Prognostic value of a tissue Doppler-derived index of left ventricular filling pressure on composite morbidity after off-pump coronary artery bypass surgery.

BACKGROUND: The ratio of early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/e') is an indicator of diastolic function that correlates well with left ventricular (LV) filling pressure and is relatively independent of systolic function and rhythm abnormalities. We prospectively evaluated the predictive value of E/e' for postoperative outcome in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB). METHODS: Patients undergoing OPCAB were classified into three groups according to their E/e' ratio: (i) normal E/e' <8; (ii) undetermined E/e' ≥8 and ≤15; and (iii) elevated E/e' >15. Among those with E/e' between 8 and 15, patients with elevated LV filling pressure were further identified by comprehensive Doppler examination. These patients were classified as having a high LV filling pressure, together with patients who had E/e' ratios >15. Univariate and multivariate regression analyses were used to evaluate the relationship between preoperative variables and composite endpoints for morbidity. RESULTS: In univariate analysis, diabetes mellitus, recent myocardial infarction, chronic obstructive pulmonary disease, serum creatinine (sCr) concentration, E/e' >15, high LV filling pressure, LV ejection fraction, New York Heart Association class III and IV, and use of diuretics were significant risk factors for postoperative morbidity. In multivariate regression analysis of these variables, only sCr (odds ratio 1.4) and E/e' >15 (odds ratio 2.4) or high LV filling pressure (odds ratio 2.8) remained as independent risk factors. CONCLUSIONS: E/e' ratio >15 was a significant predictor of composite endpoints of postoperative morbidity. We suggest that E/e' ratio should be included in the routine preoperative assessment of patients presenting for OPCAB.

Optimal dose of propofol for intubation after sevoflurane inhalation without neuromuscular blocking agent in children.

BACKGROUND: This study was designed to determine the optimal dose of propofol for excellent intubating conditions in children without neuromuscular blockade at various alveolar concentrations of sevoflurane. METHODS: Sixty-three children, aged 0.5-5 years, were randomized to three groups of end-tidal sevoflurane concentration (ETsevo) 3%, 3.5%, and 4%. Inhalation anesthesia was started with sevoflurane 7% in 100% oxygen. When the patients became unconscious, inspired concentration was adjusted to obtain the target ETsevo for each group. When ETsevo reached the target concentration, a predetermined dose of propofol was given and tracheal intubation was performed. The proper dose of propofol was determined using the 'up-and-down' method. RESULTS: The median dose (95% confidence intervals) of propofol for excellent tracheal intubating conditions in 50% of children were 1.25 mg/kg (0.84-1.75) at ETsevo of 3%, 0.76 mg/kg (0.35-1.21) at 3.5%, and 0.47 mg/kg (0.26-1.09) at 4%. The frequency of adverse effects was not different between groups during induction and recovery. CONCLUSION: Propofol 1.5-2 mg/kg provides excellent intubating conditions at 3-4% ETsevo in children without using any neuromuscular blocking agent.

Optimal effect-site concentration of remifentanil for preventing cough during emergence from sevoflurane-remifentanil anaesthesia.

This randomised, double-blinded, controlled trial was designed to identify the optimal dose of remifentanil for cough suppression without adverse effects during emergence from sevoflurane-remifentanil anaesthesia for thyroidectomy. One hundred and four patients were randomly assigned to maintain target effect-site concentrations of remifentanil at 0 (control group), 1.0 (remifentail 1 group), or 1.5 ng.ml(-1) (remifentanil 1.5 group) during emergence. The incidence of coughing was lower in the remifentanil 1.5 group (31%) than in the control group (74%) or remifentanil 1 group (63%) (p = 0.0004). In addition, the severity of coughing during extubation was lower in the remifentanil 1.5 group (median (IQR [range]) 0 (0-1 [0-1]) than in the control group (1 (0-2 [0-3])) and remifentanil 1 group (1 (0-2 [0-3])) (p = 0.004). Haemodynamic changes were reduced, but emergence time and stay in the post-anaesthesia care unit was prolonged in the remifentanil 1.5 group. Maintaining the remifentanil effect-site concentration at 1.5 ng.ml(-1) during emergence from sevoflurane-remifentanil anaesthesia reduces the incidence and severity of coughing without serious adverse events and may provide haemodynamic stability in patients undergoing thyroidectomy. However, awakening may be delayed.

Epidural sufentanil provides better analgesia from 24 h after surgery compared with epidural fentanyl in children.

BACKGROUND: Studies comparing epidural fentanyl and sufentanil in adults reported a similar analgesic effect with variable side effects. We hypothesized that epidural fentanyl and sufentanil will have a similar analgesic effect in children undergoing urological surgery. METHODS: Sixty-four children undergoing urological surgery were randomized into two groups: fentanyl in ropivacaine (fentanyl group, n=32) and sufentanil in ropivacaine (sufentanil group, n=32). After anaesthesia, an epidural catheter was inserted at the L2-3, L3-4 or L4-5 interspace. For post-operative pain relief, a solution consisting of fentanyl 0.1 mcg/kg/ml or sufentanil 0.015 mcg/kg/ml in 1.5 mg/ml ropivacaine was infused at a rate of 2 ml/h. To assess post-operative pain, the faces pain scale and the face, legs, activity, cry, consolability score were recorded at 1, 6, 24, 48 and 72 h after surgery. The incidence of adverse effects such as hypoxia, sedation, pruritus, nausea and/or vomiting was also evaluated. RESULTS: Pain scores demonstrated no significant difference between the groups. The need for rescue analgesia during 24-72 h was higher in the fentanyl group than in the sufentanil group (6/32 vs. 0/32, P=0.012). The incidence of pruritus was higher in the sufentanil group compared with that in the fentanyl group (5/32 vs. 0/32). CONCLUSIONS: Epidural sufentanil provides better analgesia from 24 h after surgery compared with epidural fentanyl in infants and children undergoing urological surgery. The incidence of pruritus in the sufentanil group was higher than that in the fentanyl group.