Does propofol mode of administration influence psychomotor recovery time after sedation for colonoscopy: A prospective randomized assessor-blinded trial.

BACKGROUND: Propofol sedation has become increasingly popular for colonoscopy. Different modes of propofol administration have been described, but their influence on psychomotor recovery time remains largely unknown. This prospective randomized assessor-blinded study tested the hypothesis that target-controlled infusion system (TCI) combined with sedation depth monitoring should be associated with a more stable sedation than intermittent bolus application with clinical monitoring of sedation depth, resulting in a faster psychomotor skills recovery. METHODS: One hundred sixty-four patients undergoing colonoscopy were randomized to receive propofol with the former (TCI group) or the latter (bolus group) mode of administration. Psychomotor skill recovery was assessed using the Choice Reaction Time (CRT) performed before and every ten minutes after waking up from propofol sedation. Clinical recovery was also assessed using the modified Post-anesthetic Discharge Scoring System (PADS). RESULTS: Induction and wake up times were longer in the TCI group, where patients received more propofol than those in the bolus group. Evolution of CRT was similar in both groups. Twenty minutes after arrival in the post-anesthesia care unit, 35 (49%) of patients in the TCI group and 43 (54%) in the bolus group achieved CRT values equal or shorter than their baseline values. Interestingly, according to the PADS score, most of the patients were considered fit for discharge at that moment. Incidence of adverse event was not different between groups. CONCLUSION: In the conditions of our study characterized by short procedure duration, target-controlled infusion of propofol does not offer any benefit in terms of psychomotor skills recovery over intermittent bolus application.

Patient Blood Management for Neonates and Children Undergoing Cardiac Surgery: 2019 NATA Guidelines.

Pediatric cardiac surgery is associated with a substantial risk of bleeding, frequently requiring the administration of allogeneic blood products. Efforts to optimize preoperative hemoglobin, limit blood sampling, improve hemostasis, reduce bleeding, correct coagulopathy, and incorporate blood sparing techniques (including restrictive transfusion practices) are key elements of patient blood management (PBM) programs, and should be applied to the pediatric cardiac surgical population as across other disciplines. Many guidelines for implementation of PBM in adults undergoing cardiac surgery are available, but evidence regarding the implementation of PBM in children is limited to systematic reviews and specific guidelines for the pediatric cardiac population are missing. The objective of the task force from the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA, www.nataonline.com) is to provide evidence-based recommendations regarding anemia management and blood transfusion practices in the perioperative care of neonates and children undergoing cardiac surgery, and to highlight potential areas where additional research is urgently required.

Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: First update 2016.

: The management of perioperative bleeding involves multiple assessments and strategies to ensure appropriate patient care. Initially, it is important to identify those patients with an increased risk of perioperative bleeding. Next, strategies should be employed to correct preoperative anaemia and to stabilise macrocirculation and microcirculation to optimise the patient's tolerance to bleeding. Finally, targeted interventions should be used to reduce intraoperative and postoperative bleeding, and so prevent subsequent morbidity and mortality. The objective of these updated guidelines is to provide healthcare professionals with an overview of the most recent evidence to help ensure improved clinical management of patients. For this update, electronic databases were searched without language restrictions from 2011 or 2012 (depending on the search) until 2015. These searches produced 18 334 articles. All articles were assessed and the existing 2013 guidelines were revised to take account of new evidence. This update includes revisions to existing recommendations with respect to the wording, or changes in the grade of recommendation, and also the addition of new recommendations. The final draft guideline was posted on the European Society of Anaesthesiology website for four weeks for review. All comments were collated and the guidelines were amended as appropriate. This publication reflects the output of this work.

A randomised trial comparing sufentanil versus remifentanil for laparoscopic gastroplasty in the morbidly obese patient.

BACKGROUND AND OBJECTIVE: This prospective, randomised double-blind study compared the effects of target control infusion (TCI) of sufentanil and remifentanil on the quality of recovery and post-operative pain control in morbidly obese patients undergoing laparoscopic gastroplasty. METHODS: Following institutional Ethics Committee approval and written informed consent, 100 morbidly obese patients were randomised to receive either TCI sufentanil (0.3 ng ml⁻¹; S-group; N = 50) or TCI remifentanil (3 ng ml⁻¹; R-group; N = 50) in combination with desflurane (O2/air mixture: FiO2, 50%). Quality of recovery was estimated by means of the modified Aldrete score and by the ability to perform psychomotor tests with the same competence post-operatively as pre-operatively. Post-operative pain was evaluated by the quantity of piritramide needed to achieve a visual analogue scale (VAS) less than 3. Statistical analysis was performed using an unpaired Student's t-test, Mann-Whitney U-test and χ² test, as appropriate. RESULTS: Patient and surgical characteristics were similar among groups. In the R-group, time to extubation was significantly shorter, but VAS significantly higher than that in the S-group (P < 0.01). Quality of recovery and duration of post-anaesthesia care unit stay were comparable between groups (S-group: 119 ± 27 min and R-group: 119 ± 35 min). Piritramide consumption during the first 4 post-operative hours was higher in the R-group than in the S-group [S-group (median, range): 11.5 mg, 5.5-16.0; R-group: 18.0 mg, 14-22, P < 0.01], but not later on. CONCLUSION: In the conditions of the present study, although TCI sufentanil resulted in slower awakening than TCI remifentanil, it was associated with a better quality of recovery.

A randomized controlled trial comparing an intraoperative goal-directed strategy with routine clinical practice in patients undergoing peripheral arterial surgery.

BACKGROUND AND OBJECTIVE: We hypothesized that, in vascular surgery patients, the application of a goal-directed strategy based on a pulse contour-derived cardiac index would be associated with a better haemodynamic status than the application of routine perioperative care and that the amount of fluid and/or inotropes required in such a goal-directed therapy depended on the general anaesthetic technique used. METHODS: Patients undergoing peripheral arterial bypass grafting were randomly assigned to three groups. In group 1, haemodynamic management was performed according to routine clinical practice. In the two other groups (groups 2 and 3) a goal-directed therapy was applied aiming to maintain the pulse contour-derived cardiac index above 2.5 l m min. Patients in groups 1 and 2 received sevoflurane-based anaesthesia and patients in group 3 propofol-based anaesthesia. Haemodynamic variables, amount of fluid and administration of inotropes were assessed at different time intervals. RESULTS: The amount of fluid administered was not significantly different between the groups. Two patients in group 1, 13 patients in group 2 and 12 patients in group 3 were treated with dobutamine (P < 0.001). None of the patients anaesthetized with sevoflurane (groups 1 and 2) experienced postoperative cardiovascular complications, whereas four patients in the total intravenous group (group 3) experienced major postoperative cardiovascular complications (P = 0.005). CONCLUSION: In the conditions of the present study, the application of a goal-directed therapy aiming to maintain the cardiac index above 2.5 l min m did not result in a higher tissue oxygen delivery than when applying the standard haemodynamic strategy nor did it depend on the anaesthetic technique used.

A randomized trial evaluating different modalities of levosimendan administration in cardiac surgery patients with myocardial dysfunction.

OBJECTIVE: To evaluate the effects of 2 different administration modalities of levosimendan (start before cardiopulmonary bypass [CPB] and at the end of CPB) compared with a standard treatment with milrinone started at the end of CPB in cardiac surgery patients with a preoperative ejection fraction <30%. DESIGN: A prospective study. SETTING: A university hospital. PARTICIPANTS: Sixty patients undergoing elective cardiac surgery with CPB. INTERVENTIONS: Patients were randomly assigned to 3 different treatment options for weaning from CPB after cardiac surgery. Group A received milrinone, 0.5 microg/kg/min, after the release of the aortic cross-clamp; group B received levosimendan, 0.1 microg/kg/min, after the induction of anesthesia; and in group C, levosimendan, 0.1 microg/kg/min, was started immediately after the release of the aortic cross-clamp. In all patients, additional dobutamine, 5 microg/kg/min, was initiated after the release of the aortic cross-clamp. Norepinephrine maintained mean arterial pressure constant. MEASUREMENTS AND MAIN RESULTS: Stroke volume after surgery was initially higher than at baseline in all groups and highest in group B. Stroke volume declined 12 hours after surgery in group A but not in groups B and C (p < 0.05 between groups), despite similar filling pressures. Four patients in group A, none in group B, and 1 in group C died within 30 days of surgery. Postoperative atrial fibrillation was observed in 10 patients in group A, 7 patients in group C, and only 1 in group B (p < 0.01). No differences were observed in postoperative troponin I release among groups. CONCLUSION: In the conditions of the present study, starting the levosimendan treatment before CPB was associated with a higher initial postoperative stroke volume and a lower incidence of postoperative atrial fibrillation, but had no effect on the extent of postoperative troponin I release.

Moderate acute isovolemic hemodilution alters myocardial function in patients with coronary artery disease.

BACKGROUND: Although moderate hemodilution is usually well tolerated in coronary artery surgery patients, this may not be the case when myocardial oxygen demand is increased. We hypothesized that, in these patients, hemodilution in the presence of an increased heart rate could be associated with an impairment of myocardial function. METHODS: Forty coronary surgery patients were randomly assigned to two groups (n=20), according to the rate of atrioventricular pacing [70 bpm (Group 70) or 90 bpm (Group 90)]. While paced at the fixed heart rate, hemodilution was performed before the start of cardiopulmonary bypass. Data were obtained from a pulmonary artery, a PiCCO catheter and a left ventricular pressure catheter. Measurements were obtained in steady-state conditions before and after isovolemic hemodilution. RESULTS: Hemodilution from 40%+/-2% to 30%+/-1% in Group 70, and from 39%+/-4% to 30%+/-2% in Group 90 resulted in a decrease in systemic vascular resistance and an increase in end-diastolic volume in both groups. This was associated with an increase in stroke volume in Group 70 but not in Group 90. In this latter group, the maximal rate of pressure development decreased significantly after hemodilution [from 856+/-93 to 716+/-80 mm Hg/s (P<0.01)], whereas it remained unchanged in Group 70 (843+/-86 mm Hg/s before and 832+/-79 mm Hg/s after hemodilution). CONCLUSIONS: In the conditions of the present study, increased heart rate during moderate hemodilution was associated with a depression of myocardial function.

Parasacral sciatic nerve block: does the elicited motor response predict the success rate?

BACKGROUND: In this prospective, randomized, double-blind study, we compared the tibial and the peroneal evoked motor response with regard to efficacy of sciatic nerve block using the parasacral approach. METHODS: Twenty-six ASA I-III patients scheduled for elective lower limb surgery were randomized to receive a parasacral sciatic block, using a nerve stimulator technique seeking either a tibial (n = 14) or peroneal (n = 12) motor response. After the evoked motor response was obtained, a solution of 10 mL 2% lidocaine with epinephrine and 10 mL 0.75% ropivacaine (actual final concentration of epinephrine, 1/160,000) was slowly injected through the needle. Sensory and motor blocks were assessed every 5 min for 30 min by an anesthesiologist blinded to the elicited motor response. If the block was not complete 30 min after injection of the local anesthetics, it was considered as failed, and general anesthesia was supplemented. RESULTS: Time to perform the block and level of minimal and maximal stimulation were not different between groups. The success rate of complete block was significantly higher in the tibial compared to the peroneal group (11 of 14 vs 2 of 12; P = 0.002). CONCLUSIONS: Eliciting a tibial motor response predicts a higher success rate than eliciting a peroneal motor response with parasacral sciatic nerve block.

The effects of levosimendan in cardiac surgery patients with poor left ventricular function.

BACKGROUND: Patients with poor left ventricular function often require inotropic drug support immediately after cardiopulmonary bypass. Levosimendan improves cardiac function by a novel mechanism of action compared to currently available drugs. We hypothesized that, in patients with severely compromised ventricular function, the use of levosimendan would be associated with better postoperative cardiac function than with inotropic drugs that increase myocardial oxygen consumption. METHODS: Thirty patients with a preoperative ejection fraction < or =30% scheduled for elective cardiac surgery with cardiopulmonary bypass were randomized to two different inotropic protocols: milrinone 0.5 microg [corrected] x kg(-1) x min(-1) or levosimendan 0.1 microg [corrected] x kg(-1) x min(-1), started immediately after the release of the aortic crossclamp. The treatment was masked to the observers. All patients received dobutamine 5 microg [corrected] x kg(-1) x min(-1). RESULTS: Stroke volume was similar between groups initially after surgery, but it declined 12 h after surgery in the milrinone group but not in the levosimendan group (P < 0.05 between groups) despite similar filling pressures. Total dose, duration of inotropic drug administration and norepinephrine dose were lower in the levosimendan group than in the milrinone group (P < 0.05). The duration of tracheal intubation was shorter in the former group compared with the milrinone group (P = 0008). Three patients in the milrinone group but none in the levosimendan group died within 30 days of surgery. CONCLUSION: In cardiac surgery patients with a low preoperative ejection fraction, stroke volume was better maintained with the combination of dobutamine with levosimendan than with the combination of dobutamine with milrinone.

Comparison of the effects of aprotinin and tranexamic acid on blood loss and red blood cell transfusion requirements during the late stages of liver transplantation.

BACKGROUND: During liver transplantation (LT), profound activation of the fibrinolytic system can contribute significantly to perioperative bleeding. Prophylactic administration of antifibrinolytic agents has been shown to reduce blood loss and the need for allogeneic transfusion in these conditions. STUDY DESIGN AND METHODS: This prospective randomized trial included 51 cirrhotic patients undergoing LT. Patients were randomly assigned to receive either 280 mg of aprotinin (AP) followed by 70 mg per hour or 40 mg per kg tranexamic acid (TA) followed by 40 mg per kg per hour, administered from the end of the anhepatic phase until 2 hours after reperfusion of the graft, and the effects on blood loss and red blood cell (RBC) transfusion requirements were compared. Transfusion policy was standardized in all patients. In addition, the biological effects of the two drugs, as assessed by coagulation and fibrinolytic markers obtained during surgery, were evaluated in a subgroup of patients from each treatment group and compared with an historical control group that did not receive antifibrinolytic drugs. RESULTS: There was no significant difference between the two groups in perioperative blood losses (AP, 6200 [4620-8735] mL; TA, 5945 [4495-8527] mL; median [range]) or in RBC transfusions requirements (AP, 9 [6.75-15.25] units; TA, 10 [6.5-13.5] units). Inhibition of fibrinolysis was observed with both drugs compared with the control group. Coagulation appeared to be activated more with AP, however, whereas fibrinolysis was inhibited more by TA. CONCLUSION: Blood losses and RBC transfusion requirements were comparable regardless of the drug administered. TA may be as valuable as AP for controlling fibrinolysis in LT.

Hydroxyethyl starch 130/0.4 versus modified fluid gelatin for volume expansion in cardiac surgery patients: the effects on perioperative bleeding and transfusion needs.

In this prospective, randomized, open controlled study we compared the effects on net red blood cell loss of 6% hydroxyethyl starch 130/0.4 (HES: n = 64) and 3% modified fluid gelatin (GEL: n = 68) administered for intravascular volume management in patients undergoing coronary surgery. Blood losses were calculated from determination of circulating blood volume and measurement of preoperative and postoperative hematocrit. Amount of colloids that could be administered was limited to 50 mL/kg. If additional fluids were required, balanced crystalloid solution was used. Anesthetic and surgical techniques were standardized. Both groups were similar with regard to demographic and intraoperative variables. Total study drug was 48.9 +/- 17.2 mL/kg in the HES group and 48.9 +/- 14.6 mL/kg in the GEL group. Total red blood cell loss was 544 +/- 305 mL in the HES group and 504 +/- 327 mL the GEL group. Measured blood losses were also similar in both groups (HES, 19.4 +/- 12.3 mL/kg; GEL, 19.2 +/- 14.5 mL/kg). Exposure to allogeneic blood product was comparable in both groups. In the conditions of the present study, HES 130/0.4 up to 50 mL/kg is a valuable alternative to modified fluid gelatin for plasma volume expansion during and after cardiac surgery.

Cardioprotective properties of sevoflurane in patients undergoing coronary surgery with cardiopulmonary bypass are related to the modalities of its administration.

BACKGROUND: Experimental studies have related the cardioprotective effects of sevoflurane both to preconditioning properties and to beneficial effects during reperfusion. In clinical studies, the cardioprotective effects of volatile agents seem more important when administered throughout the procedure than when used only in the preconditioning period. The authors hypothesized that the cardioprotective effects of sevoflurane observed in patients undergoing coronary surgery with cardiopulmonary bypass are related to timing and duration of its administration. METHODS: Elective coronary surgery patients were randomly assigned to four different anesthetic protocols (n = 50 each). In a first group, patients received a propofol based intravenous regimen (propofol group). In a second group, propofol was replaced by sevoflurane from sternotomy until the start of cardiopulmonary bypass (SEVO pre group). In a third group, propofol was replaced by sevoflurane after completion of the coronary anastomoses (SEVO post group). In a fourth group, propofol was administered until sternotomy and then replaced by sevoflurane for the remaining of the operation (SEVO all group). Postoperative concentrations of cardiac troponin I were followed during 48 h. Cardiac function was assessed perioperatively and during 24 h postoperatively. RESULTS: Postoperative troponin I concentrations in the SEVO all group were lower than in the propofol group. Stroke volume decreased transiently after cardiopulmonary bypass in the propofol group but remained unchanged throughout in the SEVO all group. In the SEVO pre and SEVO post groups, stroke volume also decreased after cardiopulmonary bypass but returned earlier to baseline values than in the propofol group. Duration of stay in the intensive care unit was lower in the SEVO all group than in the propofol group. CONCLUSION: In patients undergoing coronary artery surgery with cardiopulmonary bypass, the cardioprotective effects of sevoflurane were clinically most apparent when it was administered throughout the operation.

Choice of primary anesthetic regimen can influence intensive care unit length of stay after coronary surgery with cardiopulmonary bypass.

BACKGROUND: Volatile anesthetics protect the myocardium during coronary surgery. This study hypothesized that the use of a volatile agent in the anesthetic regimen would be associated with a shorter intensive care unit (ICU) and hospital length of stay (LOS), compared with a total intravenous anesthetic regimen. METHODS: Elective coronary surgery patients were randomly assigned to receive propofol (n = 80), midazolam (n = 80), sevoflurane (n = 80), or desflurane (n = 80) as part of a remifentanil-based anesthetic regimen. Multiple logistic regression analysis was used to identify the independent variables associated with a prolonged ICU LOS. RESULTS: Patient characteristics were similar in all groups. ICU and hospital LOS were lower in the sevoflurane and desflurane groups (P < 0.01). The number of patients who needed a prolonged ICU stay (> 48 h) was also significantly lower (propofol: n = 31; midazolam: n = 34; sevoflurane: n = 10; desflurane: n = 15; P < 0.01). Occurrence of atrial fibrillation, a postoperative troponin I concentration greater than 4 ng/ml, and the need for prolonged inotropic support (> 12 h) were identified as the significant risk factors for prolonged ICU LOS. Postoperative troponin I concentrations and need for prolonged inotropic support were lower in the sevoflurane and desflurane group (P < 0.01). Postoperative cardiac function was also better preserved with the volatile anesthetics. The incidence of other postoperative complications was similar in all groups. CONCLUSIONS: The use of sevoflurane and desflurane resulted in a shorter ICU and hospital LOS. This seemed to be related to a better preservation of early postoperative myocardial function.

3.5% urea-linked gelatin is as effective as 6% HES 200/0.5 for volume management in cardiac surgery patients.

PURPOSE: To compare the efficacy of volume expansion with 3.5% gelatin and 6% hydroxyethyl starch 200/0.5 in patients undergoing cardiac surgery. The second objective was to compare the two colloids in terms of blood losses and allogeneic blood transfusion exposure rate. METHODS: In this open-label controlled study, patients were randomly allocated to receive either 3.5% urea-linked gelatin (GEL group: n = 55) or 6% hydroxyethyl starch 200/0.5/5.1 (HES group: n = 55) for per- (including priming of the bypass machine) and postoperative volume management with a maximum dosage of 30 +/- 3 mL.kg(-1).day(-1). Volume replacement was guided according to routine per- and postoperative care based on cardiac index, mixed venous oxygen saturation, and diuresis. If additional colloid was required, 4.5% albumin had to be given. The study period comprised per- and postoperative investigations up to 18 hr after surgery. RESULTS: All hemodynamic variables were comparable in both groups. Total study drug was 25.8 +/- 4.8 mL.kg(-1) in the GEL group and 24.5 +/- 6.0 mL.kg(-1) in the HES group. There was no difference in the number of patients receiving albumin solution or in the amount of albumin administered. Total blood loss was higher in the HES than in the GEL group (11.0 +/- 7.8 mL.kg(-1) vs 8.7 +/- 4.0 mL.kg(-1); P < 0.05) resulting in a higher need for allogeneic blood transfusion (HES: nine patients received 12 units, GEL two patients received 3 units; P = 0.026). CONCLUSION: In the conditions of the present study, HES was not associated with a better plasma expansion effect than GEL. HES could result in a higher need for allogeneic blood transfusion.

Effects of propofol, desflurane, and sevoflurane on recovery of myocardial function after coronary surgery in elderly high-risk patients.

BACKGROUND: The present study investigated the effects of propofol, desflurane, and sevoflurane on recovery of myocardial function in high-risk coronary surgery patients. High-risk patients were defined as those older than 70 yr with three-vessel disease and an ejection fraction less than 50% with impaired length-dependent regulation of myocardial function. METHODS: Coronary surgery patients (n = 45) were randomly assigned to receive either target-controlled infusion of propofol or inhalational anesthesia with desflurane or sevoflurane. Cardiac function was assessed perioperatively and during 24 h postoperatively using a Swan-Ganz catheter. Perioperatively, a high-fidelity pressure catheter was positioned in the left and right atrium and ventricle. Response to increased cardiac load, obtained by leg elevation, was assessed before and after cardiopulmonary bypass (CPB). Effects on contraction were evaluated by analysis of changes in dP/dt(max). Effects on relaxation were assessed by analysis of the load-dependence of myocardial relaxation. Postoperative levels of cardiac troponin I were followed for 36 h. RESULTS: After CPB, cardiac index and dP/dt(max) were significantly lower in patients under propofol anesthesia. Post-CPB, leg elevation resulted in a significantly greater decrease in dP/dt(max) in the propofol group, whereas the responses in the desflurane and sevoflurane groups were comparable with the responses before CPB. After CPB, load dependence of left ventricular pressure drop was significantly higher in the propofol group than in the desflurane and sevoflurane group. Troponin I levels were significantly higher in the propofol group. CONCLUSIONS: Sevoflurane and desflurane but not propofol preserved left ventricular function after CPB in high-risk coronary surgery patients with less evidence of myocardial damage postoperatively.