Low dose sufentanil for major intracranial surgery.

The use of intravenous sufentanil in a single dose of 3 to 5 micrograms/kg body weight, was evaluated in 41 patients anesthetised for major intracranial surgery. It was assessed in a technique of balanced anesthesia which allowed controllable alteration in cardiovascular parameters and rapid postoperative recovery and neurological evaluation. It was concluded that the 4 micrograms/kg dose was superior regarding peroperative stability and recovery. The delayed recovery in aneurysm and fossa posterior surgery should be explained by several factors not involving the anesthetic technique.

Intranasal sufentanil for pre-operative sedation.

Sufentanil, a short-acting and potent narcotic agent, was studied as a premedicant administered by the nasal route. A total dose of 5 micrograms appeared to be too low, while either 10 or 20 micrograms was very effective in producing sedation. Side effects were minor. There appeared to be no differences between nose drops and spray. In a further study, sufentanil nose drops were compared with saline 0.9% in a double-blind fashion. Sedation of rapid onset but of limited duration was observed in the majority of patients who received sufentanil.

Postpartum headache, seizures and bloodstained C.S.F.: a possible complication of dural puncture?

A 32-year-old parturient developed severe headache with subsequent convulsions on the third day after the delivery under epidural anesthesia. Neuroradiological investigations were negative. All complaints disappeared promptly after the performance of an epidural blood patch.

Propofol-fentanyl anaesthesia for coronary bypass surgery in patients with good left ventricular function.

The haemodynamic effects of propofol-fentanyl anaesthesia for elective coronary bypass surgery were studied in 15 patients with good left ventricular function. The induction dose of propofol was 1.5 mg kg-1. The mean infusion rate during maintenance was 5.15 mg kg-1 h-1 (range 4.05-8.82 mg kg-1 h-1). The total dose of fentanyl given in the pre-bypass period was 32 micrograms kg-1. Induction of anaesthesia was associated with significant (P less than 0.05) decreases in systolic (-28%) and diastolic (-23%) pressures, systemic vascular resistance (-25%) and left ventricular stroke work index (LVSWI) (-32%). The decrease in LVSWI (P less than 0.05) during induction and maintenance with unchanged filling pressures, indicated myocardial depression. Clinical signs that could reflect myocardial ischaemia were not observed during the operation. There were no changes in the concentrations of the cardiac enzymes in the postoperative period and ECG morphology was unchanged.

Isoflurane-fentanyl anesthesia for coronary bypass surgery in patients with good left ventricular function.

The hemodynamic effects of a balanced anesthetic technique where a moderate dose of fentanyl (32 micrograms/kg) is supplemented with isoflurane were studied in 15 patients with good left ventricular function. Mean inspired isoflurane concentration was 0.63% during induction and 0.74% during maintenance. Induction of anesthesia was associated with a significant decrease (p less than 0.05) in systolic and diastolic pressure and left ventricular stroke work index (LVSWI). During maintenance systolic blood pressure and LVSWI remained significantly depressed. It is concluded that isoflurane-fentanyl anesthesia has myocardial depressant properties. There is a reduced incidence of break-through hypertension during noxious stimuli, when compared with high-dose fentanyl anesthesia. During maintenance, clinical signs that could reflect myocardial ischemia were not observed. Heart enzymes remained within normal range postoperatively in all patients and ECG morphology was unchanged.

A hemodynamic study of epidural versus intravenous anesthesia for aortofemoral bypass surgery.

The hemodynamic effects of two types of anesthesia on aortofemoral bypass surgery were studied in a randomised prospective trial. Epidural anesthesia supplemented with nitrous oxide (group I) and total intravenous anesthesia combining fentanyl and a continuous infusion of etomidate (group II) were compared. A high incidence of preoperative disease was found and all 18 patients were classified in ASA classes III-IV. It is concluded that epidural anesthesia provides excellent anesthetic and hemodynamic stability provided that an optimal filling pressure is maintained. Total intravenous anesthesia resulted in significant hypertensive reactions during surgery, which were not specifically related to crossclamping. Decreasing the high SVRI with vasodilatory treatment was necessary to treat hypertension in all those patients with preoperative hypertensive disease. No problems were seen in the intravenous group patients without preoperative hypertension. Cardiac work was higher in the intravenous group due to the high impedance of the cardiovascular system provoked by the absence of vasodilatory properties with this type of intravenous anesthesia. Monitoring of PWP and CI by Swan-Ganz catheter is shown to be very useful for optimalization of hemodynamics and fluid management especially during crossclamping, when normal Frank-Starling relationships might not be valid anymore. The effect of vasodilatory treatment, crossclamping and declamping could be carefully evaluated.

Craniostenosis: the importance of the anesthesiologist.

Based on the experience with 15 patients operated for craniostenosis in our hospital, guidelines were determined for the anesthetic and postoperative management with optimal maintenance of vital parameters. Subgaleal accumulation of blood may cause a spectacular drop of hemoglobin level during the first postoperative days. Since it is better to prevent than to cure, systematic anti-convulsive and antibiotic prophylaxis must be considered.

Supraclavicular brachial plexus block with the aid of a nerve stimulator.

Hundred supraclavicular brachial plexus blocks according to the subclavian perivascular technique were performed with the aid of a nerve stimulator Neutracer in order to verify the value of the technique and the acceptance by the patients. The technique is extensively described and the results and complications are presented. The rationale for the use of the supraclavicular approach and the advantages of the use of a nerve stimulator in regional anesthesia are discussed.

Needs for computing facilities in anesthesiology.

The use of computers in the practice of anesthesiology appears to be very promising--therefore the time has come to reflect on ways to utilize the possibilities of computers in this field. The anesthesiologist is faced with an existing "medical information science" and system developments and must now address these questions: How do computers fit in these systems? What is the kind of support and help one can expect from the use of computers? Next one attempts to define the needs for computer support, taking into account the specific working conditions of various anesthesia teams. A description is made of how a system for medical information is automatized--and by way of an example--how such a computer system for anesthesiologists is linked to a larger regional facility. Advantages and disadvantages of such a system are discussed.

Acute cardiovascular collapse after administration of suxamethonium.

The case is reported of an acute cardiovascular collapse immediately after the administration of suxamethonium to a 25-year-old woman undergoing a diagnostic laparoscopy under general anesthesia. Reintervention 14 days later--without the use of suxamethonium--was uneventful. A skin prik test with suxamethonium proved highly positive. A survey of the literature is given and an attempt is made to distinguish between true anaphylaxis and anaphylactoid reaction.

Gallamine and pancuronium inhibit pre- and postjunctional muscarine receptors in canine saphenous veins.

The influence of gallamine, pancuronium, suxamethonium and d-tubocurarine on adrenergic neurotransmission was studied in the isolated saphenous vein of the dog. Pancuronium but not the other muscle relaxants increased significantly the response to sympathetic stimulation and to exogenous norepipephrine; these increases were abolished after blockade of neuronal uptake by cocaine. Pancuronium and gallamine inhibited both the relaxation produced by lower doses of acetylcholine added during sympathetic stimulation (prejunctional effect) and the direct contractions evoked by high doses of the amine (postjunctional effect). In strips previously incubated with [3H]norepinephrine, gallamine had no effect on [3H]norepinephrine efflux in basal conditions and during sympathetic stimulation; it increased markedly the efflux evoked by sympathetic stimulation in the presence of acetylcholine confirming that gallamine inhibits the prejunctional effect of the latter on adrenergic transmission. When extrapolated to the intact organism, the present experiments indicate that gallamine and pancuronium augment the release of norepinephrine in vascular tissue under vagal control, which explains in part the cardiovascular effects of these muscle relaxants.

Influence of gallamine, pancuronium, d-tubocurarine and succinylcholine on adrenergic neurotransmission.

The influence of gallamine, pancuronium, d-tubocurarine and succinylcholine on adrenergic neurotransmission was studied in the isolated saphenous vein of the dog. Pancuronium increased the response of vascular smooth muscle to adrenergic nerve stimulation and to exogenous norepinephrine; gallamine, d-tubocurarine and succinylcholine had no effect. The relaxation caused by small doses of acetylcholine added during sympathetic nerve stimulation (prejunctional effect), was inhibited by pancuronium and by gallamine. In vein strips, charged with (3H) norepinephrine, acetylcholine inhibits the catecholamine-efflux evoked by sympathetic nerve stimulation. That inhibition was abolished by gallamine. This confirms that gallamine inhibits the prejunctional effect of acetylcholine on adrenergic neurotransmission. When extrapolated to the intact organism, this means that gallamine and pancuronium will augment the release of norepinephrine by acting as muscarinic antagonists also at prejunctional receptor sites in tissues exposed to combined sympathetic and vagal nerve activity. This mechanism would explain in part the cardiovascular effects of these muscle relaxants.

Clinical use of etomidate, influence on blood pressure and heart rate. Comparison with thiopentone and methohexital.

This study deals with blood pressure and heart rate measurements during the use of etomidate after premedication; the injection of etomidate is always preceded by 0.10 mg of fentanyl. Etomidate is compared with thiopentone and methohexitone. There appears to be no gross difference between the drugs as far as the blood pressure is concerned: it is decreased by 15-20%. The influence on the heart rate is typical for each drug: whereas thiopentone causes a rise of 23%, and methohexitone of nearly 40%, the rate remains constant in the etomidate series.

Mobile intensive care unit. Present conception and realisation.

A new Mobile Intensive Care Unit has been put in use at the "Service 900" of the Ministry of Health in Belgium. Its size was decided to enable efficient treatment of one patient. The type of suspension was chosen to give the patient adequate protection against untoward effects of travelling sickness. Radio-communication with the control center and hospital is ensured. The O2 supply-system provides an autonomy of 11 hours. Besides an electric distribution of 12 V. DC, a 220 V. AC is also available.