Robotic laparoscopic radical cystectomy inhalational versus total intravenous anesthesia: a pilot study

Robotic assistance may refine laparoscopic radical cystectomy. Steep Trendelenburg tilt [TT] and pneumoperitoneum [PP] are challenging anesthesia maneuvers. In view of those maneuvers, would inhalational anesthesia or total intravenous anesthesia [TIVA] be the more appropriate anesthetic management for this kind of surgery?. This issue is under consideration in this clinical trial. 15 patients scheduled for robotic laparoscopic radical cystectomy [RLRC] were randomly allocated into two groups to be anesthetized by either isoflurane anesthesia [ISO n = 8] or ketamine-midazolam-fentanyl total intravenous anesthesia [TIVA n = 7]. The hemo-respiratory dynamics, oxygenation and biochemical variables were monitored taking into consideration the system organ function as primary outcomes, and operative conditions and recovery profile as secondary outcomes. PP and TT increased the mean arterial and airway pressures and decreased lung compliance, and were associated with respiratory acidemia, while changes in heart rate remained within normal range. The duration of PP was shorter in TIVA patients but mean arterial pressure was higher than ISO group. ISO was associated with increased plasma concentrations of prothrombin, fibrinogen and aspartate aminotransferase. Though the number of patients is small in this study [n = 15], it nevertheless brings to light the advantages of TIVA during the robotic laparoscopic radical cystectomy [RLRC], by shortening the duration of PP without an increase in prothrombin and fibrinogen concentrations. A larger number of clinical trial are needed to further clarify this issue

Hypobaric bupivacaine spinal anesthesia for cystoscopic intervention: the impact of adding fentanyl

Addition of fentanyl to hyperbaric bupivacaine spinal anesthesia prolonged the duration of sensory block. This study seeks to test the hypothesis that adding fentanyl to small dose hypobaric spinal anesthesia will improve intraoperative patients and surgeon satisfaction without delay in recovery. Patients [n = 80] subjected to minor cystoscopic surgery were randomly assigned to have spinal anesthesia with either 5mg bupivacaine 0.1% or 5mg bupivacaine 0.1% mixed with 20microg fentanyl. The main outcome measures included intraoperative patient and endoscopist satisfaction, sedative/analgesic supplementation, postoperative side effects and time to ambulation. Patients in the bupivacaine group needed more analgesic supplementation. Analgesia was more adequate in the bupivacaine-fentaynl group. Pruritus was the main side effect in the bupivacaine fentanyl group. Ambulation and discharge of patients were nearly the same in both groups. Conclusions: Spinal anesthesia with small dose [5mg] hypobaric [0.1%] bupivacaine mixed with fentanyl [20micro g] produced adequate anesthesia for short cystoscopic procedures with minimal side effects and without delay in ambulation

Can we increase hepatic oxygen availability? the role of intentional hypercarbia

Our hypothesis is that hypercarbia produces sympathetic stimulant effect and local vasodilatation. We studied the effect of intentional hypercarbia [IHC] on hepatic venous oxygen saturation. The hepatic vein [HV] was cannulated in 15 patients through either the right internal jugular vein or the femoral vein to measure HV oxygen saturation and calculate oxygen content. The inferior vena cava [IVC] was cannulated in 6 patients above and below drainage of the hepatic veins for oxygen saturation and content difference along the IVC. IHC was achieved in awake patients by breathing oxygen enriched air at a flow rate of 2L/ min for 10 min, and during anesthesia by increasing anesthetic dead space and reducing tidal volume. IHC increased HV blood oxygen saturation, decreased the arterio-hepatic vein oxygen content difference and decreased oxygen saturation difference and oxygen content difference along IVC

Good correlation between mixed and central venous oxygen variables in both hyperdynamic and normodynamic states

This study was undertaken to assess whether or not central venous oxygen variables [CvO2] measurement can replace mixed venous oxygen variables [MvO2] measurement in two clinical settings, hyperdynamic kidney recipient [KR] and normodynamic patients subjected to radical cystectomy [RC]. MV and CV oxygen tension [PvO2], saturation [SvO2] and arteriovenous O2 content difference [a-vDO2] during the perioperative period of kidney transplantation [10 patients, 69 samples] and radical cystectomy [10 patients, 83 samples] under different FiO2 [0.21-0.35] were compared. The findings of this study demonstrate strong correlation between MvO2 and CvO2 variables in both hyperdynamic and normodynamic clinical settings

Perianaesthetic blood glucose measurement; evaluation of a rapid method

This study has been planned to evaluate the accuracy of glucometer [Accutrend]. Fourty blood glucose measurements were randomly included in this study. Patients were anaesthetized by different techniques. Blood glucose concentration was measured by both glucometer and the st and ard laboratory glucose-oxidase method [Beckman Autoanalyser]. From the results of this study, blood glucose values measured by glucometer [Accutrend] are always lower than those measured by the st and ard lab glucose oxidase method and the calculated bias value was 17.6 +/- 51.8 and the limits of agreement were wide ranging from 121.2 to -86mg dL-1 which are unaccepted for clinical purposes

Morphine-midazolam combination dose for presurgical analgesia in children

We have examined the use of presurgical morphine-midazolam combination in 80 children aged 2-10 y undergoing repair of hypospadias. They were allocated randomly, in a double-blind study, to receive one of four morphine-midazolam combination doses [n = 20 each]; [group I: 76 mg/kg each] [group II: 75 mg/kg morphine, 50 mg/kg midazolam]; [group III: 50 mg/kg morphine, 75 mg/kg midazolam]; [group IV: 50 mg/kg each]. Drugs were given after induction of anesthesia and before the start of surgery. Observational scoring system, using crying, movement, agitation, posture and localization of pain as scoring criteria, was used to assess the children during their stay in the recovery room together with their sedative and/or analgesic requirement. Pre-surgical morphine-midazolam administration produced stable hemodynamic variables with satisfactory postoperative analgesia suggesting 75 mg/kg dose of both morphine and midazolam as upper permissible dose, and 50 mg/kg each as lower effective dose

Hemodynamic and oxygenation variables during radical cystectomy

The effect of anesthetics on hemodynamic variables [HV] has been clarified, but ambiguity existed concerning their effect on oxygenation variables [OV]. Radical cystectomy provided a clinical setting for studying the effect of anesthetics on perioperative HV and OV. Patients subjectd to radical cystectomy [n = 33] were assigned through balanced randomization to receive one of four anesthetic modalities, namely, group I: inhalation anesthesia using N[2] O:O[2],halothane, d-tubocurarine [n 11]; group II: inhalation anesthesia sing N[2] O:O[2], halothane, d-tubocurarine, and supplemented with epidural analgesia [EA] [n = 11]; group III: total intravenous anesthesia [TIVA] using ketamine 10-30 micro g. kg[-1]. min [-1], propofol 2 mg. kg[-1]. h [-1], d-tubocurarine, and supplemented with continuous EA [n = 6]: and group IV:TIVA using ketamine 20-50 micro g. kg[-1]. min [-1], midazolam in increments of 1.5 to 5 mg, and supplemented with intermittent EA [n = 5]. Monitoring entailed continuous ECG, pulse oximetry, invasive arterial pressure, and pulmonary artery catheter for HV [HR, MAP, PAP, PAOP, CO, SVR, and PVR] and OV [PaO[2], SaO[2], PvO[2], SvO[2], a-vDO[2], O[2]ext, Q[s]/Q[t], DO[2], and VO[2]]. The heart rate was lower in TIVA while other HV did not show striking differences. Group I showed higher arterial oxygen tension than group II and IV. Mixed venous oxygen tension and saturation were higher in group I over group IV. Other OV did not show remarkable differences. In conclusion, HV and OV in 4 anesthetic modalities did not elicit striking differences

Peep modulation of haemodynamic parameters and blood gasometry

This study was conducted to evaluate the hemodynamic and blood gas variations in response to PEEP at different levels during mechanical ventilation in 30 adult patients having normal cardio-respiratory functions. Thiopentone, suxamethonium, halothane, nitrous oxide in oxygen and atracurium were used for induction and maintenance of anesthesia. Ventilation was controlled with ZEEP for 30 minutes followed by PEEP for another 30 minutes. Level of PEEP varied according to the group [5, 10 or 15 cm H20]. Hemodynamic changes in the form of decreased systolic and mean blood pressure and increased CVP were prominent with higher levels of PEEP. These levels were accompanied with decreased PaO2, increased PaCO2 and decreased pH. PEEP of 10 cm H20 was found to be a suitable level with minimal hemodynamic, ventilatory and metabolic changes, above which undesirable effects mostly develop. So, PEEP of 10 cm H20 is recommended in patients submitted to prolonged surgical procedures

Ketamine anesthesia for short transurethral urologic procedures

Ketamine [K] is a good analgesic and anesthetic agent in short procedures, but the associated cardiovascular responses and emergence reactions limit its use. Benzoodiazepines have been used to improve recovery with favorable reports for midazolam [M]. Methylphenidate [MPH], the mild CNS stimulant, improves behaviour and mental concentration and can be used to improve recovery from K anaesthesia. This was tested, alone and in combination with M by a double-blind study in 30 patients subjected to short transurethral urologic procedures. Patients were randomized into 3 equal groups to receive K-MPH, K-M or K-M-MPH. M [7.5 mg] was mixed with K and MPH [20 mg] was given at the end of urologic procedures. Perioperative monitoring included pulse rate, blood pressure, ECG, and plasma catecholamines. Recovery was assessed by a triad VAS and recovery area was calculated. Distribution-free statistics were used to assess inter group differences of similar variables. Ketamine produced satisfactory anesthesia for short transurethral urologic procedures. Addition of M did not change the cardiovascular responses of K but resulted in smooth recovery with no change in the recovery scores. MPH did not improve the recovery scores but increased the incidence of vomiting, excessive talking, and limb movements

Pre-surgical analgesia in children subjected to hypospadias repair

The validity of pre-surgical analgesic strategies in hypospadias repair was tested in 30 children, their ages ranged 2 - 10 years. They were randomized in a double-blind placebo controlled protocol, to receive one of three analgesic modalities [n = 10 each]: Lumber extradural analgesia using 1 mg.kg-1 bupivacaine 0.5% mixed with 50 ug.kg-1 morphine, intramuscular 100 ug.kg-1 morphine, or subpubic block 0.5 mg.kg-1 bupivacaine 0.5% for each side. These analgesics were given after induction of anesthesia and before the start of surgery. Surgical outcome measures included measurements of heart rate, arterial blood pressure, plasma adrenaline and noradrenaline, and anesthetic supplementation. Postoperative outcome measures included observational scoring and requirements. Plasma morphine concentrations were determined through 4 hours after administration. Children given extradural analgesia displayed lower and more stable hemodynamic and neurohumoral variables, and needed less anesthetic supplementation, with low scoring and no analgesic requirements in the postoperative period. Children given i.m. morphine or subpubic block demonstrated modest outcome measures. Nausea and/or vomiting were not reported in children given subpubic block