The effect of desmopressin on blood loss in patients with rheumatoid arthritis undergoing hip arthroplasty.

BACKGROUND: Blood loss is an important issue for patients with rheumatoid arthritis undergoing hip surgery. We hypothesised that intraoperative desmopressin treatment would result in a reduction in blood loss in rheumatoid patients undergoing total hip arthroplasty. METHODS: Seventy-five patients scheduled for elective total hip arthroplasty were randomised to three groups to receive 0.4 microg/kg desmopressin (D 0.4), 0.2 microg/kg desmopressin (D 0.2) or placebo intraoperatively in a double-blind fashion. Blood transfusions were based on calculated safe allowable blood loss and haemoglobin measurements (trigger 90 g/l, 5.59 mmol/l). The primary endpoint was the total blood loss measured till the end of the fourth post-operative day. Secondary endpoints included red cell transfusion requirements and haemoglobin. RESULTS: Total blood loss during the study period was not significantly different between the groups (D 0.4 1829 +/- 1068; D 0.2 2240 +/- 843 and placebo 2254 +/- 1040 ml; P= 0.50). The total amount of red cell transfusions was fewer in group D 0.4 (3.6 +/- 1.6 U) when compared with D 0.2 (4.4 +/- 1.7 U; P=0.009) and placebo (4.5 +/- 2.0 U; P= 0.011) groups. Haemoglobin concentration was lower in the placebo group in the first (5.42 +/- 1.16 vs. 5.98 +/- 0.47 mmol/l; P=0.033) and the second (6.28 +/- 0.66 vs. 6.69 +/- 0.47 mmol/l; P=0.033) post-operative mornings compared with group D 0.4. CONCLUSION: Despite a lack of difference in the primary outcome, total blood loss, intraoperative administration of 0.4 microg/kg desmopressin resulted in fewer total red cell transfusion requirements in rheumatoid patients undergoing total hip arthroplasty when compared with 0.2 microg/kg treatment and placebo.

Spread of spinal block in patients with rheumatoid arthritis.

BACKGROUND: In clinical practice, we noticed a greater than expected spread of sensory spinal block in patients with rheumatoid arthritis. We decided to test this impression and compared the spread of standard spinal anaesthesia in rheumatoid and non-rheumatoid control patients. METHODS: Spinal anaesthesia with 3.4 ml (17 mg) of plain bupivacaine was administered to 50 patients with seropositive rheumatioid arthritis and to 50 non-rheumatoid control patients. The protocol was standardised for all patients. All the patients were undergoing lower limb surgery and the rheumatoid patients were operated on due to their rheumatoid disease. The spread of sensory block was recorded 30 min from the dural puncture using a pin prick test and a cold ice-filled container. The impact of body mass index (BMI), height and age on the spread were analysed. RESULTS: The spread of sensory block was greater in patients with rheumatoid arthritis (15.6+/-3.1 dermatomes) than in non-rheumatoid patients (14.1+/-3.3 dermatomes) (P<0.05). Increasing BMI was related to cephalad spread of block in the rheumatoid group (P<0.05), but not in the control group. CONCLUSION: The mean spread of sensory block 30 min after the injection of plain bupivacaine was 1.5 segments cephalad in patients with rheumatoid arthritis than in those without this disease. BMI might be a patient-related factor contributing to the extent of the block in rheumatoid patients. These findings should be considered when performing a spinal block in rheumatoid patients.

Reducing the risk of systemic embolization during gynecologic laparoscopy--effect of volume preload.

BACKGROUND: About 27% of the population is known to have a patent foramen ovale. It can be opened if the left atrial pressure is less than the right atrial pressure. This pressure reversal has been reported during gynecologic laparoscopic surgery. The present paper describes with help of transesophageal echocardiography the pressure relationship between the atria during laparoscopic surgery and the effect of volume preload. METHODS: Twenty-one gynecologic ASA 1-3 patients were included in this open study. The movement of interatrial septum was monitored with transesophageal echocardiography during the procedure. If the septum movement was to the left, the patient was given 500 mL hydroxyethyl starch to increase the filling pressures. RESULTS: After induction, the mobile part of foramen ovale rounded to the right in 15 patients but six patients showed movement to the left. After pneumoperitoneum and head-down tilt, one patient of the six returned to normal but eight additional patients showed movement to the left. These 13 patients had a filling infusion of 500 mL hydroxyethyl starch. The movement was normalized in 12 patients. We saw echogenic particles coming from the inferior caval vein in every patient. Only one patient had very small atrial septal defects and no embolic complications. CONCLUSION: The head-down tilt and pneumoperitoneum had a more negative influence on the filling of the left side than on the filling of the right side of the heart. The pressure reversal occurs in systole during expiration of mechanical ventilation. The infusion of volume helps to normalize the pressure relationship and to diminish the embolic risk.

Reperfusion ventricular fibrillation and electric countershocks during coronary artery bypass operations--association with postoperative CK-MB release.

Reperfusion ventricular fibrillation during coronary artery bypass surgery is common and electric shocks are often needed to terminate it. Both the fibrillation and the reversing electric shocks are potentially detrimental to the myocardium. In 61 aortocoronary bypass patients with uncomplicated clinical course (no difficulties in weaning from bypass, no ECG changes and no inotropic medication), serial creatine kinase-MB values were recorded. Evaluated explanatory variables were patient age, ejection fraction, aortic occlusion time, perfusion time, number of peripheral anastomoses and of anastomoses to marginal branches, myocardial fibrillation time before aortic cross-clamping, after cross-clamping prior to cardiac arrest and after declamping, and number of defibrillations. The results indicated that reperfusion fibrillation times up to 10 minutes are not harmful, provided that left ventricular decompression is carried out. Too early and thus numerous defibrillations raise creatine kinase-MB levels and probably also damage the myocardium, and therefore should be avoided.

The effect of arterial pH on whole body oxygen uptake during hypothermic cardiopulmonary bypass in man.

To test the hypothesis of Rahn and Reeves that the optimal arterial pH during hypothermia follows the alpha-stat concept, we studied 50 patients during coronary artery bypass grafting or valve replacement (or both) and aortic occlusion. Intravenous anesthesia was produced by high-dose fentanyl. Thiopentone 3 mg.kg-1 body weight and pancuronium 0.1 mg.kg-1 body weight were given at the start of cardiopulmonary bypass to prevent shivering. When the temperature of venous blood reached 25 degrees C, pump flow was reduced to 1.8 L.m-2.min-1. In 17 patients (group I), arterial pH was changed in a randomized order either from high to low or from low to high by adjusting the carbon dioxide fraction of the gas flow to the bubble oxygenator. At the end of 10-minute periods with stable arterial pH, oxygen uptake was calculated by multiplying pump flow and the arteriovenous oxygen difference. In 33 other patients (group II), arterial pH was kept constant during the period of stable hypothermia at 25 degrees C, and two to five determinations of oxygen uptake were performed in each patient. The carbon dioxide fraction in the gas and arterial pH varied between the patients. In group I, oxygen uptake was 31.4 ml.m-2.min-1 at pH 7.31 and 40.3 ml.m-2.min-1 at pH 7.52-a significant difference (p less than 0.001). In group II, oxygen uptake was positively correlated to arterial pH (r = 0.52, p less than 0.01). Thus the results were in line with the alpha-stat concept of acid-base management during hypothermia.

Reversed left internal mammary artery graft for coronary bypass. Evaluation of function with digital subtraction angiography and radionuclide imaging.

Reversed left internal mammary artery grafting with retrograde flow to the left anterior descending coronary branch was used in five of 500 consecutive bypass operations. The indications were significant stenosis in the left subclavian artery (3 patients) or the proximal left internal mammary artery (1) and proximal damage to the left internal mammary artery during dissection from the thoracic wall (1). The postoperative clinical course was smooth in all five patients, with no evidence of myocardial ischemia. In follow-up averaging 14 months four patients were asymptomatic. The reversed internal mammary artery graft was visualized with digital subtraction angiography in four cases. Radionuclide imaging during exercise confirmed graft patency in all but the symptomatic patient, who was found to have an area of reversible ischemia anteriorly in the left ventricle.

The effect of thoracic epidural analgesia on respiratory function after cholecystectomy.

To assess the effect of thoracic epidural analgesia (TEA) on postoperative respiratory function and pulmonary complications, a prospective randomized trial was conducted in patients undergoing cholecystectomy. One hundred patients were allocated to TEA (n = 30), TEA + general anesthesia (TEA + GA) (n = 30), or general anaesthesia (GA) (n = 40) groups. Respiratory function was analysed by measuring forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), functional residual capacity (FRC), total lung capacity (TLC), peak expiratory flow (PEF) in the supine and sitting postures, and arterial blood gases. Postoperative pulmonary complications were carefully documented. TEA significantly prevented the postoperative deterioration of respiratory function as compared with general anaesthesia. FVC, FEV1 and PEF decreased by 20% in patients receiving TEA, in contrast to 55% in patients after GA on the day of operation. This improvement continued until the 2nd day after operation, when FVC, FEV1 and PEF and their recovery rates were equal in all groups. In the sitting posture the preoperative FVC, FEV1 and PEF were about 10% greater than in the supine position. After operation, this difference was further increased. The preoperative difference of 27% in FRC between the sitting and supine postures was maintained after operation. PaO2 decreased by 0.8 kPa after TEA, by 1.5 kPa after TEA + GA with the lowest value on the 2nd postoperative day and by 1.5 kPa after GA, with the lowest value immediately after operation. Simultaneous hypercarbia indicated hypoventilation, which may have contributed to impaired respiratory function on the following days.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of thoracic epidural analgesia on postoperative stress and morbidity.

A hundred patients scheduled for cholecystectomy were randomized to either thoracic epidural anaesthesia and analgesia for 24 h with bupivacaine intraoperatively about 100 mg and 15 mg/h thereafter (TEA) for postoperative analgesia, TEA combined with general anaesthesia (low dose fentanyl) (TEA + GA) and general anaesthesia (GA) (low dose fentanyl). During TEA and TEA + GA the arterial pressure was significantly decreased as compared with GA. TEA was associated by an intense haemodilution in comparison with GA. Blood glucose and plasma cortisol responses were significantly suppressed by TEA. The decreases in peripheral blood lymphocyte and eosinophilic counts observed after operation under GA was significantly reduced by TEA. The increase in the neutrophil count was inhibited by TEA but the increase in non-filamented neutrophils was significantly augmented by TEA. The postoperative alleviation of the alteration of the above mentioned parameters by TEA was slightly diminished in the TEA + GA group. However, we found no significant reduction in cardiac dysrhythmias (TEA 7%, TEA + GA 7% and GA 10%), ST-segment depression (TEA 17%), TEA + GA 3.3% and GA 12.5%), wound complication (TEA 3%, TEA + GA 0%, GA 0%), pneumonia (TEA 3%, TEA + GA 3% and GA 0%), subphrenic abscess (TEA 6%, TEA + GA 0%, GA 3%), mortality (TEA 0%, TEA + GA 3%, GA 0%), and urinary tract infect (TEA 17%, TEA + GA 7% and GA 2.5%). Since an equal number of patients in each group, about 30%, suffered one or more of the postoperative complications this epidural analgesia was not effective in reducing postoperative morbidity albeit the significant alleviation of the postoperative stress response.

[Peridural anesthesia with bupivacaine-CO2 and bupivacaine-HCl. A comparative study]. / Periduralanaesthesie mit Bupivacain-CO2 und Bupivacain-HCl. Eine vergleichende Untersuchung.

Carbonated bupivacaine and bupivacaine hydrochloride were used for epidural anaesthesia in patients undergoing surgery of the lower extremities. Thirty patients received 20 ml 0.5% bupivacaine hydrochloride and 32 patients 20 ml 0.42% carbonated bupivacaine. Carbonated bupivacaine had a more rapid onset of action and spread of both sensory and motor blockade than its hydrochloride salt. The differences were statistically significant.

Circulatory effects of pancuronium and alcuronium in patients with coronary artery stenosis.

Heart rate and systemic arterial blood pressure were recorded during induction of anaesthesia up to 9 min after endotracheal intubation in 92 patients scheduled for coronary artery bypass surgery, in order to study to what degree the circulatory response to induction of anaesthesia and intubation was modified by different relaxants. Pancuronium (pancuronium bromide) 0.1 mg X kg b.w.-1 and alcuronium (diallyl-nortoxiferine) 0.25 mg X kg b.w.-1 were randomly studied in 36 patients during induction with high-dose fentanyl and in 36 patients induced with thiopentone, diazepam, fentanyl and nitrous oxide. In patients given high-dose fentanyl anaesthesia, systolic blood pressure before, during and after intubation was significantly lower with alcuronium (P less than 0.01). The same difference between alcuronium and pancuronium was observed in balanced anaesthesia before endotracheal intubation. Induction of anaesthesia and intubation were followed by a moderate increase in heart rate, irrespective of the type of anaesthesia and relaxant. Subsequently, 20 patients (10 with high-dose fentanyl and 10 with balanced anaesthesia) were studied. They received pancuronium 0.05 mg X kg b.w.-1 + alcuronium 0.125 mg X kg b.w.-1. This mixture of relaxants produced an intermediate blood pressure response.

Hydroxyethyl starches, dextran and balanced salt solution in correction of hypotension during epidural anaesthesia.

A low molecular weight (Mw 38 000) and a medium molecular weight (Mw 125 000) hydroxyethyl starch and a medium molecular weight dextran (Mw 70 000) solution were compared with a balanced salt solution in 123 patients undergoing operations of the lower extremities in epidural anaesthesia; 500 ml of the studied solutions were infused during 15 min after the injection of the epidural anaesthetic. The need for etilefrine hydrochloride as a vasoconstrictor in correcting hypotensive reactions was recorded. Changes in haemoglobin (Hb), haematocrit (Hct), serum total protein and serum albumin concentrations were measured. The number of patients given etilefrine hydrochloride in the plasma-substitute groups was smaller than in the control group. The differences were, however, not statistically significant. The fall in blood pressure cannot be totally inhibited by administration of 500 ml plasma substitute. According to the differences in Hb, Hct, serum protein and albumin values, the hydroxyethyl starch solutions were significantly more effective plasma substitutes than the balanced salt solution and as effective as dextran. No side-effects attributable to the solutions used were observed.

Thoracic epidural analgesia and deep vein thrombosis in cholecystectomized patients.

The effect of continuous thoracic epidural analgesia (TEA) on the occurrence of postoperative deep vein thrombosis (DVT) was studied with the [125I]-fibrinogen uptake test in patients undergoing elective gallbladder surgery. The 98 patients were randomly allocated to three groups, viz. TEA for 24 hours, TEA plus general anesthesia with intermittent positive-pressure ventilation (IPPV) and general anaesthesia with IPPV but no TEA. The frequency of DVT was 13% in the group with general anaesthesia only and 7% in both of the other groups.