Perioperative management of patients with cancer pain treated with opioids: a retrospective study.

PURPOSE: We retrospectively studied perioperative management of patients receiving opioid treatment for cancer pain to facilitate establishing a standard policy for our institute. METHODS: Subjects were patients who had been administered strong opioids for cancer pain and had undergone surgery with general anesthesia. We divided the patients into groups C and D. Group C was comprised of patients who had been administered their baseline opioids continuously during the perioperative period, and group D of those who had discontinued baseline opioid use during this period. RESULTS: We identified 70 evaluable patients, 36 in group C and 34 in group D. The intraoperative anesthesia courses were similar, being uneventful, in all cases. With respect to postoperative adverse effects within 24 h after awakening from anesthesia, severe adverse effects (additional administration of more than four analgesics and intense agitation) were significantly more frequent in group D than in group C (12 vs 1, respectively. p = 0.004). Univariate analysis revealed that baseline opioid discontinuation was the only factor associated with severe adverse effects [odds ratio 12.6, 95% confidence interval (1.49-105.8), p = 0.01]. CONCLUSION: Discontinuation of baseline opioid increased adverse effects in the early postoperative period, which were attributed to exacerbation of early postoperative pain.

Esophageal submucosal hematoma developed after endovascular surgery for unruptured cerebral aneurysm under general anesthesia: a case report.

BACKGROUND: Esophageal submucosal hematoma is a rare complication after endovascular surgery. We report a case of an esophageal submucosal hematoma which may have been caused by rigorous cough during extubation. CASE PRESENTATION: A 75-year-old woman underwent endovascular treatment for unruptured cerebral aneurysm under general anesthesia. The patient received aspirin and clopidogrel before surgery and heparin during surgery. Activated clotting time was 316 s at the end of surgery. Protamine was not administered and continuous infusion of argatroban was started after surgery. She had a rigorous cough during removal of the tracheal tube and reported retrosternal discomfort postoperatively. She developed hemorrhagic shock after massive hematemesis. A diagnosis of esophageal submucosal hematoma was made by endoscopic examination and computed tomography. Hemostasis was achieved by compression with a Sengstaken-Blakemore tube and endoscopic cauterization. Blood pressure was recovered by blood transfusion. Endoscopic examination performed 7 days after surgery showed that esophageal submucosal hematoma had almost disappeared and slough had adhered to the mucosal laceration. The patient showed good recovery and was discharged 21 days after surgery. CONCLUSIONS: Careful extubation and postoperative observation are required in patients receiving antiplatelet and anticoagulant therapy.

[Metoclopramide Induced Acute Dystonia during Intravenous Patient-controlled Analgesia with Droperidol].

A patient developed acute dystonia following intravenous administration of metocroplamide 20 mg. A 34-year-old woman underwent right hepatectomy, under general anesthesia managed with desflurane, remifentanil, and rocuronium. At the start of surgery, droperidol 1.5 mg was given intravenously for anti-emetic prophylaxis. Operation was completed uneventfully. Intravenous patient-controlled analgesia (i.v.-PCA) with fentanyl, containing droperidol, was selected for postoperative pain management The patient showed a reasonable postoperative course; however, around 15 hours post-operatively, she complained of nausea, although droperidol 2.625 mg had been administrated (maximum dose). Nausea subsequently disappeared following intravenous metocroplamide 20 mg, and i.v.-PCA was terminated. The patient gradually complained of excessive sleepiness. Finally, she showed akinesis and bilateral oculomotor disturbance 140 minutes after metocroplamide administration. However, her vital signs remained stable. Examinations including magnetic resonance imaging, electroencephalogram, and blood test did not show abnormalities. She was diagnosed with acute dystonia. She recovered without medications 300 minutes after the onset of akinesis. She could communicate with her eyes, opening/closing, throughout this episode. The effects of antiemetics acting on different receptors are additive. However, we should remember that coadministration of metocroplamide and butyrophenone induces extrapyramidal signs like acute dystonia. Intraoperative management extending beyond postoperative antiemetic therapy is necessary.

[Two cases of medicinal treatment of diabetic post treatment painful neuropathy].

Painful diabetic neuropathy is a common, difficult-to-manage complication of diabetes. We report two case of intractable painful diabetic neuropathy which occurred after the rapid lowering of blood sugar level. Although pregabalin, antidepressants, opioid analgetics and various nerve block did not improve their pain, clomipramine dramatically reduced their pain.

[Recovery from sevoflurane anesthesia delayed in hepatectomy patients due to influence of operation].

BACKGROUND: We reported that recovery from total intravenous anesthesia with propofol was delayed in hepatectomy patients, and the hazard ratio was half against controls. This study was designed to evaluate recovery from sevoflurane anesthesia in patients for hepatectomy. METHODS: Sixteen patients receiving hepatectomy and 17 patients receiving other epigastric surgeries (controls) were anesthetized with sevoflurane. Fentanyl was injected repeatedly to insure maintenance of the effect-site concentration of 2.0 ng x ml(-1). Propofol was administered for induction of general anesthesia, and then inhaled sevoflurane was titrated to maintain a Bispectral Index (BIS) value between 40 and 50. The intervals to emergence and extubation after sevoflurane discontinuation, and the predicted fentanyl concentrations were recorded. RESULTS: The amount of sevoflurane and concentration of fentanyl in hepatectomy were similar to those in controls. The extubation time was longer in hepatectomy patients than in control subjects, and the hazard ratio was half against controls. CONCLUSIONS: Recovery from anesthesia with sevoflurane was delayed in hepatectomy, and the hazard ratios were half against controls. We speculate that the influence of hepatectomy caused delay of recovery from anesthesia in hepatectomy patients.

Nicorandil decreases cardiac events during and after noncardiac surgery.

STUDY OBJECTIVE: To assess whether nicorandil reduces the likelihood of cardiac events during and after intermediate risk surgery. DESIGN: Multicenter study. SETTING: 13 hospitals in Japan. PATIENTS: Intermediate-risk patients were identified by the presence of risk factors such as angina, a history of myocardial infarction, heart failure, diabetes mellitus, and abnormal electrocardiography (ECG). INTERVENTIONS: Nicorandil was given to these patients during the operation. MEASUREMENTS AND MAIN RESULTS: Cardiac events during the operation and the following 5 days were monitored. The frequency of cardiac events in nicorandil-treated patients was compared with those in nontreated patients. Eighty-four patients received nicorandil during surgery and 237 patients received standard care. Cardiac events in the nicorandil-treated group occurred less frequently both during the operation (odds ratio, 0.15; 95% confidence interval, 0.03-0.76; P=0.02) and after it (odds ratio, 0.24; 95% confidence interval, 0.06-0.90; P=0.04). CONCLUSIONS: Nicorandil reduces the frequency of cardiac events in patients undergoing noncardiac surgery, both during and after the operation.

Effects of dopamine and olprinone on ventricular energetics in sevoflurane-induced acute left ventricular depression in dogs.

OBJECTIVE: The purpose of this study was to compare the effects of dopamine and a new phosphodiesterase (PDE)-3 inhibitor, olprinone, on hemodynamics and myocardial energetics in dogs with acute myocardial depression. DESIGN: Prospective, randomized, crossover study. SETTING: University animal laboratory. SUBJECTS: Mongrel dogs. INTERVENTIONS: Eight open-chest, barbiturate-anesthetized dogs with instruments for measurement of left ventricular pressure and volume were exposed to 2 MAC (minimum alveolar concentration) of sevoflurane to induce acute myocardial depression. Each dog was randomly assigned for either infusion of dopamine (5 microg/kg/min) for 15 minutes or bolus of olprinone (10 microg/kg), followed by an infusion (0.3 microg/kg/min) for 30 minutes. Treatment was crossed over after a washout period of 90 minutes. MEASUREMENTS AND MAIN RESULTS: For analysis of ventricular energetics, ventriculoarterial coupling was assessed using the ratio of arterial elastance to end-systolic pressure-volume relation and mechanical efficiency was calculated using the ratio of external work to pressure-volume area. Measurements were performed prior to sevoflurane administration, and before and after treatment. Two MAC of sevoflurane significantly impaired ventriculoarterial coupling and mechanical efficiency. Both olprinone and dopamine improved ventriculoarterial coupling and mechanical efficiency to similar degrees, but by different mechanisms. Olprinone improved ventricular energetics at a lower energy expenditure, probably because of olprinone's vasodilating effect, which augments energy transfer from the ventricle into the systemic circulation. CONCLUSION: Although both dopamine and olprinone improve sevoflurane-induced impairment of ventricular energetics, olprinone accomplishes this with lower ventricular energy expenditure.

[Recovery from propofol anesthesia is delayed in hepatectomy patients due to altered pharmacodynamics].

BACKGROUND: Liver dysfunction has major impacts on the pharmacokinetics and pharmacodynamics of anesthetics. This study was designed to evaluate propofol concentrations during and at the end of total intravenous anesthesia (TIVA) for hepatectomy. METHODS: Fifty patients receiving hepatectomy (n = 25) or other epigastric surgeries (controls, n = 25) were anesthetized with TIVA. Fentanyl was injected repeatedly to insure maintenance of the effect-site concentration in the 2.0 to 2.5 ng x ml(-1) range with off line computer similation program. Propofol was administered with target-controlled infusion at the initial target concentration of 3.0 mcg x kg(-1), and then titrated to maintain bispectral index (BIS) values between 40 and 50. The intervals after propofol discontinuation to emergence and extubation and the predicted propofol and fentanyl concentrations were recorded. Propofol concentrations at emergence were measured with blood sample in eight cases. RESULTS: The propofol dose in hepatectomy patients as well as both measured and predicted concentrations of propofol at extubation, were lower than in control patients. The extubation time was longer in hepatectomy than in control subjects. CONCLUSIONS: Recovery from TIVA is delayed in hepatectomy patients. We speculate that this is attributable to altered pharmacodynamics in these patients.

Are the incidences of cardiac events during noncardiac surgery in Japan the same as in the United States and Europe?

In Japan, an ever-present problem in the preoperative evaluation of patients with ischemic heart disease is that although such evaluations are based on Western data, these data serve as the basis for determining perioperative risk in Japanese patients. To remedy this problem, the Cardiac Ischemia and Anesthesia Research Committee was formed in 1997 and has conducted studies of perioperative complications in noncardiac surgery in Japan. In two retrospective studies in 1997, the proportions of patients with ischemic heart disease were 3.9% and 3.1%, approximately one tenth the rates reported in Europe and the United States. The incidences of perioperative cardiac complications in patients with ischemic heart disease were 16.4% and 13.2%, not widely divergent from rates reported in Europe and the United States. To investigate the baseline characteristics involved in perioperative complications, we conducted a prospective study of 237 patients classified as having intermediate risk for perioperative cardiac complications according to the American College of Cardiology/American Heart Association Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery. We found that the prominent factor in intraoperative cardiac complications was the presence of hypertension (odds ratio = 2.911). Factors contributing to postoperative cardiac complications included those reflecting coronary lesion severity and cardiac dysfunction (history of heart failure; odds ratio = 6.884, coronary risk index grade; odds ratio = 2.884, and a history of intervention; odds ratio = 4.774).