Hemodiafiltration: a synergy yet to be convincing / Hemodiafiltração: uma sinergia ainda não convincente

ABSTRACT The desperate attempt to improve mortality, morbidity, quality of life and patient-reported outcomes in patients on hemodialysis has led to multiple attempts to improve the different modes, frequencies, and durations of dialysis sessions in the last few decades. Nothing has been more appealing than the combination of diffusion and convection in the form of hemodiafiltration. Despite the concrete evidence of better clearance of middle weight molecules and better hemodynamic stability, tangible evidence to support the universal adoption is still at a distance. Survival benefits seen in selected groups who are likely to tolerate hemodiafiltration with better vascular access and with lower comorbid burden, need to be extended to real life dialysis patients who are older than the population studied and have significantly higher comorbid burden. Technical demands of initiation hemodiafiltration, the associated costs, and the incremental benefits targeted, along with patient-reported outcomes, need to be explored further before recommending hemodiafiltration as the mode of choice.

RESUMO A tentativa desesperada de melhorar a mortalidade, morbidade, qualidade de vida e desfechos relatados pelos pacientes em indivíduos em hemodiálise levou a diversas tentativas de aprimorar os diferentes modos, frequências e durações das sessões de diálise nas últimas décadas. Nada foi mais atrativo do que a combinação de difusão e convecção na forma de hemodiafiltração. Apesar das evidências concretas de melhor depuração de moléculas de peso médio e melhor estabilidade hemodinâmica, evidências tangíveis para apoiar a adoção universal ainda estão distantes. Os benefícios de sobrevida observados em grupos selecionados que provavelmente toleram a hemodiafiltração com melhor acesso vascular e com menor carga de comorbidades precisam ser estendidos aos pacientes reais em diálise, que são mais velhos do que a população estudada e apresentam uma carga de comorbidades significativamente maior. As exigências técnicas do início da hemodiafiltração, os custos associados e os benefícios incrementais almejados, juntamente com os desfechos relatados pelos pacientes, precisam ser melhor explorados antes de se recomendar a hemodiafiltração como o modo de escolha.

Fluid preloading before beach chair positioning for arthroscopic shoulder procedures: a randomized controlled trial

Abstract Background and objectives The Beach Chair Position (BCP) has many advantages such as less neurovascular injury and better intra-articular visualization, but it has also negative consequences, including hemodynamic instability. Although maintaining normal Mean Arterial Pressure (MAP) is important, fluid management is also a crucial concept for hemodynamic stability. The main objective of this study is whether preloading before positioning would be effective for less hemodynamic instability. Methods This randomized, controlled study was conducted in a single center in the Istanbul University, Istanbul Faculty of Medicine. Forty-nine patients undergoing elective arthroscopic surgery in the BCP were recruited. In the study group, crystalloid fluid at 10 mL.kg-1 of ideal body weight was administered intravenously 30 min before the BCP for preloading. The primary outcome measures were differences of hemodynamic variables as MAP, Stroke Volume (SV), Heart Rate (HR), and Cardiac Output (CO). The secondary outcome measures were Postoperative Nausea and Vomiting (PONV) rates in postoperative first day, surgical satisfaction scale, total ephedrine dose used during surgery, and total amount of fluid. Results The MAP, CO, and SV measurements of the study group were higher than those of the control group in the 5th minute after the BCP (respectively, p= 0.001, p= 0.016, p= 0.01). The total amount of crystalloid and surgical satisfaction scales were higher in the study group (respectively, p= 0.016, p= 0.001). Total amount of colloid and ephedrine dose used in the intraoperative period, and PONV rates were lower in the study group (p= 0.003, p= 0.018, p= 0.019, respectively). Conclusion Consequently, preloading can be favorable approach to preserve hemodynamic stability.

Craneotomía en el paciente despierto / Awake craniotomy

Introducción: La craneotomía con el paciente despierto es útil para lograr resecciones cerebrales amplias de lesiones de áreas elocuentes. Objetivo: Presentar un caso al que se le realizó la técnica dormido- despierto. Método: Se realizó la inducción de la anestesia con propofol/fentanilo/rocuronio y se colocó una mascarilla laríngea. Después del bloqueo de escalpe se mantuvo la infusión de propofol/fentanilo y lidocaína hasta que se realizó la craneotomía. Se disminuyó la velocidad de infusión y se mantuvo de esta manera hasta finalizada la intervención. Resultados: Se logró el despertar del paciente a los 13 minutos de reducida la infusión. Se mantuvo buena estabilidad hemodinámica, sin depresión respiratoria ni otras complicaciones. El paciente se mantuvo colaborador, respondió preguntas y movilizó sus extremidades. No presentó complicaciones posoperatorias. Discusión: Dentro de las técnicas anestésicas utilizadas en el mundo la dormido- despierto-dormido es la más popular; sin embargo, constituye una alternativa no dormir nuevamente al paciente ni reinstrumentar la vía respiratoria. Los medicamentos más empleados son el propofol/remifentanilo, aunque la comparación con otros opioides no arrojan diferencias significativas; aunque sí supone un beneficio adicional la dexmedetomidina. Conclusiones: La craneotomía con el paciente despierto es posible de realizar en el entorno hospitalario siempre que exista un equipo multidisciplinario que consensue las mejores acciones médicas para el paciente(AU)

Introduction: Awake craniotomy is useful to achieve wide brain resections of lesions in eloquent areas. Objective: To present the case of a patient who was operated on with the asleep-awake-asleep technique. Method: Anesthesia was induced with propofol-fentanyl-rocuronium and a laryngeal mask was placed. After scalp block, the propofol-fentanyl and lidocaine infusion was maintained until craniotomy was performed. The infusion rate was decreased and remained this way until the end of the intervention. Results: The patient was awakened thirteen minutes after the infusion was reduced. Good hemodynamic stability was maintained, without respiratory depression or other complications. The patient remained collaborative, answered questions, and mobilized his limbs. He had no postoperative complications. Discussion: Among the anesthetic techniques used in the world, asleep-awake-asleep is the most popular. However, it is an alternative not to put the patient back to sleep or re-instrument the airway. The most commonly used drugs are propofol-remifentanil, although the comparison with other opioids does not show significant differences, except for dexmedetomidine, which does represent an additional benefit. Conclusions: Awake craniotomy is possible to be performed in the hospital setting as long as there is a multidisciplinary team that agrees on the best medical actions for the patient(AU)

A prospective and retrospective study on conservative management of hepatic and splenic injury following blunt abdominal trauma

Background: worldwide road traffic accidents accounts as the leading cause of death of young people. For a very long time most of the intra-abdominal injuries following blunt abdominal trauma were managed operatively. Conservative management is becoming more acceptable and effective management option for blunt abdominal trauma during the last few decades.Methods: This study was conducted in Government Medical College, Kottayam during September 2007 to December 2008. All conservatively managed blunt abdominal trauma patients during the study period were included in the study.Results: Out of 22 patients, 4 patients failed conservative management. Success rate was 81%. Most commonly injured solid organ in the study group was liver (77%). Maximum cases were of age group 10 to 20 (31.81%) years. 81% of patients were males. Motor vehicle accident was the most common cause of trauma (77%). Mean stay in intensive care unit was 4.2 days and mean hospital stay was 15.7 days. Mean systolic blood pressure was 110 mmHg ranging from 70 to 130 mmHg. 50% of patients had moderate hemoperitoneum and non-had massive hemoperitoneum.Conclusions: Non operative management is safe and effective approach in blunt spleen and liver injuries. Non operative management should be treatment of choice for all hemodynamically stable patients with blunt liver and splenic trauma.

Umbilical Cord Milking Reduces Duration of Inotrope Support in Preterm Infants Less than 32 Weeks of Gestation, Born with Cesarean Section in Comparison to Delayed Cord Clamping

Objective: Very preterm infants commonly need inotrope support. We aimed to demonstrate that umbilical cord milking (UCM)would reduce the need for inotropes in preterm infants born with cesarean section in comparison to delayed cord clamping (DCC).Study Design: We compared the need of inotrope support, in a pilot randomized controlled trial, among preterm infants<32 weeks’ gestation receiving UCM (n = 25) in comparison to those who underwent DCC (n = 24).Results: Baseline maternal and newborn characteristics were similar. There was a significant reduction in the total duration ofinotrope support (P = 0.004) and total duration of respiratory support (P = 0.021) in babies undergoing UCM when comparedto those undergoing DCC. Trend toward reduction in incidence of hemodynamically significant patent ductus arteriosus andintraventricular hemorrhage was noted in UCM group.Conclusion: UCM significantly improved respiratory and hemodynamic stability in preterm infants <32 weeks’ gestation withoutassociated complications.

A Comparative Study of Haemodynamic Changes on LMA Insertion with Propofol, Etomidate and Propofol+Etomidate Admixture in Laparoscopic Cholecystectomy

The objective of current study was to compare the efficacy of three different anaesthesia induction approachesi.e. Inj propofol, Inj etomidate and admixture of Inj propofol and Inj etomidate in maintaining hemodynamicstability during induction and following Proseal LMA insertion in laparoscopic cholecystectomy. Patientswere randomly divided in to 3 groups with 90 patients each and received 2.5mg/kg of propofol(P), 0.3mg/kgof etomidate(E) and 1mg/kg of propofol+0.2mg/kg of etomidate which was mixed in a 20ml syringe. We alsostudied side-effects like PONV, myoclonus, pain on Injection, allergic reactions and thrombophlebitis. Wefound that the use of P-E admixture for induction of Proseal LMA provides hemodynamic stability as itprevents hypotension caused by propofol and also hypertension caused by etomidate when used alone. Admixturewas also associated with less incidence of other side effects like PONV, pain on Injection and myoclonus. Weconcluded that combination of propofol and etomidate for induction of anaesthesia for Proseal LMA issignificantly better than either drug used alone

Efficacy of Injection Ketamine and Injection Dexmedetomidine for Relief of Shoulder Pain in Laparoscopic Appendectomy Under Spinal Anaesthesia

Background: Laparoscopic appendectomy is preferred because of increasing popularity and certain benefits over open method. Laparoscopic surgeries are conventionally done under general anaesthesia with positive pressure ventilation to avoid shoulder pain, respiratory embarrassment and abdominal discomfort caused by pneumoperitoneum. The data regarding use of spinal anaesthesia for laparoscopic appendectomy is limited. This study was designed to evaluate laparoscopic appendectomy under spinal anaesthesia along with the use of intravenous injection ketamine and intravenous injection dexmedetomidine. Objectives of this study were to observe efficacy of both drugs in reducing shoulder pain, need of rescue analgesia, need of conversion to open method due patient discomfort, changes in hemodynamic parameters, postoperative nausea and vomiting. Methods: After approval of ethical committee of institute , 100 patients of age group between 18-60 years with ASA grade I or II undergoing laparoscopic appendectomy with written informed consent were included in this study .All patients were informed about standard spinal anaesthesia technique in detail and also about the risk of conversion to general anaesthesia.Spinal anaesthesia procedure was carried out with hyperbaric injection bupivacaine 0.5% . Patients were randomized in two groups. One is Group K (n=50) patients who received injection Ketamine and other is Group D (n=50) patients who received injection Dexmedetomidine intravenously.Intraoperative hemodynamic parameters,shoulder pain,abdominal discomfort,need of rescue analgesia ,postoperative recovery were monitored and recorded. Results: No patients during study required conversion to general anaesthesia or open method. VDS(verbal descriptive scale) score for referred shoulder pain was statistically lower in group K compared to group D.Group D was associated with statistically significant lower heart rate and blood pressure than Group K. Conclusion:Injection ketamine and injection dexmedetomidine, both drugs are efficacious for reduction of referred shoulder pain with more hemodynamic stability in ketamine group during laparoscopic appendectomy.

A Comparative Study Of Propofol-Ketamine And Propofol-Fentanyl For Total Intravenous Anaesthesia For Short Surgical Cases In Paediatric Patients

Aims and objective :To compare combinations of Propofol-Ketamine and Propofol-Fentanyl for total intravenous anesthesia in short surgical cases in pediatric patients. The study also compared recovery characteristics and the incidence of side effects / complications in the groups. Methodology: The patients were randomly divided into two groups depending upon the drug combination used for Total Intravenous Anaesthesia. Group I : 30 patients were given i.v. Ketamine followed by Propofol. Group II: 30 patients were given i.v. Fentanyl followed by Propofol Recovery characteristics were compared and the incidence of side effects and complications in two groups were noted. Results: The pulse rate and blood pressure remained near to preinduction value in group I, while in group II these values decreased. After induction RR increased in group I but decreased in group II at 1,3%5 min after induction.None of the patients in both groups were observed to have nausea, vomiting and respiratory depression. . A significant no. of the patients in group II were observed to have either pain on injection site or restlessness. Conclusion: Propofol-Ketamine and Propofol-Fentanyl combinations provide satisfactory surgical conditions for minor surgical procedures in paediatric patients, but the Propofol-Ketamine combination gives better hemodynamic stability and less restlessness during induction and maintenance of anaesthesia.

Early fluid loading for septic patients: Any safety limit needed? / 中华创伤杂志(英文版)

Early adequate fluid loading was the corner stone of hemodynamic optimization for sepsis and septic shock. Meanwhile, recent recommended protocol for fluid resuscitation was increasingly debated on hemodynamic stability vs risk of overloading. In recent publications, it was found that a priority was often given to hemodynamic stability rather than organ function alternation in the early fluid resuscitation of sepsis. However, no safety limits were used at all in most of these reports. In this article, the rationality and safety of early aggressive fluid loading for septic patients were discussed. It was concluded that early aggressive fluid loading improved hemodynamics transitorily, but was probably traded off with a follow-up organ function impairment, such as worsening oxygenation by reduction of lung aeration, in a part of septic patients at least. Thus, a safeguard is needed against unnecessary excessive fluids in early aggressive fluid loading for septic patients.

¿Es la Hemodialfiltración On-line de alto volumen el mejor tratamiento en pacientes con enfermedad renal crónica estadio V? / Is High-Volume On-line Hemodiafiltration the best treatment for patients with Chronic Kidney Disease Stage V?

INTRODUCCIÓN: La hemodiafiltración en línea de alto volumen (HVHDF) es una técnica eficaz que permite la remoción de toxinas urémicas de mayor PM debido al transporte convectivo. Esta modalidad permite mayor estabilidad hemodinámica, disminución de los parámetros inflamatorios y reducción de la mortalidad cardiovascular y por todas las causas comparada con la hemodiálisis (HD). Estos beneficios se producen cuando los volúmenes de sustitución (VS) son mayores a 21 L/sesión de allí la denominación de hemodiafiltración de alto volumen. OBJETIVOS: Evaluar la eficacia de la HVHDF en comparación con HD y determinar si el cambio de modalidad se asocia a mayor estabilidad hemodinámica, mejoría en los resultados de laboratorio, en la cantidad de hospitalizaciones y en la calidad de vida. MATERIAL Y MÉTODOS: Estudio retrospectivo, observacional, en único centro que incluyó 53 pacientes, que completaron 6 meses de HVHDF luego de haber realizado al menos 6 meses de HD. Se analizaron datos demográficos, episodios de hipotensión, número y días de internación tanto en HD como en HVHDF. Se compararon: Hemoglobina (Hb), fósforo (P), parathormona intacta (PTHi), albúmina (alb), proteína C reactiva (PCR), KTV, y dosis de eritropoyetina durante el último mes de HD y sexto mes de HVHDF. Se analizó la encuesta sobre calidad de vida Kidney Disease Quality of Life-36 (KDQOL-36) al inicio y a los 6 meses de HVHDF. RESULTADOS: LA edad media fue de 60,6 años, el 67.9 % eran hombres. La FAV fue el acceso vascular en el 69.8% de los pacientes, mientras que 38 pacientes (71,1%) cumplían con volumen de sustitución > 21 litros/sesión. El 39,6 % presentó algún episodio de hipotensión en HD y 30.2 % lo hizo en HVHDF (p<0.001). El número de episodios de hipotensión fue significativamente mayor en hemodiálisis que en HVHDFL, 40 (18-68) vs 11 (3-33) (p< 0.001). El 32% de pacientes en HD requirió internación y sólo el 11% en HVHDF. Hubo mejoría significativa en la Hb: 10.7 a 11.3 (p<0.01), KTV: 1.4 a 1.5 (p<0.03) y menor requerimiento de EPO (p< 0,02) al 6° mes de HVHDF. En la encuesta de calidad de vida, KDQOL-36, se observó mejoría en el módulo, síntomas problemas, siendo estadísticamente significativo, adicionándose mejoría en short form 12 (SF) físico y mental sólo en los pacientes con volúmenes de sustitución > 21l/sesión. CONCLUSIÓN: En nuestra cohorte el cambio de HD a HVHDF se asoció a una disminución en el número de episodios de hipotensión, reflejando una mayor estabilidad hemodinámica, menor número de internaciones, una mejoría en la hemoglobina, KTV y disminución de dosis semanal de eritropoyetina

INTRODUCTION: High-volume online hemodiafiltration (HV-OL-HDF) is an effective technique to remove uremic toxins with higher molecular weight through convective transport. In correlation with hemodialysis (HD), through this method, greater hemodynamic stability, lower inflammatory parameters and a smaller risk of death due to cardiovascular or any other factors are achieved. These benefits are obtained when substitution volume (SV) is higher than 21L/session; that is the reason why the technique is called high-volume hemodiafiltration (HVHDF). OBJECTIVES: To assess the effectiveness of HVHDF as compared to HD and to determine if changing the type of therapy results in greater hemodynamic stability, better lab test results, a lower number of hospital admissions and a superior quality of life. METHODS: This retrospective observational study was conducted in only one center and included 53 patients who underwent HVHDF during 6 months after having hemodialysis (HD) for at least 6 months. We analyzed demographic variables, number of hypotension events, number of hospital admissions, and length of stay for each type of treatment. The following were compared: hemoglobin (Hb), phosphate (P), intact parathormone (iPTH), albumin (ALB), C-reactive protein (CRP), Kt/V and erythropoietin dose during the last month of HD and the sixth month of HVHDF. The Kidney Disease Quality of Life-36 (KDQOL-36™) questionnaire was completed at the beginning and after 6 months of HVHDF. RESULTS: The average age was 60.6 years old and 67.9% of the participants were men. The vascular access was created using an arteriovenous fistula in 69.8% of patients and 38 of them (71.1%) had substitution volume of > 21L/session. Some patients (39.6 %) experienced a hypotension event during HD and others (30.2%) during HVHDF (p<0.001). The number of hypotension events was significantly higher in patients treated with HD than in patients treated with HV-OL-HDF: 40 (18-68) vs. 11 (3-33) (p< 0.001). The percentage of patients admitted to hospital was the following: 32% for HD and 11% for HVHDF. A considerable improvement was observed in Hb (10.7 to 11.3 [p<0.01]) and Kt/V (1.4 to 1.5 [p<0.03]; a lower dose of EPO was needed after 6 months of HVHDF (p< 0.02). Only patients with substitution volume of > 21L/session showed statistically significant improvement in the symptoms/problems section of KDQOL-36 and in the Short Form-12 (SF-12) Physical and Mental Health Summary. CONCLUSION: When changing from HD to HVHDF, our study group had a lower number of hypotension events; greater hemodynamic stability; a smaller number of hospital admissions; better Hb levels and Kt/V, and they needed a lower dose of erythropoietin

Study of dexmedetomidine as an intrathecal adjuvant to ropivacaine for hemodynamic stability and for postoperative analgesia

Background: Various adjuvants that can be added to local anesthetics and administered in central neuraxial blockade are Opioids, α2 agonists, benzodiazepines. Knowledge and use of adjuvant drug therapy has rendered neuraxial analgesia more effective in the management of both acute and chronic pain conditions. α-2 adrenergic agonists have both analgesic and sedative properties when used as adjuvant in regional anaesthesia. Aim: To study the effects of intrathecal dexmedetomidine added to ropivacaine for surgeries under spinal anesthesia. Materials and methods: Clinical study conducted on 50 patients of ASA PS 1 and 2 in the age group of 18-50 years of either sex posted for elective lower limb orthopaedic and lower abdominal surgeries under spinal anaesthesia. Results: Subjects among the age groups and the mean age of study population was 40 years (SD: ±11.5). 66% (n=33) of study population were male and 34% (n=17) were female. Most of the study population had healthy BMI. 76% (n= 38) of subjects belonged to ASA grade 1 and 34% (n=12) subjects belonged to ASA grade 2. The average duration of surgery was 94.4 min ± 34.4 min. Level of sensory block was T6 in 24 (48%) of subjects, T4 in 17 (34%) of subjects, T8 in 6 (12%) and T2 in 3 (6%) of subjects. The mean duration for onset of Sensory block was 4.12 minutes (SD: ± 1.69) and the mean duration for onset of motor block was 10.12 minutes (SD: ± 2.89). Hypotension was Swetha Ambati, Mukesh Kumar B. Study of dexmedetomidine as an intrathecal adjuvant to ropivacaine for hemodynamic stability and for postoperative analgesia. IAIM, 2017; 4(11): 27-36. Page 28 observed in 3 patients after SAB (Fall in SBP > 20%) after 4 to 6 min. The mean RSS was 2.08 with SD 0.27. Side effects observed were mainly hypotension, nausea and shivering. Conclusions: 5 microgram dexmedetomidine is alternative as an adjuvant to spinal ropivacaine in surgical procedures. It has excellent quality of postoperative analgesia with minimal side effects.

Comparative Analysis of Unilateral Subarachnoid block with Ankle block for elective foot surgery.

Background: There are many accepted anesthesia techniques for elective foot surgery ranging from general anesthesia to regional anesthesia, regional anesthesia being the preferred method. Regional anesthesia techniques employed for foot surgery includes subarachnoid block, epidural anesthesia and ankle block. Objective: The present study is aimed at providing comparative analysis of ankle block with unilateral subarachnoid block for elective foot surgeries in terms of hemodynamic safety profile and post operative analgesia. Material and Methods: Study includes prospective analysis of 80 ASA II and III patients who underwent elective foot surgery. Patients were randomly divided into two groups of 40 each, Ankle block group (AB) and Unilateral subarachnoid group (US). The parameters recorded for study includes systolic blood pressure, diastolic blood pressure, heart rate, visual analogue scale for pain severity, time of first analgesic need and the complications. Results: There were minimal blood pressure changes and heart rate variability in AB group as compared to US group when compared with basal values (p<0.05). The time for first analgesic requirement is prolonged in AB group as compared to US group. The visual analogue scale score was assessed at 2nd ,4th and 6th hours for group AB were lowered as compared to group US (p <0.05).

A comparative study between propofol and etomidate in patients under general anesthesia / Estudo comparativo entre propofol e etomidato em pacientes sob anestesia geral

ABSTRACT BACKGROUND AND OBJECTIVES: Induction of anesthesia is a critical part of anesthesia practice. Sudden hypotension, arrhythmias, and cardiovascular collapse are threatening complications following injection of induction agent in hemodynamically unstable patients. It is desirable to use a safe agent with fewer adverse effects for this purpose. Present prospective randomized study is designed to compare propofol and etomidate for their effect on hemodynamics and various adverse effects on patients in general anesthesia. METHODS: Hundred ASA I and II patients of age group 18-60 years scheduled for elective surgical procedure under general anesthesia were randomly divided into two groups of 50 each receiving propofol (2 mg/kg) and etomidate (0.3 mg/kg) as an induction agent. Vital parameters at induction, laryngoscopy and thereafter recorded for comparison. Adverse effect viz. pain on injection, apnea and myoclonus were carefully watched. RESULTS: Demographic variables were comparable in both the groups. Patients in etomidate group showed little change in mean arterial pressure (MAP) and heart rate (HR) compared to propofol (p > 0.05) from baseline value. Pain on injection was more in propofol group while myoclonus activity was higher in etomidate group. CONCLUSIONS: This study concludes that etomidate is a better agent for induction than propofol in view of hemodynamic stability and less pain on injection.

RESUMO JUSTIFICATIVA E OBJETIVOS: A indução é uma parte crítica da prática de anestesia. Hipotensão súbita, arritmias e colapso cardiovascular são complicações ameaçadoras após a injeção de agente de indução em pacientes hemodinamicamente instáveis. É aconselhável o uso de um agente seguro com menos efeitos adversos para esse propósito. O presente estudo prospectivo, randômico, teve como objetivo comparar propofol e etomidato quanto a seus efeitos sobre a hemodinâmica e aos vários efeitos adversos em pacientes sob anestesia geral. MÉTODOS: Cem pacientes ASA I e II, entre 18-60 anos, programados para procedimento cirúrgico eletivo sob anestesia geral, foram divididos aleatoriamente em dois grupos de 50 cada para receber propofol (2 mg/kg) e etomidato (0,3 mg/kg) como um agente de indução. Os parâmetros vitais na indução, laringoscopia e posteriormente foram registrados para comparação. Efeitos adversos como dor à injeção, apneia e mioclonia foram cuidadosamente monitorados. RESULTADOS: As variáveis demográficas foram comparáveis em ambos os grupos. Os pacientes do grupo etomidato apresentaram pouca alteração da pressão arterial média (PAM) e da frequência cardíaca (FC) em comparação com o grupo propofol (p < 0,05) a partir do valor basal. Houve mais dor à injeção no grupo propofol, enquanto houve mais atividade mioclônica no grupo etomidato. CONCLUSÕES: Este estudo conclui que etomidato é um agente melhor para a indução do que o propofol em relação à estabilidade hemodinâmica e menos dor à injeção.

Intrathecal Anaesthesia for Elderly Patients Undergoing Short Transurethral Procedures: A Dose-Finding Study.

Background: To reduce effects associated the adverse hemodynamic effects associated with the spinal anesthesia– induced medical sympathectomy, combinations of very small doses of local anesthetic and adjuvant opioids are frequently administered. However, for elderly patients undergoing transurethral procedures, the optimal bupivacaine-fentanyl dose is unknown. The aim of the study is to find the optimal dosage of intrathecal anesthesia for elderly patients undergoing short transurethral procedures with bupivacaine–fentanyl, with stable hemodynamics. Methods: The study included 75 patients, ASA I, II and III scheduled for transurethral procedures at Kamineni hospitals, L.B. Nagar, Hyderabad which is a 350 bedded super-speciality tertiary care center. These patients were randomly allocated into three groups, 25 patients in each group. Group A received 7.5 mg bupivacaine, Group B were given 5 mg bupivacaine along with fentanyl 20 μg while patients in Group C received bupivacaine 4 mg with fentanyl 20 μg. Intrathecal fentanyl as an analgesic adjuvant to bupivacaine anesthesia. Intraoperative pain was assessed using Visual Analog Scale (VAS). Demographics, time intervals, and continuous variables (MAP, heart rate, SpO2, VAS) were analyzed using the one-way analysis of variance (ANOVA) test. Results: Demographic characteristics as well as intraoperative MAP, heart rate and SpO2 were similar among groups. Intraoperative rescue fentanyl requirements were significantly higher in group C (bupivacaine 4 mg + fentanyl 20μg) when compared with those in the other two groups. In group A (bupivacaine 7.5 mg), there was significant difference in mephenteramine requirements. Conclusion: Of the doses investigated bupivacaine 5 mg with fentanyl 20μg, provided adequate analgesia and was associated with hemodynamic stability and the fewest side effects.

Comparison of an Intraoperative Infusion of Dexmedetomidine, Fentanyl, and Remifentanil on Perioperative Hemodynamics, Sedation Quality, and Postoperative Pain Control

We aimed to compare fentanyl, remifentanil and dexmedetomidine with respect to hemodynamic stability, postoperative pain control and achievement of sedation at the postanesthetic care unit (PACU). In this randomized double-blind study, 90 consecutive total laparoscopic hysterectomy patients scheduled for elective surgery were randomly assigned to receive fentanyl (1.0 µg/kg) over 1 minute followed by a 0.4 µg/kg/hr infusion (FK group, n = 30), or remifentanil (1.0 µg/kg) over 1 minute followed by a 0.08 µg/kg/min infusion (RK group, n = 30), or dexmedetomidine (1 µg/kg) over 10 minutes followed by a 0.5 µg/kg/hr infusion (DK group, n = 30) initiating at the end of main procedures of the operation to the time in the PACU. A single dose of intravenous ketorolac (30 mg) was given to all patients at the end of surgery. We respectively evaluated the pain VAS scores, the modified OAA/S scores, the BIS, the vital signs and the perioperative side effects to compare the efficacy of fentanyl, remifentanil and dexmedetomidine. Compared with other groups, the modified OAA/S scores were significantly lower in DK group at 0, 5 and 10 minutes after arrival at the PACU (P < 0.05), whereas the pain VAS and BIS were not significantly different from other groups. The blood pressure and heart rate in the DK group were significantly lower than those of other groups at the PACU (P < 0.05). DK group, at sedative doses, had the better postoperative hemodynamic stability than RK group or FK group and demonstrated a similar effect of pain control as RK group and FK group with patient awareness during sedation in the PACU. (World Health Organization registry, KCT0001524).

Comparison of an intraoperative infusion of dexmedetomidine or fentanyl for the perioperative hemodynamics, achieving hypnosis and sedation, and the postoperative pain control

BACKGROUND: The aim of this study was to compare dexmedetomidine (DEX), which is a selective, short-acting, central alpha2-adrenergic agonist, with fentanyl in terms of the hemodynamic stability, achieving hypnosis and sedation, and the postoperative pain control at the PACU (postanesthetic care unit). METHODS: In this double-blind study, 50 consecutive total laparoscopic hysterectomy patients scheduled for elective surgery were randomly assigned to receive either dexmedetomidine 1 microg/kg over 10 min followed by a 0.5 microg/kg/hr infusion (the DK group) or fentanyl 0.8-1.2 microg/kg over 1 min followed by a 0.2-0.6 microg/kg/hr infusion (the FK group) from the time of ending the operation after total hysterectomy to the time in the PACU. We evaluated the pain VAS scores, the modified OAA/S scores, the BIS, the vital signs, the respiratory variables (SpO2, RR and EtCO2) and the perioperative side effects to compare the efficacy of dexmedetomidine and fentanyl. RESULTS: Compared with the fentanyl-ketorolac (FK) group, the modified OAA/S scores were significantly lower in the dexmedetomine-ketorolac (DK) group at 0, 5 and 10 min after arrival at the PACU (P < 0.05), whereas the pain VAS and BIS were not significantly different between the two groups. The blood pressure and heart rate in the DK group was significantly lower than that of the FK group at the PACU (P < 0.05). CONCLUSIONS: The DK group, at the doses used in this study, has a significant advantage over the FK group in terms of the postoperative hemodynamic stability at the PACU. There was no significant difference between the two groups for the postoperative pain control.

Comparison of an intraoperative infusion of dexmedetomidine or fentanyl for the perioperative hemodynamics, achieving hypnosis and sedation, and the postoperative pain control

BACKGROUND: The aim of this study was to compare dexmedetomidine (DEX), which is a selective, short-acting, central alpha2-adrenergic agonist, with fentanyl in terms of the hemodynamic stability, achieving hypnosis and sedation, and the postoperative pain control at the PACU (postanesthetic care unit). METHODS: In this double-blind study, 50 consecutive total laparoscopic hysterectomy patients scheduled for elective surgery were randomly assigned to receive either dexmedetomidine 1 microg/kg over 10 min followed by a 0.5 microg/kg/hr infusion (the DK group) or fentanyl 0.8-1.2 microg/kg over 1 min followed by a 0.2-0.6 microg/kg/hr infusion (the FK group) from the time of ending the operation after total hysterectomy to the time in the PACU. We evaluated the pain VAS scores, the modified OAA/S scores, the BIS, the vital signs, the respiratory variables (SpO2, RR and EtCO2) and the perioperative side effects to compare the efficacy of dexmedetomidine and fentanyl. RESULTS: Compared with the fentanyl-ketorolac (FK) group, the modified OAA/S scores were significantly lower in the dexmedetomine-ketorolac (DK) group at 0, 5 and 10 min after arrival at the PACU (P < 0.05), whereas the pain VAS and BIS were not significantly different between the two groups. The blood pressure and heart rate in the DK group was significantly lower than that of the FK group at the PACU (P < 0.05). CONCLUSIONS: The DK group, at the doses used in this study, has a significant advantage over the FK group in terms of the postoperative hemodynamic stability at the PACU. There was no significant difference between the two groups for the postoperative pain control.

The Effects of Intravascular Volume Expansion on the Stability of Hemodynamic Responses in Patients undergoing Carotid Endarterectomy / 대한마취과학회지

BACKGROUND: During carotid endarterectomy, hemodynamic stability is very important to reduce the incidence of cerebral stroke and myocardial infarction. Therefore, we studied the effects of intravascular volume expansion using colloid solution on hemodynamic stability. METHODS: We studied 22 patients undergoing elective surgery under general anesthesia. Preanesthetic mean arterial blood pressure (MABP) and heart rate (HR) were checked, and the intraoperative target range was taken +/- 20% of these values. Following standardized anesthetic technique including intravenous induction with thiopental sodium and vecuronium, standard intraoperative monitoring and direct arterial blood pressure monitoring were instituted. Patients were randomly assigned to a Hartmann's solution group (group H, n = 11) or a pentastarch group (group P, n = 11). Distinct intraoperative episodes beyond the predetermined target range, and the number of episodes requiring interventional therapy were recorded. RESULTS: The pentastarch group had a significantly lower incidence of episodes requiring interventional drug therapy during the pre-reperfusion period. No difference was found between out of target incidents in MABP and HR. CONCLUSIONS: During carotid endarterectomy, the infusion of pentastarch solution reduced drug therapy requirement for hemodynamic stability during pre-reperfusion period only.

Effects of Propofol and Oral Clonidine on Blood Loss and Hemodynamic Stability during Endoscopic Sinus Surgery / 대한마취과학회지

BACKGROUND: This study was designed to evaluate the effect of propofol and oral clonidine on bleeding and their efficacy in blunting the hemodynamic effects of epinephrine during endoscopic sinus surgery. METHODS: Informed consent was obtained from eighty patients scheduled for endoscopic sinus surgery under general anesthesia. All patients received atropine 0.5 mg IM for premedication. Group I (n = 20) received thiopental sodium 5 mg/kg and vecuronium 0.1 mg/kg followed by an isoflurane 1 - 1.5 vol% in O2/N2O 50/50. Group P (n = 20) received propofol 2 mg/kg and vecuronium 0.1 mg/kg followed by an infusion of 6 - 10 mg/kg/hour in O2/N2O 40/60. Group P + 75 (n = 20) received oral clonidine 75ng and Group P + 150 (n = 20) received oral clonidine 150ng 60 min before induction of anesthesia. In anesthetic induction and maintenance, Group P + 75 and Group P + 150 were identical to Group P. Blood pressure, heart rate, EKG and SpO2 were continuously monitored. Blood losses were collected and measured at the end of each procedure. Pre- and postoperative hematocrit were checked. The duration of heart rate to peaked level and side effects were observed in all patients after the intranasal injection of epinephrine. RESULTS: The average estimated blood losses in Group P, P + 75 and P + 150 were significantly less than that of Group I (P < 0.05). In Group P + 150, the duration of heart rate increase was significantly shorter than that of Group I (P < 0.05). In Group P + 150, mean arterial pressure and the difference between preoperative and postoperative hematocrit were significantly less than that of Group I (P < 0.05). CONCLUSIONS: General anesthesia based on propofol infusion may have the advantage of decreased bleeding compared with conventional inhalation agents during endoscopic sinus surgery. Tachycardia inresponse to intranasal epinephrine injection was attenuated by oral clonidine.