Anaesthesia for cardioversion: a comparison of sevoflurane and propofol.

This study compared the induction time, haemodynamic changes, recovery characteristics and patient satisfaction for sevoflurane and propofol when used as the main anaesthetic agents for cardioversion. Sixty-one unpremedicated patients scheduled for elective cardioversion were anaesthetised with either inhaled sevoflurane 8% or an intravenous propofol target-controlled infusion set at 6 microg.ml(-1). There was no significant difference in induction time between the two groups: mean (SD) = 90.1(40) s in the sevoflurane group vs. 83.7(35) s in the propofol group. Mean (SD) time to recovery was significantly shorter in the sevoflurane group than in the propofol group: 318 (127) s vs.738 (355) s, respectively, p < 0.001. At recovery, the patients in the propofol group had significantly lower systolic and diastolic blood pressures than those in the sevoflurane group, p < 0.001. The incidence of complications was low in both groups, with similar patient satisfaction expressed after the procedure. We conclude that sevoflurane is a suitable choice for anaesthesia for cardioversion and may provide greater haemodynamic stability than a target-controlled infusion of propofol.

Randomized trial of diaspirin cross-linked hemoglobin solution as an alternative to blood transfusion after cardiac surgery. The DCLHb Cardiac Surgery Trial Collaborative Group.

BACKGROUND: Risks associated with transfusion of allogeneic blood have prompted development of methods to avoid or reduce blood transfusions. New oxygen-carrying compounds such as diaspirin cross-linked hemoglobin (DCLHb) could enable more patients to avoid allogeneic blood transfusion. METHODS: The efficacy, safety, hemodynamic effects, and plasma persistence of DCLHb were investigated in a randomized, active-control, single-blind, multicenter study in post-cardiac bypass surgery patients. Of 1,956 screened patients, 209 were determined to require a blood transfusion and met the inclusion criteria during the 24-h post-cardiac bypass period. These patients were randomized to receive up to three 250-ml infusions of DCLHb (n = 104) or three units of packed erythrocytes (pRBCs; n = 105). Further transfusions of pRBCs or whole blood were permitted, if indicated. Primary efficacy end points were the avoidance of blood transfusion through hospital discharge or 7 days postsurgery, whichever came first, and a reduction in the number of units of pRBCs transfused during this same time period. Various laboratory, physiologic, and hemodynamic parameters were monitored to define the safety and pharmacologic effect of DCLHb in this patient population. RESULTS: During the period from the end of cardiopulmonary bypass surgery through postoperative day 7 or hospital discharge, 20 of 104 (19%) DCLHb recipients did not receive a transfusion of pRBCs compared with 100% of control patients (P < 0.05). The overall number of pRBCs administered during the 7-day postoperative period was not significantly different. Mortality was similar between the DCLHb (6 of 104 patients) and the control (8 of 105 patients) groups. Hypertension, jaundice/hyperbilirubinemia, increased serum glutamic oxalo-acetic transaminase, abnormal urine, and hematuria were reported more frequently in the DCLHb group, and there was one case of renal failure in each group. The hemodynamic effects of DCLHb included a consistent and slightly greater increase in systemic and pulmonary vascular resistance with associated increases in systemic and pulmonary arterial pressures compared with pRBC. Cardiac output values decreased more in the DCLHb group patients after the first administration than the control group patients. At 24 h postinfusion, the plasma hemoglobin level was less than one half the maximal level for any amount of DCLHb infused. CONCLUSIONS: Administration of DCLHb allowed a significant number (19%) of cardiac surgery patients to avoid exposure to erythrocytes postoperatively.

Post-thoracotomy paraplegia coincident with epidural anaesthesia.

We report a case of paraplegia in the immediate postoperative period following right bilobectomy for carcinoma of the lung. An epidural catheter had been inserted following induction of anaesthesia and an infusion of bupivacaine 0.15% was used for postoperative pain relief. Magnetic resonance imaging failed to reveal any spinal or epidural haematoma or spinal cord ischaemia. The patient developed respiratory failure on the third postoperative day and required assisted ventilation. He was weaned from the ventilator on day 15. Two days later he sustained a cardiac arrest and died. Post-mortem examination demonstrated spinal cord infarction and severely stenosed spinal arteries. The thoracotomy position and/or intra-operative hypotension might have compromised the blood flow to the spinal cord and although suspected as a possible cause, the use of epidural analgesia was not implicated.

Proinflammatory cytokine release during pediatric cardiopulmonary bypass: influence of centrifugal and roller pumps.

OBJECTIVE: It has been proposed that nonocclusive centrifugal pumps may elicit less blood cell trauma and hence a reduced inflammatory response than standard roller pumps. However, there have been no reports describing the impact of such pumps on proinflammatory cytokine release in pediatric cohorts. DESIGN: A prospective randomized study was undertaken. SETTING: A regional cardiothoracic center of a university hospital. PARTICIPANTS: Thirty-four pediatric patients undergoing cardiopulmonary bypass (CPB) for the correction of complex congenital heart defects were recruited. INTERVENTIONS: Either standard twin roller (n = 17), or centrifugal vortex (Biopump, Medtronic Biomedicus Inc, MN) (n = 17) blood pumping. MEASUREMENTS AND MAIN RESULTS: Venous blood was drawn (1) on induction of anesthesia, (2) 5 minutes on bypass, (3) end of CPB, (4) 30 minutes post-protamine, (5) 2 hours and (6) 24 hours postoperation. Neutrophil count, level of plasma leukocyte elastase, terminal complement complex (C5b-9); interleukin-6 (IL-6) and interleukin-8 (IL-8) were increased during and after CPB compared with the postinduction baseline. C5b-9 levels in both groups peaked at the end of CPB before returning to baseline at 24 hours: (median [range]), 564 (16 to 1,136) ng/mL in centrifugal group versus 508 (0 to 1,128) ng/mL in the roller group. IL-6 in both groups reached its peak level at 2 hours postprotamine (208 [98 to 411] pg/mL in centrifugal versus 205 [60-327] pg/mL in the roller group), before coming back to baseline at 24 hours. Plasma leukocyte elastase and IL-8 reached their maximum level 15 minutes after protamine administration: 215 (64 to 375) pg/mL in centrifugal versus 235 (87 to 410) pg/mL in roller group; and 700 (90 to 5,925) ng/mL versus 362 (120 to 3,400) ng/mL, respectively. CONCLUSIONS: The current study confirms the proinflammatory nature of pediatric CPB surgery, but failed to show a significant advantage of centrifugal pumping over roller perfusion in terms of the inflammatory response.

Silent myocardial ischaemia in a patient with anaemia before operation.

A patient with ischaemic heart disease and anaemia presenting for surgery underwent ambulatory electrocardiographic monitoring. Significant episodes of silent myocardial ischaemia were demonstrated. Following preoperative correction of the anaemia, ischaemia was not detected.

Obstetric anaesthetic workload in a teaching unit.

The distribution of obstetric anaesthetic work through the day was examined. Workload audit and prediction are discussed with their relevance to service and training.

Premedication with piroxicam in patients having dental surgery under general anaesthesia with halothane or isoflurane.

Pain, analgesic requirements, mouth opening and emesis were assessed in 60 patients who received either piroxicam 40 mg or placebo before dental surgery under general anaesthesia which included breathing either halothane or isoflurane. Patients went home on the day after surgery and completed a questionnaire concerning pain and emesis. There were four groups of 15 subjects: piroxicam-halothane, piroxicam-isoflurane, placebo-halothane or placebo-isoflurane. Pain increased at 2 and 4 h and had reduced by 18 h after surgery; there were no significant differences between the groups in pain scores. After operation, fewer patients in the piroxicam-isoflurane group required papaveretum compared with the piroxicam-halothane and placebo-halothane groups. Mouth opening was reduced between 2 and 4 h after surgery, but was less restricted after piroxicam-isoflurane than placebo-halothane. There was no difference between the groups in the incidence of emesis within 18 h of surgery. The postal questionnaire suggested that pain and emesis were reduced significantly during the 3 days after surgery in patients who had received piroxicam before surgery, compared with those who had received placebo.