[Perioperative Effect of Intraoperative Fluid Restriction with the Same Fixed Volume of 5 ml · kg(-1) · h(-1) in Patients Undergoing Major Abdominal Versus Thoracic Surgery].

BACKGROUND: Major abdominal surgery accompanies the higher magnitude of physiological stress response and may require an additional replacement fluid for the redistributed volume. Intraoperative volume restriction strategy is recommended to avoid fluid overload leading to increased mortality. We conducted a comparative study of the perioperative effects of intraoperative fluid restriction in abdominal versus thoracic surgery. METHODS: Each 15 patients having major abdominal or thoracic surgery were studied prospectively. All participants were identically given intraoperative iv crystalloid of 5 ml · kg(-1) · hr(-1) under combined epidural/general anesthesia. Plasma level of AVP, aldosterone, angiotensin II and IL-6 as well as body water composition by bioelectrical impedance analysis was examined at preoperative period, at the end of surgery and on the first postoperative day. RESULTS: In abdominal surgery group there was significantly less intraoperative urine output compared with thoracic surgery group. No significant differences were found between two groups in extracellular water volume chnages, AVP, aldosterone angiotensin II, IL-6 level and postoperative renal function. CONCLUSIONS: Restrictive fluid therapy with intraoperative crystalloid of 5 ml · kg(-1) · hr(-1) can be safely used with no serious adverse events in abdominal surgery. In conclusion we had better not make any traditional difference in intraoperative fluid management between abdominal and thoracic surgery even if their stress response differs in magnitude.

[Efficacy and safety of remifentanil-based regimen for postoperative pain management in abdominal surgery patients: a double-blind study with low-dose remifentanil infusion of 0.02 microg x kg(-1) x min(-1)].

BACKGROUND: Remifentanil is a powerful analgesic with fast onset and ultra-short duration of action. Its context-sensitive half-time is consistently short even after a prolonged infusion. Remifentanil is effective for providing better postoperative analgesia, but this method is not generally accepted in Japan. The present study was conducted to document efficacy and safety of low-dose remifentanil infusion in postoperative patients. METHODS: Forty patients undergoing abdominal surgery were studied prospectively. They were randomly assigned to either remifentanil (0.02 microg x kg(-1) x min(-1)) or placebo group. Postoperatively all patients received continuous epidural anesthesia with lidocaine and IV patient-controlled analgesia with fentanyl. Flurbiprofen was administered only when no pain relief was achieved. Visual analogue scale (VAS), requirement of fentanyl and flurbiprofen, and the incidence of remifentanil-related adverse effects (respiratory depression, nausea, vomiting, pruritus) were examined at 3 hourly intervals for 12 hours. RESULTS: There are no statistical differences between two groups in pain scores. No adverse events including respiratory depression occurred throughout the study in both groups. CONCLUSIONS: Remifentanil infusion at 0.02 microg x kg(-1) x min(-1) can safely be used without any serious adverse events, while it may not be enough for postoperative analgesia. The best dosage of this drug for postoperative analgesia remains to be elucidated.

[Postoperative pain management in video-assisted thoracic surgery using a continuous unilateral intercostal analgesia].

BACKGROUND: Optimal pain management after video-assisted thoracic surgery (VATS) remains an open issue. We prospectively studied the analgesic effect of intercostal analgegia (ICA) by comparison with epidural analgesia. METHODS: Twenty-two patients undergoing VATS procedures were randomly divided into ICA (n = 8) or epidural (n = 14) group. Postoperatively 2 ml x hr(-1) of 0.2% ropivacaine was delivered continuously through intercostal or epidural catheter. Moreover, each group received the equal dose of fentanyl (0.25 x µg(-1). kg(-1) x hr(-1)) intravenously or epidurally. When no pain relief was achieved, iv fentanyl was given as a rescue. Requirement of additional fentanyl and pain score using a visual analogue scale (VAS) were documented for 19 hours. RESULTS: The mean pain scores at rest, mobilization and with coghing were slightly higher in the ICA group. Total additional dose of iv fentanyl was significantly different between the groups (ICA 147 ± 41 vs Epidural 39 ± 15 µg; P = 0.015). Pain scores and fentanyl requirements spread over the lower range. The mean of VAS in ICA group was less than 5 even at coughing, suggesting clinically irrelevant. CONCLUSIONS: In patients with coagulopathy, multimodal approach using intercostal analgesia supplemented by intravenous patient-controlled analgesia may be an alternative to epidural analgesia for postoperative pain management.

[Intraperitoneal irrigation for pseudomyxoma peritonei-a case of critical metabolic alkalosis precipitated by irrigation with 101 of sodium bicarbonate--].

Pseudomyxoma peritonei causes marked accumulation of jelly-like ascites in the peritoneal cavity. Removal of much mucinous ascites by irrigating the cavity appears to be an effective treatment. We describe a patient who underwent the irrigation with sodium bicarbonate solution and developed critical alkalemia. A 68-year-old woman with normal renal function was operated on for recurrent pseudomyxoma peritonei. Fol- lowing the excision of primary lesion, her intraperitoneal cavity was irrigated with 10 1 of 7% sodium bicarbonate in about 45 minutes. Thirty minutes after irrigation, blood gas analysis revealed severe metabolic alkalosis (pH 7.714, BE 25.6 mmol x l-1 ) with electrolyte disorder (Na 157.8 mmol x l-1 K 2.31mmol x l-1, Ca 0.73 mmol x l-1). Hypotension (<60 mmHg) and sinus tachycardia (>130 beats x min -1) supervened 75 minutes later. Transferring to the ICU, she was given KC1 solution intravenously based on serial blood analysis while on mechanical ventilation. The next day acid-base disturbance returned spontaneously to normal (pH 7.45, BE 8.0mmol x l-1), leading to endotracheal extubation. Electrolyte imbalance was gradually resolved on 2nd POD and she was discharged from the ICU. Intraperitoneal irrigation with sodium bicarbonate requires special perioperative considerations for lifethreatening alkalemia, especially in a patient with renal impairment.

[The evaluation of total body water composition during caesarean section under spinal anesthesia].

BACKGROUND: Hypotension is a common adverse effect of spinal anesthesia (SA). Preoperative fluid infusion is recommended to prevent hypotension during caesarean section. The aim of this study is to document relationship between preoperative total body water (TBW) and the amount of the vasopressors given intraoperatively and to evaluate the change of maternal body water composition (BWC). METHODS: In 57 patients scheduled for caesarean section under SA, maternal BWC was measured by bioelectrical impedance analysis method. SA was performed using 0.5% isobaric bupivacaine 2 ml and fentanyl 20 microg at L3-4 intervertebral space. After this procedure, the impedance was measured again. We investigated the correlation between TBW and the amount of the vasopressor and the change of maternal BWC before and after SA. RESULTS: No positive linear correlation existed between the preoperative TBW and the amount of vasopressors given intraoperatively. SA produced a 3.8% increase in TBW and a 4.7% increase in extracellular water (ECW, P < 0.01). CONCLUSIONS: Preoperative TBW does not affect the amount of vasopressors given during caesarean section, which suggested massive fluid infusion can not always prevent hypotension after SA. A slight changes in TBW and ECW may be induced by SA, while the exact physiological and clinical significance of these observation remains to be elucidated.

[A case-control study of airway management for 68 patients with cervical spine injury: comparison of the direct laryngoscope with a Macintosh blade and the fiberoptic bronchoscope].

BACKGROUND: As for cervical spine injury, special consideration for airway management is required but the optimal strategy remains controversial. Direct laryngoscopy (DL) creates some degree of cervical extension leading to secondary neurologic deterioration. Fiberoptic bronchoscopy (FOB) may facilitate tracheal intubation with little cervical motion, but has several inherent limitations. A few objective data prompted us to compare the neurologic outcome relating to the orotracheal intubation using the different types of technique, the DL with a Macintosh blade or the FOB. METHODS: To identify the effect of different methods on the intubation time, neurologic disability, and adverse effects, 68 cervical spine-injured patients with the use of DL (group L; 36 patients) or FOB (group F; 32 patients) were retrospectively reviewed using hospital records. Following the induction of general anesthesia, the trachea was intubated with no immobilizing forces in group L, while awake intubation was accomplished in group F after judicious application of local anesthesia to the larynx and trachea. RESULTS: No significant differences were observed between the groups in age, BMI, intubation time, postoperative neurologic outcome or incidence of aspiration pneumonia. Moreover, no neurologic deterioration was shown after DL and orotracheal intubation. CONCLUSIONS: We found no evidence to support the routine practice of the bronchoscope-assisted awake intubation in patients with cervical spine injury. The clinical value of this technique in offering some neurologic advantage remains limited.

[Anesthetic considerations for spine surgery in 71 patients with infectious spondylitis: effects of different pathogen either pyogenic or tuberculous on intraoperative blood loss].

BACKGROUND: Little information is available about anesthetic management in spine surgery for infectious spondylitis, in which major bleeding can be expected. The amount of blood loss may vary somewhat with pyogenic or tuberculous spondylitis. Limited data prompted us to get a clue to determine how best to care for these patients. METHODS: To examine the amount of intraoperative bleeding, 71 patients with either pyogenic (group A; 44 patients) or tuberculous spondylitis (group B; 27 patients) were retrospectively reviewed using hospital records. They underwent posterior fusion with instrumentation and anterior radical resection of the lesion. RESULTS: No significant differences were observed between the groups in age, gender, comorbidity or length of hospital stay. Operative time was longer in patients with group B (A: 126 +/- 41 vs B: 197 +/- 76 min, P<0.01). There was a trend toward greater blood loss in group B, especially massive bleeding (>1.5 l) occurred at a higher rate (13.6 vs 33.3%, P=0.05). The number of involved vertebrae was more in group B (1.8 +/- 0.9 vs 2.9 +/- 1.3, P<0.01). Both operative time and blood loss volume showed a good correlation with the number of vertebrae infected, suggesting that extensive eradication over several spinal segments may be indicated for tuberculous spondylitis. CONCLUSIONS: Spine surgery for tuberculous spondylitis is more likely to carry risks of longer operative time and higher rate of blood loss.

[Case of obstructive sleep apnea possibly having led to postoperative appearance of generalized convulsion].

Adverse surgical outcomes appear to be more frequent in patients with known obstructive sleep apnea (OSA). However, OSA patients may present for surgery without a prior diagnosis. A 37-year-old man underwent craniotomy for surgical direct neck clipping of the right ruptured internal carotid aneurysm. His intraoperative and early postoperative courses were uneventful. At night, about 48 hr after surgery, he developed sudden generalized tonic-clonic convulsion and temporary depressed consciousness resulting in marked hypercapnea (Pa(CO2)>100 mmHg). His respiration was transiently supported by PSV mode via LMA. He soon got well without neurologic deficits. At night, about 74 hr postoperatively, a generalized convulsion was again observed with hypercapnea. Aside from the respiratory support, percutaneous cricothyroidotomy was performed using Minitrach II system for his airway control, leading to no further recurrence of seizure. He was suspected to have unrecognized OSA due to such characteristic findings of sleep apnea as obesity (BMI>30) and witnessed apneas by his family. Postoperative rapid eye movement (REM) sleep rebound has been suggested to contribute to two consecutive night appearance of seizure. Clinical suspicion for OSA should be required preoperatively and perioperative heightened awareness is recommended.

[Cardiac arrest induced by dexmedetomidine].

A 64-year-old woman with hypertension, diabetes mellitus and asymptomatic first degree AV block underwent low anterior resection of the rectum. Anesthesia was induced with propofol, vecuronium bromide and remifentanil and maintained with nitrous oxide in oxygen, propofol and remifentanil. We did not use epidural anesthesia. After the operation, the patient was admitted to the intensive care unit under general anesthesia with propofol and remifentanil. In addition, dexmedetomidine was given without loading dose. The EKG changed from first degree AV block to second degree AV block followed by complete AV block and finally cardiac arrest. As soon as we performed heart massage, sinus rhythm appeared. We should be careful in giving dexmedetomidine to a patient with AV block.