Combined epidural-general anesthesia [CEGA] in patients undergoing pancreatic surgery: comparison between bupivacaine 0.125% and 0.25%

Major abdominal surgery results in homodynamic instability mainly due to endogenous prostacyclin release, bleeding, major intercompartemental fluid shift and the hormonal surgical response. This study compared the effects of low thoracic epidural anesthesia with 0.125% and 0.25% bupivacaine on haemodynamic variables, sevoflurane requirements, and stress hormone responses during pancreatic surgery under combined epidural-general anaesthesia [CEGA]. Forty patients undergoing different pancreatic surgery were randomly allocated into two equal groups to receive 10 ml of either isobaric bupivacaine 0.125% [group I] or 0.25% [group II] by low thoracic epidural with sevoflurane general anaesthesia. Sevoflurane was adjusted to achieve a target bispectral index [BIS] of 40-60. Measurements included the inspired [F'SEVO] and the end-tidal sevoflurane concentrations [E'SEVO], blood pressure [BP] and heart rate [HR] before surgery and every 5 min during surgery for 2 h, and stress hormones. Plasma samples for stress response evaluation were taken before and 1 and 2 h after the start of surgery for measurements of epinephrine, and cortisol. During surgery, both groups were similar for HR, BPand BIS, but [EISEVO] and [E'SEVO] were significantly higher and more fluctuated with bupivacaine 0.125% than with 0.25%. Moreover, the total amount of propofol used for induction of general anesthesia and the total fentanyl used during anesthesia were significantly low in 0.25% bupivacaine group. Intraoperative requirements of ephedrine were higher in 0.25% bupivacaine group, Intraoperative blood loss and fluid requirements were significantly increase in 0.125% group. Plasma concentrations of epinephrine and cortisol were found to be higher with bupivacaine 0.125% as compared with 0.25%. Combined thoracic epidural-general anesthesia [CEGA] for pancreatic surgery, with 0.25% bupivacaine significantly reduces sevoflurane requirements, blood loss and fluid requirements. In addition, bupivacaine 0.25% suppressed the stress hormone responses better than 0.125% did. However this was on the expenses of more ephedrine requirements

Plain versus hyperbaric ropivacaine for spinal anesthesia in cirrhotic patients undergoing ano-rectal surgery

In cirrhotic patients undergoing ano-rectal surgery, spinal anesthesia/analgesia remains a challenge. Coagulopathy and intraoperative hypotension represent a major challenge for the anesthetist during spinal anesthesia in those patients. This study was designed to examine the efficacy and the adverse effects of ropivacaine [plain, hyperbaric] spinal anesthesia for anorectal surgery in cirrhotic. Forty known cirrhotic patients categorized as Child-A, scheduled for ano-rectal surgery under spinal anesthesia were enrolled in this study. Patients were randomly allocated into 2 equal groups. Patients received 2.0 ml ropivacaine 0.6% [6 mg/ml], either. In plain solution [group I] or with glucose [hyperbaric] group II. 10 micro g fentanyl was added for each solution. The extent and duration of sensory and motor block, pulse rate, blood pressure, and time to mobilization were recorded. Any unwanted effects related to spinal blockade were also recorded. There were significant differences in median time to onset of sensory block at T10 [plain 9 min; hyperbaric 3 min; P < 0.01], median maximum extent [plain T8; hyperbaric T6; P < 0.05], and median duration of sensory block at T10 [plain 66 min; hyperbaric 113 min; P < 0.01]. However, median times to complete regression of both sensory [183 vs 156 min; P < 0.05] and motor [158 vs 123 min; P < 0.05] block were longer in the plain group. Patients mobilized sooner in the hyperbaric group [plain 192 vs hyperbaric 131 min; P < 0.01]. All the hyperbaric blocks were adequate for surgery, but three patients receiving plain ropivacaine required sedative/analgesic bolus during anal dilatation. The practice of spinal anesthesia in patients with mild cirrhosis is a safe and reliable anesthetic technique. Addition of glucose 50 mg/ml to plain ropivacaine 6% increases the speed of onset, block reliability, duration of useful block for ano-rectal surgery, and speed of recovery. Moreover hemodynamic stability is a prominent feature of that block

Low central venous pressure anaesethesia in major hepatic resection

Blood loss and transfusion requirements are major determinants of morbidity and mortality following liver resection. This study evaluates the association of low central venous pressure [LCVP] with blood loss and blood transfusion during liver resection. Thirty consecutive hepatic resections were studied prospectively concerning CVP, volume of blood loss and volume of blood transfusion and renal outcome. Data were analyzed for those with a CVP 5 mmHg. A muitivariate analysis assessed potential confounding factors in the comparison. The mean blood loss in patients with a CVP of 5 mmHg or less was < 500 ml and that in those with a CVP > 5 mmHg was > 2000 ml. [p <0.0001]. Only two patients with a CVP of 5 mmHg required transfusion. No incidences of air embolism or permanent renal shutdown have been reported. In conclusion: The volume of blood loss and blood transfusion during liver resection correlates with the CVP during parenchyma! transection. Lowering the CVP to less than 5 mmHg is a simple and effective technique to reduce blood loss during liver resection and delete the need for blood transfusion with its hazards

Spinal ropivacaine in fast-track TURP

The addition of fentanyl to spinal ropivacaine anaesthesia has been shown to improve the quality of block, increase duration of sensory block, and provide postoperative analgesia without affecting motor function. in a randomized controlled, double blind study, we examined the efficacy and the adverse effects of three different regimen of spinal anesthesia Forty-five patients scheduled for transuretherai resection of the prostate [TURP] under sudarachnoid anesthesia. Patients were randomly assigned to Group I [G I] hyperbaric bupivacaine 10 mg. Group II [G II] 15 mg heavy ropivacaine, and Group III [G III] ropivacaine 10 mg with 20 micro g fentanyl. Evaluation of the block and side effects were performed after spinal anaesthesia. Three patients in bupivacaine group, three patients in ropivacaine group and one patient in fentanyl group required sedative / analgesic supplementations. Patients of fentanyl group showed significant prolonged sensory block and significant decrease in the motor block. Time to walk was significantly shortened in fentanyl group, it was 150 mm versus 197 and 162 mm in bupivacaine and ropivacaine groups respectively. The visual analogue score for pain at 3, 6 and 12 hours after jntrathecal anaesthesia in G II and III were significantly less than G I. No patient experienced respiratory depression, hypoxemia. hypotension or bradycardia dunng the postoperative penod Pruritus was reported in 12 patients [80%] of fentanyl group, but it was mild and did not necessitate medical treatment. Shivering was significantly less in the patients of fentanyl group. Intratnecal ropivacaine 10 mg plus 20 micro g fentanyl resulted in sufficient analgesia comparable to 15 mg ropivacaine or 10 mg bupivacaine with better analgesia and discharge criteria for fast-track TURP

Propofol versus remifentanil patient controlled sedation for awake craniotomy during epileptic surgeries

Anaesthesia for neurosurgical procedures, specificaity craniotomies requiring patient participation presents a challenge to both the neuroanaesthesiologist and the neurosurgeon Despite the popularity of general anaesthesia for these procedures, there has been a renewed interest in this technique of awake craniotomy due to its definite advantages m specific patient populations. This study evaluate two anaesthetic regimens for propofoi and remifentanil for awake craniotomy in epileptic surgeries. Total drug administered, incidence of complications, sedation score and patient satisfaction were assessed in 20 patients, randomely assigned into 2 equal groups, aged 18-55 years undergoing awake craniotomy for epileptic surgeries. Sedation was induced vis propofol patient controlled sedation in group I and via remifentanil patient controlled sedation in group II. five patients in the remifentanil group versus two patients in propofol group experienced nausea and /or vomiting. Respiratory rate depression, desturation were more frequent in remifentanil group while pain and hypotension were more frequent in propofoi group Both groups achieved a good level of sedation and patient satisfaction. Propofol and remifentanil are almost ideal drugs for conscious sedation during avjake craniotomy

Effect of albumin administration prior to graft reperfusion on the severity of reperfusion syndrome during living related liver transplantation

A prospective randomized study to evaluate the effect of intra-operative use of Albumin [20%] infusion prior to graft reperfusion on the severity of reperfusion syndrome during living donor liver transplantation Twenty patients were included with Child-Pughs C classification [ESLD]. Samples and measurements were taken pnor to reperfusion, during and after reperfusion of the donor liver graft. I. V fluids, blood and blood products were used to adjust a Hb level at [8-10 gm/dl] and Hct between 24-28% for better graft function and survival The reperfusion syndrome was severe as regard the decrease in MABP in No Albumin group [MABP = 48.2 +/- 7.23 mmHg] compared to Albumin group [MABP = 63.45 +/- 6.96 mmHg]. [P=00002] CVP was highly significant increased in Albumin group during reperfusion compared to No Albumin group [p = 0.0002]. Also. CVP correlated positively with S albumin level [r = 0.81. p = 0.002] dunng reperfusion syndrome. Patients of No Albumin group needed more motropic support than patients of Albumin group. In conclusion Albumin 20% in a dose of 1.5 ml/kg causes volume retention and expansion of intravascuiar volume which was a beneficial effect in liver transplant surgery to elevate the CVP prior to graft reperfusion and hence decreasing the severity of reperfusion syndrome and also elevating the already low serum albumin level and oncotic pressure

Low central venous pressure anesthesia in major hepatic resection

Blood loss and transfusion requirements are major determinants of morbidity and mortality following liver resection. This study evaluates the association of low central venous pressure [LCVP] with blood loss and blood transfusion during liver resection. Thirty consecutive hepatic resections were studied prospectively concerning CVP, volume of blood loss and volume of blood transfusion and renal outcome. Data were analyzed for those with a CVP 5 mmHg. A multivariate analysis assessed potential confounding factors in the comparison. The mean blood loss in patients with a CVP of 5 mmHg or less was <500 ml and that in those with a CVP >5 mmHg was >2000 ml. [p <0.001]. Only two patients with a CVP of 5 mmHg required transfusion. No incidences of air embolism or permanent renal shutdown have been reported. It is concluded that the volume of blood loss and blood transfusion during liver resection correlates with the CVP during parenchymal transection. Lowering the CVP to less than 5 mmHg is a simple and effective technique to reduce blood loss during liver resection and delete the need for blood transfusion with its hazards

Acute phase proteins as predictors of post-operative infections in cirrhotic patients undergoing major abdominal surgery

Tissue injury and infection leads to local production of interleukin-6 and other cytokines that mediate most of the systemic aspects of inflammation. We conducted this study to 1-Evaluate the effect of hepatic cirrhosis on the time course of acute phase proteins [APPs] following major surgery; and 2- Assess this effect in confirming or refuting the suspicion of postoperative infection in these patients during their stay in the surgical intensive care unit [SICU]. We prospectively studied 40 patients scheduled for major abdominal surgery, of whom 21 were non-cirrhotic [control group] and 19 had either known history or clinical evidence of hepatic cirrhosis [study group]. Central venous samples were obtained from all patients for laboratory assessment at induction of anaesthesia, at the end of surgery and at 24 h, 48 h and 72 h postoperatively [PO]. On the fourth PO day, patients from both groups were categorized into infected and non-infected sub-groups [using criteria of Centers for Disease Control] and another blood samples were obtained Laboratory assay: the collected blood samples were analyzed for the serum levels of APPs namely: interleukin-6 [IL-6], C-reactive protein [C-RP], serum amyloid A [SAA] and serum albumin. Liver functions were also assessed by serum concentrations of alanine aminotransferase [ALT], lactic dehydrogenase [LDH], total bilirubin [TB] and prothromhin time [PT]. IL-6 reacted fast in non-cirrhotic patients and reached a peak concentration at 2 h PO [400 +/- 122 pg.ml[-1], P<0.001]. In cirrhotic patients, the reaction of IL-6 was delayed and peak concentrations were not achieved except at 48 h PO [220 +/- 72 pg.ml[-1], P<0.001]. Sera levels of IL-6 were significantly lower in cirrhotic as compared with non-cirrhotic patients at 2,24,48 and 72 hrs PO. C-RP and SAA increased slower and later than IL-6. In both groups, peak concentrations of C-RP and SAA were recorded at 48 and 72h PO, respectively. Serum concentrations of CRP and SAA were not significantly different between the 2 groups throughout the study period [P >0.05]. Serum albumin levels in cirrhotic patients were significantly lower than those in non-cirrhotic at all measured times [P<0.05]. On the fourth postoperative day, patients who developed infection showed significantly higher serum IL-6 levels as compared with non-infected patients in both cirrhotic and non-cirrhotic patients. Serum albumin levels in patients who developed PO infection were significantly lower compared with non-infected patients in both groups. PO infection rate correlated positively with serum IL-6 concentrations and negatively with serum albumin levels in both cirrhotic and control groups. The serum concentrations of C-RP and SAA were not significantly different between infected and non-infected patients of either group [P>0.05]. ALT, LDH, TB and PT were higher in cirrhotic as compared with non-cirrhotic patients at all times [P<0.01], but did not differ significantly between infected and non-infected patients of either group. Major surgery causes substantial increase of the plasma concentrations of APPs in both cirrhotic and non-cirrhotic patients. Among the studied parameters, IL-6 showed the most rapid change, and appears to be a good marker for the early detection of acute phase reaction. Both IL-6 increase and albumin decrease correlated well with postoperative infection rate, and may be used as early predictors of sepsis in these groups of patients

Neuromuscular and haemodynamic effects of mivacurium in patients with hepatic cirrhosis

Forty patients who underwent intermediate elective surgeries were included in the present study. Ten patients were free from hepatic disease [group A], and thirty patients had evident hepatic cirrhosis, [group B]. Using Child-Pugh score, group B patients were further subdivided into three equal subgroups, group B1 was Child A, group B2 patients were Child B and group B3 patients were Child C. Induction of anesthesia was carried out by propofol, fentanyl NO2-O2 and isoflurane. After stabilization of control response using a force displacement transducer and neuromuscular function analyzer, all patients received a bolus of mivacurium 0.15 mg/ kg over 15 seconds [2x ED95] and spontaneous recovery was recorded. Mivacurium infusion was started at T1 of 10% [first response of TOF] and the block was maintained at T1 depression of 95%. Haemodynamic changes were recorded before start of anesthesia and throughout surgery. After bolus injection of mivacuirium, both lag time and onset time didn't show any significant change among groups. Recovery indices were comparable between group A and sub group BO1 [Child A], whereas, there were significant increase of T1 to 10%, 25%, 75% and 90% of control in patients with moderate to severe liver cirrhosis [group B2 and B3] in comparison to group A. TOF ratio of 0. 7 showed the same pattern of change, it was significantly higher in subgroups B2 and B3 in comparison to control group A. Similarly, recovery index was significantly higher in subgroups B2 and B3. The mean infusion requirements of mivacurium were generally less in group B in comparison to group A. Steady state infusion rates were achieved over 10 mm in all groups. Differences in mean mivacurium requirements from 10 min and forward were significantly less in subgroups B2 and B3 in comparison to control A. At end of surgery, residual neuromuscular blockade was antagonized and a TOF ratio of 0.7 was reached in about 7 minutes. None of patients experienced any signs of recurarization in the recovery room. In conclusion, mivacurium has a stable neuromuscular and haemodynamic profile in patients free from hepatic disease and patients of child score A. However, in child score B and C patients the drug profile is unstable and even unpredictable. Therefore, the use of mivacurium is only recommended, if ever, for short procedures in cases of mild liver cirrhosis