[The effects of perioperative continuous administration of mivazerol on early postoperative hemodynamics and plasma catecholamines after major surgery]. / Die Auswirkungen der perioperativen Gabe des alpha 2-Adrenorezeptor-Agonisten Mivazerol auf frühpostoperative Hämodynamik und Plasmakatecholaminspiegel nach grossen chirurgischen Eingriffen.

OBJECTIVE: During and after surgical procedures a strong activation of the sympatho-adrenergic system is common with correlation to adverse cardiac outcome. Several drugs (alpha 2-adrenoceptor-agonists, beta blockers) are discussed to prevent this reaction. The new alpha 2-adrenoceptor-agonist mivazerol with marked specificity for alpha 2-adrenergic receptors may be suitable for this indication. The aim of the present study was to investigate the effects of perioperative continuous administration of mivazerol on plasma catecholamines, body temperature and calculated haemodynamic parameters in the early postoperative period in cardiac risk patients undergoing non-cardiac surgery. METHODS: 36 patients with known coronary heart disease or risk factors for coronary heart disease scheduled for elective abdominal or vascular surgery were included in the study. Patients received either mivazerol (n = 18) or placebo (n = 18) [initial dose 4 micrograms kg-1 for 10 minutes before induction of anaesthesia, followed by a continuous infusion of 1.5 micrograms kg-1 h-1 intraoperatively and for as long as 72 h after surgery] in a double-blinded, randomized manner. Blood pressure, heart rate and body temperature were measured every 10 minutes until 240 minutes after arrival at the ICU. During 240 minutes after arrival at the ICU measured parameters (CVP, PAP, PCWP, SaO2, SvO2, CO), calculated parameters (CI, SVR, PVR, VO2) and plasma catecholamines were measured at defined time intervalls. RESULTS: The plasma concentrations of epinephrine and norepinephrine and the heart rate were significantly lower in the mivazerol group in the study period. Regarding blood pressure and body temperature there were no differences between the groups. At some measuring points preload was higher in the mivazerol group, but there were no differences between the groups for measured (SaO2, SvO2, CO) and calculated (CI, SVR, PVR, VO2) cardiorespiratory parameters. The incidence of shivering, nausea and vomiting were similar in both groups. CONCLUSION: Continuous, perioperative administration of mivazerol decreased the heart rate and the plasma catecholamines in the early postoperative period, but did not affect blood pressure, body temperature and the incidence of shivering. There were also no effects of mivazerol on calculated haemodynamic parameters (CO, SVR, PVR, VO2). These findings show a selective decrease in heart rate by Mivazerol without markedly cardiorespiratory side effects.

[A method for continuous monitoring of total peripheral and pulmonary vascular resistance in high risk cardiac patients]. / Eine Methode zur kontinuierlichen Erfassung des Totalen Peripheren und Pulmonalen Gefässwiderstandes bei kardialen Hochrisikopatienten.

In this study we present a computer-assisted monitoring system ("Opserver") which allows a continuous registration of directly measured values: hear rate (HR), systolic, diastolic and mean arterial pressure (SAP, DAP, MAP): systolic, diastolic and mean pulmonary arterial pressure (PAPs, PAPd, PAPm), central venous pressure (CVP), mixed venous oxygen saturation (SvO2), pulse-oxymetrically measured oxygen saturation (SaO2), cardiac output (CO) and calculated haemodynamic parameters: cardiac index (CI), total peripheral vascular resistance (TPVR) and pulmonary vascular resistance (PVR). The basic principle of this on-line monitoring system is the registration of calculated parameters combining data of various devices by specially-developed software. The procedure is shown in several clinical examples. The advantages of this system are:--monitoring of critical haemodynamic responses in cardiac high-risk patients relating to induction and finishing of anaesthesia including in- and extubation, recovery from anaesthesia, operation and transport and--exact documentation of the data for the purpose of clinical studies. Based on continuous measurement, this monitoring system allows an optimum evaluation of cardiorespiratory acute incidents, thereby permitting a problem-oriented therapy in high-risk patients with vasoactive medication in the perioperative period and in the intensive care unit.

[Remifentanil and alfentanil: Sympathetic-adrenergic effect in the first postoperative phase in patients at cardiovascular risk]. / Remifentanil und Alfentanil: Sympathiko-adrenerge Effekte in der frühen postoperativen Phase beim kardiovaskulären Risikopatienten.

UNLABELLED: Extubation and the immediate postoperative period are critical periods with strong sympatho-adrenergic stimulation. The aim of the present study was to investigate this period after balanced anaesthesia with remifentanil and alfentanil in cardiac risk patients. METHODS: 52 patients with coronary artery disease or with risk factors for coronary heart disease scheduled for elective extraperitoneal and extrathoracic operation were included in this study. Anaesthesia was induced by intravenous administration of etomidate, vecuronium and remifentanil (n = 27, 1 microgram/kg) or alfentanil (n = 25, 25 micrograms/kg). Anaesthesia was maintained with an Isoflurane/N2O/O2 mixture and by continuous intravenous infusion of remifentanil (0.25 microgram/kg/min) or alfentanil (45 micrograms/kg/h). During the first 60 minutes after extubation haemodynamic parameters were monitored and catecholamines were determined at defined time intervals. Parameters of recovery, the requirement of analgesics and cardiac medications were compared in both groups. Myocardial ischaemia was assessed by two-channel Holter electrocardiography. RESULTS: The beginning of spontaneous respiration and time of extubation were similar in both groups. The time interval until opening eyes and the time between the beginning of spontaneous respiration and extubation was shorter in the patients treated with remifentanil. In this group patients suffered earlier from pain and had a higher pain score. Although the plasma catecholamines were comparable in both groups, in the patients treated with remifentanil changes in haemodynamic parameters were more pronounced. The incidence of shivering and the requirements of analgesics and cardiac medications were higher in these patients. The incidence of ST-segment changes indicating myocardial ischaemia was similar. CONCLUSIONS: After balanced anaesthesia with remifentanil a more pronounced sympatho-adrenergic stimulation occurs because of the more rapid clearance of the analgesic effect in the recovery period compared to alfentanil requiring more analgesics and medications for the control of the haemodynamic parameters. Because of these specific pharmacological effects the use of remifentanil in cardiac risk patients has to be critically discussed.

Intraoperative monitoring of the potassium-activity and pH- value on the myocardial surface during coronary bypass surgery.

INTRODUCTION: Ischemic periods very often occur a dysfunction of the heart. In this series the intraoperative changes of potassium-activity and pH- value on the heart undergoing cardioplegic induced cardiac arrest were studied. Furthermore, the sensitivity of the system in diagnostic fields of ischemic periods and reperfusion damages were investigated. METHODS: In eight patients (7 male and 1 female pts.) undergoing elective cardiosurgical procedures (aortocoronary bypass grafts) the ion activity of potassium and hydrogen ions were monitored on the heart, intraoperatively. By ion-selective electrodes the superficial cardiac ion activities were evaluated on definitive time periods on the left (LV) and right ventricle (RV). RESULTS: Preliminary results suggest: In the reperfusion-period different pH-values result on the ventricles. In the end of reperfusion the pH-values return to the starting points. Though the evaluated parameters are too alcaline in comparison to physiological intervals. The time course of epicardial potassium-concentrations is not different between the RV and LV. Initially, only low concentrations were found during perfusion and reperfusion, in the last interval of reperfusion period an increase of potassium on both ventricles were evaluated. In the end of the operations the superficial ion concentrations approximate to the values evaluated at the starting points. CONCLUSION: These results suggests, that the dynamics of ion-exchange-processes in the myocardium can be monitored with the help of ion-selective probes. This new technique opens new strategies in the qualitative check-up of myocardial protective procedures during cardioplegic cardiac arrest.

[A study of post-traumatic stress reactions among war refugees based on medical records. A standard model may support the treatment]. / Journalstudie av krigsflyktingars posttraumatiska stressreaktioner. Standardmall kan ge stöd i behandlingen.

A special project designed to aid Bosnian refugees in Stockholm County was initiated and funded by the County Council in February 1994. The present study, a joint endeavour involving the Bosnian Project, the Centre for Trauma and Torture Diagnostics, and the Red Cross Centre for torture victims, was designed to fulfil the following aims: To characterise the patient population in terms of social situation, trauma history, symptoms and treatment; To review accumulated experience at the three centres; To outline and discuss the treatment; and To suggest new avenues for further research concerning refugees and trauma. To obtain comparable material for this retrospective review of case records at the three centres, a special case chart format was adopted, covering pre-war and pre-treatment information on general background, social situation, health status and medication, as well as trauma history, symptoms and treatment. Most patients reported good pre-war health, but at the time of the study exhibited manifest effects of trauma history; 95 per cent reported mental problems, and 39 per cent medical disease or physical disorders. These refugees were thus characterised by manifest post-traumatic stress symptoms and need of treatment. Despite their relatively short time in Sweden, almost all had permanent residence permits and fixed addresses. The absence of a comparable control group precluded comparison with other refugee or normal populations. The findings suggest the need of co-ordination and co-operation between the special facilities available to refugees, and of a standardised format for case records.