Hydroxyethyl starch 130/0.4 versus modified fluid gelatin for cardiopulmonary bypass priming: the effects on postoperative bleeding and volume expansion needs after elective CABG.

UNLABELLED: Concerned about high dose starches and potential coagulopathy, we performed a double blinded randomised prospective study on the influence of gelatine or 6% HES 130/04 pump prime on postoperative blood loss and transfusion requirements after CABG surgery. METHODS: After informed consent, 157 electively scheduled patients were randomly allocated to 6% HES (n=85) or gelatine (n=72) CPB priming. Postoperatively, chest tube drainage was noted hourly during the first 24 hours and every unit of colloid, albumin, FFP or Packed Red Cells needed to maintain hemodynamic stability was carefully registered. Blood losses were standardised as ml blood loss/kg body weight. Three patients in the HES group were excluded from the study because of postoperative haemorrhage of pure surgical origin. Data analysis consisted in unpaired t-test and Fisher exact test where appropriate. RESULTS: Chest tube drainage was significantly higher at 1 hour in the HES group (2.38 ml/kg vs. 3.15 ml/kg, p = 0.03). At 24 hours, total blood loss was still higher in the HES group without reaching statistical significance (p = 0.07). Albumin supplements occurred more frequently in the HES group between 2 and 3 hours postoperatively (p = 0.02). Total artificial colloid supplement was significantly higher in the gelatin group (13.36 versus 8.96 ml/kg, p < 0.001). There were no differences in the number of packed red cells, fresh frozen plasma or platelets transfused between the two groups. CONCLUSION: 6% HES 130/0.4 is a safe alternative to gelatine pump prime with a volume effect persisting longer in the postoperative phase, mandating less volume expansion with artificial colloid during the first 24 postoperative hours and not causing additional allogeneic blood component exposure.

Coagulation and fibrinolytic parameters in patients undergoing total hip replacement: influence of the anaesthesia technique.

Eighty patients undergoing total hip replacement (THR) were randomly allocated to three groups. Group I (n = 29) received general anaesthesia, Group II (n = 29) epidural anaesthesia and Group III (n = 22) the same epidural as Group II and the same general anaesthesia as Group I but with a lower isoflurane concentration. Prothrombin time (PT), activated thromboplastin time (APTT), fibrinogen (FG), plasminogen (PG), antithrombin III (AT III), protein C (Proc C), alpha-2-antiplasmin (alpha 2AP), Factor VIII coagulating activity (F VIII:C), von Willebrand factor antigen (vWF:Ag), von Willebrand ristocetin cofactor (vWF:Rcof), tissue plasminogen activator (tPA) as antigen and activity were measured before induction (A), at the end of surgery (B), on the first postoperative morning (C) and 7 days postoperatively (D). The most relevant finding was that AT III was equally depressed immediately after surgery in all groups, but returned to normal significantly faster in the epidural group (mean values at C: 96.2% in Group I, 104.1% in Group II, 92.7% in Group III). The faster return to normal of AT III after epidural anaesthesia could be one of the mechanisms responsible for the beneficial effect of this technique on the prevention of thromboembolic complications.

Propofol for arthroscopy in outpatients. Comparison of three anaesthetic techniques.

Sixty unpremedicated adult patients, undergoing arthroscopy, received propofol 2 mg kg-1 for induction of anaesthesia, before random allocation to three groups receiving one of the following: a continuous infusion of propofol supplemented with nitrous oxide in oxygen (group I); isoflurane and nitrous oxide in oxygen (group II); a continuous infusion of propofol in combination with repeated bolus doses of alfentanil (group III). The results showed no major differences in cardiovascular variables between the groups. Ventilation rate was highest in group II. Early recovery was less smooth and showed slight impairment in group III compared with the other groups. The data suggest that induction of anaesthesia with propofol followed by maintenance with isoflurane or continuous infusion of propofol is preferable for this procedure.

Double-blind comparison between nalbuphine and pentazocine in the control of postoperative pain after orthopedic surgery.

A double blind randomized study was done to compare Nalbuphine 20 mg I.M. to pentazocine 30 mg I.M. for postoperative pain relief after orthopedic surgery. This dose of pentazocine was choosen according to reports in the literature and to our standard practice. Sixty patients entered the study and were observed regularly till up 6 h post injection. The test drug was given when a pain score of 6 was shown on a VAS from 0 to 10. Onset, duration and quality of pain relief were significantly superior for nalbuphine with 50% of the patients still having no or only moderate pain at the end of the observation period. Cardiovascular and side effect were in both groups minor.

Intrathecal sufentanil as a supplement to subarachnoid anaesthesia with lignocaine.

The combination of low-dose sufentanil with lignocaine for subarachnoid anaesthesia was studied in a double-blind comparative trial in 40 urological patients. Patients were allocated randomly to two groups and received 5% heavy lignocaine 1.5 ml together with either 1.5 ml of sufentanil 5 micrograms ml-1, or physiological saline 1.5 ml. No statistically significant differences were observed between the two groups with respect to analgesia or anaesthesia. The only clear benefit of the addition of a low dose of sufentanil to lignocaine was the significantly longer period of postoperative analgesia. There was no significant difference in the number of patients requiring supplementary analgesics. Side-effects were similar in both groups.

Epidural sufentanil versus intramuscular buprenorphine for postoperative analgesia. A double-blind comparative trial.

Epidural sufentanil 50 micrograms was compared with intramuscular buprenorphine 0.3 mg for postoperative pain relief. Patients were assigned randomly to one of two treatment groups and received both an intramuscular and epidural injection, one of which was a placebo. Onset of pain relief was faster and quality of analgesia superior during the first 2 hours in the patients who received epidural sufentanil but the duration of analgesia was longer in the buprenorphine group. Cardiovascular variables remained stable in all patients and no respiratory depression was observed. Side effects were more frequent following buprenorphine.

A comparison of midazolam and diazepam for sedation during locoregional anesthesia.

Midazolam is a recently introduced benzodiazepine with a half life of 1-4 hours. Midazolam (0.15 mg/kg) has been compared with diazepam (0.2 mg/kg) for sedation during locoregional anesthesia in 60 premedicated patients. No difference among the two groups for heart rate, bloodpressure, respiratory rate and incidence, and duration of apnoea was noticed after an i.v. bolus administration. The recovery time was equal in both groups. Midazolam was significantly less painful at injection. The sedation pattern between both groups is only different at 60 minutes, where more better sedated patients are seen in the midazolam group. Except the pain at injection and a better sedation pattern after 60 min. the differences in the other parameters are only borderline.

Anesthesia for foreign bodies in the tracheo-bronchial tree in children.

The authors present the anesthetic and ventilation techniques, used in 106 children, who were suspected of foreign body aspiration in the respiratory tract. In 62 children a foreign body was found. The youngest child was 8 months old and the oldest 13 years, with an age distribution peak in the 1 to 2 years age group. A predominance for the male sex (60%) was present. Foreign bodies of organic nature were found most frequently (80%), 39 of them consisting of peanuts. The bronchi were involved more often than the trachea and the foreign body was located more frequently at the right bronchus (38 pt). The children were ventilated initially with an intermittent oxygen jet injection technique, using a home made apparatus, but since 1978 with HFPPV, using the AGA Bronchovent. Induction of anesthesia was done with halothane and maintenance with etomidate infusion (10-20 micrograms/kg/min.) or thiopental increments (2 to 3 mg/kg). The technique so far used, proved to be satisfactory, specially since HFPPV is used. Few complications occurred. One child died during the bronchoscopic procedure and in an other child a tracheostomy had to be performed for extraction of the foreign body.

Epidural sufentanil for postoperative pain relief.

An open pilot study was undertaken to evaluate the analgesic properties of epidurally administered sufentanil in the early postoperative period. After orthopaedic surgery of the lower extremity, four different groups of five adult patients each received either 15 micrograms (group 1), 30 micrograms (group 2), 50 micrograms (group 3) or 75 micrograms (group 4) sufentanil via an epidural catheter previously used for the surgical procedure. Results were satisfactory in groups 3 and 4 with very good relief of pain and a mean duration of action of 372 and 307 minutes respectively. Dosage above 50 micrograms did not seem to improve the quality or duration of pain relief, although the onset of action was faster with 75 micrograms. Sedation was always present in patients with effective analgesia. In the present study respiratory depression was not evident, but three patients complained of itching and two of urinary retention.