Epidural analgesia in abdominal surgery: 0.2% ropivacaine with sufentanil.

AIM: Combining an opioid with peridural local analgesia is an excellent technique to control post-operative pain. Sufentanil is a widely used opioid agent, but its optimal dosage has not yet been defined. In this study we wanted to determine the best dose of epidural sufentanil in major surgery. METHODS: Before the operation, 45 major abdominal surgery patients received blended anesthesia through an epidural chest catheter. The patients were randomized into 3 groups of 15 subjects according to different sufentanil doses [0.2% ropivacaine combined with sufentanil at a dose of 0.5 microg/ml(-1), 0.75 microg/ml(-1), or 1 microg/ml(-1) (groups A, B and C, respectively)] administered through an epidural chest catheter connected to an elastometric pump (5 ml/h) for the first 36 postoperative hours. The level of postoperative analgesia in motion and at rest was measured using an analog visual scale (VAS-R, VAS-I). RESULTS: Analgesia was best in group A, and similar in groups B and C; 2 cases of pruritus were noted in group C. The VAS-I scores were <3 across all 3 patient groups. CONCLUSION: Epidural analgesia is an efficacious and reliable technique. The combination of 0.2% ropivacaine and 0.75 microg/ml(-1) sufentanil was found to be the optimum choice between analgesic efficacy and minor side effects, which correlated with the higher dose of sufentanil given to group C.

Transesophageal echocardiographic assessment of hemodynamic function during laparoscopic cholecystectomy in healthy patients.

BACKGROUND: This study aimed by means of transesophageal echocardiography, to evaluate hemodynamic changes induced by pneumoperitoneum in patients with normal cardiac performance. METHODS: In this study, 11 ASA I-II patients (mean age, 39 years) with normal cardiac performance undergoing laparoscopic cholecystectomy were evaluated. A 5-MHz transesophageal biplane phased-array transducer connected to an echocardiographer was inserted after induction of anesthesia. Data were collected at three different times: before insufflation (T1), 10 min after insufflation (T2), and 5 min after desufflation (T3). At these same times, heart rate, systolic blood pressure, diastolic blood pressure, end-tidal carbon dioxide (CO(2)), and peak airway pressure were recorded. Statistical analysis was performed using one-way and two-way analysis of variance (ANOVA). A p value less than 0.05 was considered significant. RESULTS: End-systolic and end-diastolic diameters of the left ventricle, contractility, and performance parameters did not change significantly. Conversely, at insufflation, color Doppler area of the mitral backflow increased significantly (p < 0.05) when already present or showed up abruptly (T1: 0.22 +/- 0.28 cm(2); T2: 1.28 +/- 1.02 cm(2); T3: 0.49 +/- 0.53 cm(2)). CONCLUSIONS: Such an event is not interpreted as a mitral insufficiency. It is possibly the result of a "contrast effect" caused by the absorption of CO(2) microbubbles in the blood.

Changes in cerebral hemodynamics during laparoscopic cholecystectomy.

Laparoscopic surgery requires a series of procedures, including intraperitoneal CO2 insufflation, which can cause cardiovascular and hemogasanalytic modifications, potentially able to impair cerebral perfusion. The aim of this study was to evaluate changes in cerebral blood flow velocity during laparoscopic cholecystectomy. Eighteen patients undergoing laparoscopic cholecystectomy were studied. Middle cerebral artery blood flow velocity was monitored using transcranial Doppler ultrasonography. Electrical bioimpedance was employed to measure cardiac output, stroke volume and to calculate derived parameters. End-tidal CO2, mean arterial blood pressure, end expiratory anesthetic concentration and O2 saturation were monitored non-invasively. Cerebral artery blood flow velocity increased significantly after CO2 insufflation (p < 0.05) and remained stable. The highest values were reached after CO2 desufflation. A significant reduction in stroke volume and cardiac output (p < 0.05) associated with increased vascular systemic resistances (p < 0.001) was observed soon after CO2 insufflation. The decrease in cardiac output and the increase in vascular systemic resistances remained significant throughout abdominal insufflation. Heart rate and mean arterial pressure remained substantially unchanged with the exception of a significant decrease (p < 0.001) before CO2 insufflation. There was no significant change in end-tidal CO2 during abdominal insufflation. These findings suggest that the cerebrovascular system can undergo adaptive changes during all phases of laparoscopic surgery. However, the extent of cardio- and cerebrovascular variation indicates the need for careful preliminary evaluation of cerebral hemodynamics in patients with vascular disorders before laparoscopic surgery.

[Anesthesia in the elderly patient. Our experience]. / L'anestesia nel paziente anziano. Nostra esperienza.

A study has been carried out in 435 patients over 80 years old underwent elective or emergency general surgical operations with general or loco-regional anaesthesia in order to evaluate possible risk factors. Preoperative evaluation has shown coexisting cardiovascular and respiratory diseases in 68% of patients. Treatment of functional decline of organ malnutrition and dehydration and use of adequate anaesthesiology management contributed to contain postoperative morbidity and mortality compared with other analogue experiences. The authors conclude that elderly age, although is a risk factor, cannot be considered an absolute contraindication to major surgery. However physiopathological modification of the elderly must be evaluate.

[The use of subarachnoid bupivacaine analgesia in malignant hyperthermia-susceptible subjects. A clinical case report]. / Impiego dell'analgesia subaracnoidea con bupivacaina in soggetti suscettibili di ipertermia maligna. Descrizione di un caso clinico.

The authors report a case of malignant hyperthermia in susceptible woman undergoing safenectomy. Spinal anesthesia with bupivacaine was performed after dantrolene prophylaxis per os. No complications occurred during and after surgery. This case confirms the safety of local anesthetics and it suggests that anaesthesia should not be refused to caffeine halothane contracture test positive patients.

Intra-hospital transport of the anaesthetized patient.

This study evaluated the anaesthetic management of 20 patients, undergoing intra-operative radiation therapy for pancreatic or rectal tumours. Patients with a re-approximated surgical incision were transferred from the operating room to the radiotherapy department while still under anaesthesia. The risks of such transport as well as guidelines for the patient's care during this phase are examined. The results of this study indicate that in order to transport anaesthetized patients safely it is necessary to ensure stable cardiovascular, respiratory and metabolic conditions prior to their transfer. It is also important to guarantee adequate analgesia and to establish appropriate monitoring during transport.

[Anesthesia in thymectomy. Experience with 115 cases]. / L'anestesia negli interventi di timectomia. Esperienza su 115 casi.

The authors have conducted a retrospective study on 115 patients with myasthenia gravis undergoing transsternal or transcervical thymectomy at the Policlinico A. Gemelli of Rome in the period June 1984- to June 1991. A prolonged postoperative mechanical ventilation immediately and a few days following surgery was required respectively in 7 and 3 patients, while atelectasia and broncopneumonia have developed in 10 patients. No relationship could be established between the incidence of respiratory complications and factors such as preoperative symptomatology and treatment anesthetic agents, the surgical approach to the thymus and thymic pathology. However a significantly greater postoperative morbidity has been observed in the group of patients receiving suxametonium as compared to the patients receiving non-depolarizing muscle relaxants. Vecuronium and atracurium very frequently allowed ad adequate resumption of spontaneous respiration after anesthesia and made possible a safe early extubation of patients before leaving the operating room. The authors also stressed that all patients, irrespective of their clinical conditions, must be transferred after thymectomy. Oto the surgical ICU where anticholinesterase therapy can be safely restarted and cardiorespiratory status carefully monitored.

[Intraoperative radiotherapy: anesthesiologic problems during transport of patients]. / Radioterapia intraoperatoria: problemi anestesiologici durante il trasporto del paziente.

In this study the condition of anesthesia in 8 patients, undergoing intraoperative radiation therapy (IORT) for pancreatic or rectal tumors, is evaluated. Patients with reapproximated surgical incision were transferred from the operating room to the radiotherapy department while still under anesthesia. The risks of such transport as well as guidelines for the patient's care during this phase are examined. The results of this study indicate that in order to move anesthetized patients safely it is necessary to ensure stable cardiovascular, respiratory and metabolic conditions prior to their transfer. It is also important to guarantee adequate analgesia and to establish appropriate monitoring during transport.

[A comparison of the hemodynamic effects of midazolam and propofol during anesthetic induction in patients at vascular risk]. / Comparaison des effets hémodynamiques du midazolam et du propofol à l'induction de l'anesthésie chez le sujet à risque vasculaire.

The haemodynamic effects of midazolam or propofol, with a low dose of fentanyl, were studied during induction of anaesthesia and tracheal intubation in 20 patients undergoing aortic reconstructive surgery. This study demonstrates that both drugs induce important modifications of haemodynamic parameters undesirable in elderly, high-risk patients.

[The effects of nitrous oxide on evoked potentials recorded during enflurane and isoflurane anesthesia]. / Effets du protoxyde d'azote sur les potentiels évoqués enregistrés pendant l'anesthésie à l'enflurane et à l'isoflurane.

The effects on median nerve somatosensory evoked potentials produced by nitrous-oxide (67%) were studied in 20 patients undergoing elective surgery under enflurane or isoflurane anaesthesia. This study demonstrates that nitrous-oxide does not significantly modify spinal (N13) and cortical (N20) component latencies nor central conduction time. The addition of nitrous-oxide to enflurane or isoflurane (up to 1 MAC) causes a significant reduction of N20 amplitude.

Cardiomyopathy in phaeochromocytoma: a case report.

This case report describes the anaesthetic management of a patient with bilateral phaeochromocytoma and cardiomyopathy. The hypertension and supraventricular tachycardia commonly seen during manipulation of this tumour was controlled by administration of sodium nitroprusside and verapamil. Verapamil allowed effective management of supraventricular rhythm disturbances and arterial blood pressure, and cardiac index remained unchanged during and after phaeochromocytoma removal. As the haemodynamic side-effects of the calcium blocking agent are readily reversed by intravenous calcium chloride, it may have a useful part to play in such cases.