mechanical ventilatory support. There were no differences among the groups in the incidence of nausea/vomiting and pruritus. It is concluded that both thoracic and lumbar epidural morphine provide excellent postthoracotomy pain relief, whereas, respiratory depression is more common with thoracic than lumbar epidural morphine.

Comparison of pronuclear stage embryo transfer and in vitro fertilization-embryo transfer following intracytoplasmic sperm injection.

To determine whether the mode of embryo transfer (PROST vs IVF) affected the outcome in intracytoplasmic sperm injection (ICSI) cycles, 237 ICSI cycles (106 PROST and 131 IVF) were analyzed. Several parameters, including patient age, duration of infertility, amounts of hMG used, number of mature eggs retrieved and injected, fertilization rate, number of embryos transferred, and clinical pregnancy rate, were compared. Most of the variable factors were not significantly different, except the mean numbers of transferred embryos which were significantly higher in the PROST group. The clinical pregnancy rate showed no statistical difference between PROST and IVF cycles (25.5 and 16.8%; p = 0.139). This study suggests that even the pregnancy rate in PROST cycles was slightly higher than IVF cycles, but there was no statistically significant difference between the two groups.

Cryopreservation of human spermatozoa: comparison of two cryoprotectants and two freezing methods.

A prospective experimental study was performed to compare sperm cryosurvival rate between two kinds of cyroprotective media: citrate-egg yolk-glycerol (CEG) and TEST-citrate-egg yolk-glycerol (TEST-EYG), and between two freezing methods: noncontrolled rate (NCR) freezing and computer controlled rate (CR) freezing. One hundred semen samples were included in the study. Each sample was divided into two parts, which were prepared as two CEG and two TEST-EYG mixture straws, then one straw from each mixture was frozen by the NCR-freezing method and the complementary straw was frozen by the CR-freezing method. After one week of cryostorage, the straws were thawed and the post-thaw sperm survival was assessed. As the results, the post-thaw sperm survival rate of the CEG media group was slightly higher than the TEST-EYG group in both the NCR-freezing method (51.2% vs 47.0%, p < 0.05) and the CR-freezing method (48.2% vs 43.4%, p < 0.05); and similarly; the NCR-freezing group yielded a slightly higher post-thaw sperm survival rate than the CR-freezing group in both the CEG media used (51.2% vs 48.2%, p < 0.05) and the TEST-EYG media used (47.0% vs 43.4%, p < 0.05). However, these did not have clinical significance because the differences were too small. In conclusion, the use of either CEG or TEST-EYG media, and either the NCR or CR-freezing method did not have clinical differences on the post-thaw sperm survival.

Acute hemodilution and autotransfusion in cardiac surgery: a comparison between rather healthy and high risk patients.

The effects of acute normovolemic hemodilution and autologous blood transfusion were studied in open heart patients, compared with rather healthy patients, NYHA class 1-2 and the high risk patients, NYHA class >2. Thirty-nine patients were involved in this study, 15 of them were identified as the rather healthy group while 24 patients belonged to the high risk group. Acute hemodilution was performed after anesthetic induction and before heparinization. Using an equal volume of polygeline 3.5 per cent (Haemaccel) to replace autologous blood removal, the number of patients who needed inotropic support to achieve normal arterial blood pressure was not significantly different between the groups. Following retransfusion of pump perfusate and autologous blood after the termination cardiopulmonary bypass, the number of patients who received additional homologous blood as well as the amount used percase were significantly less in the rather healthy patients. There was none in this group, but half of the high risk patients suffered from serious perioperative complications and one died. We conclude that this technique is safe and benefits blood conservation in rather healthy cardiac patients undergoing open heart surgery, but special precautions against risk should be considered in high risk patients.

Anaesthetic management of a parturient with eisenmenger’s syndrome.

The case of a parturient with Eisenmenger’s syndrome from an uncorrected ASD is reported. She was admintted to the hospital because of tiredness and cyanosis. She had labor pain at the end of 35th week gestational age. The obstetrician decided she should undergo caesarean section. A balanced general anaesthesia with endotracheal tube was successfully achieved by using fentanyl, pentothal, artacurium, midazolam, oxygen and halothane. Mild hypotension which occurred shortly after delivery of the foetus was promptly treated with volume and vasopressor. No serious complication was found in the postpartum period.