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Manninen, Pirjo H.; Raman, Sitaram K.; Boyle, Kevin; El-Beheiry, Hossam
doi: 10.1007/bf03012507pmid: 10078396
PurposeTo assess the incidence and characteristics of early postoperative complications in patients following neurosurgical procedures.MethodsAll patients undergoing neurosurgery during a four month period were followed postoperatively for up to four hours in the post anesthetic care unit or intensive care unit. Patient information and all complications were documented by the investigators on a standardized form. Complications were classified as respiratory, cardiovascular, nausea and vomiting, shivering and other. Risk factors analyzed for the occurrence of complications included age, sex, ASA status, type of surgery, elective or emergency surgery and postoperative placement.ResultsFour hundred eighty six adult patients were followed, but in 55 patients the trachea remained intubated during the four hour study period and they were eliminated from the analysis of postoperative complications. At least one complication occurred in 54.5% of the remaining 431 patients. Respiratory problems occurred in 2.8%, trauma to the airway in 4.4%, cardiovascular complications in 6.7%, neurological in 5.7% and nausea and/or vomiting in 38%. The highest incidence of patients with complications was during spine (65%) and vascular (66%) surgery, compared with tumour (47%) and other (43%) surgery, P < 0.05. Other risk factors included age < 70 yr for nausea and vomiting (P < 0.02), and elective surgery for spine and vascular surgery (P < 0.001 ).ConclusionThere was a high incidence of early postoperative complications in neurosurgical patients. The most common problem was nausea and vomiting especially in the younger patient undergoing elective spine surgery.
Viitanen, Hanna; Tarkkila, Pekka; Mennander, Susanna; Viitanen, Matti; Annila, Päivi
doi: 10.1007/bf03012509pmid: 10078398
PurposeTo compare the induction and recovery characteristics of sevoflurane anesthesia induced with either propofol or sevoflurane in pédiatric outpatients.MethodsFifty-two children, aged 1–3 yr, presenting for ambulatory adenoidectomy were randomly allocated to receive 3 mg·kg−1 propofoliv or sevoflurane 8% inspired concentration for induction of anesthesia. Tracheal intubation was facilitated with 0.2 mg·kg−1 mivacurium. Anesthesia was maintained with nitrous oxide/oxygen (F1O2 0.3) and sevoflurane approximately 3–5% inspired concentration with controlled ventilation. Intubation was assessed by an anesthetist blinded to the induction method. Recovery characteristics were compared using the modified Aldrete scoring system, the Pain/Discomfort scale and measuring specific recovery times. A postoperative questionnaire was used to evaluate the children’s well-being at home.ResultsIntubating conditions were similar in both groups. Emergence from anesthesia occurred earlier with sevoflurane for induction than with propofol (11 ± 4 vs 17 ± 7 min (mean ± SD), P = 0.0002). More children in the sevoflurane group achieved full points on the modified Aldrete scoring system during the first 20 min after anesthesia (P < 0.05). However, children in the sevoflurane group scored higher in the Pain/Discomfort scale at 10 min after anesthesia (P = 0.04) and were given postoperative analgesics earlier than children in the propofol group (13 ± 5 min vs 18 ± 11 min,P = 0.03). The time to meet discharge criteria and recovery at home were similar.ConclusionsInduction of sevoflurane anesthesia with propofol for day-case adenoidectomy results in longer, but more calm, early recovery but does not delay discharge or affect recovery at home.
Lowry, Darryl W.; Mirakhur, Rajinder K.; Carroll, Miriam T.; McCarthy, Gerard J.; Hughes, Damien A.; O’Hare, Ronan A.
doi: 10.1007/bf03012510pmid: 10078399
PurposeTo determine the potency and time course of action of mivacurium neuromuscular block under routine clinical conditions during sevoflurane, isoflurane and intravenous anesthesia.MethodPatients were anesthetized with nitrous oxide 66% in oxygen and 1.5 MAC sevoflurane or isoflurane or a propofol infusion, neuromuscular block being monitored using mechanomyography. Potency was determined using administration of single doses of mivacurium of 40–100 μg·kg−1 and construction of dose-response curves (n = 72). The onset and duration of action were determined following a bolus dose of 0.2 mg·kg−1 of mivacurium (n = 30).ResultsThe ED50 and ED95 (with 95% confidence limits) were estimated to be 42 (35–51 ) and 86 (74–98) μg·kg−1, 52 (45–60) and 89 (72–110) μg·kg−1, and 53 (45–62) and 95 (81–112) μg·kg−1 during sevoflurane, isoflurane and propofol anesthesia respectively (P < 0.05 between sevoflurane and propofol). Following administration of the 0.2 mg·kg−1 dose, neither the times (mean ± SD) to maximum block ( 1.6 ± 0.31, 1.7 ± 0.21 and 1.6 ± 0.45 min, respectively) nor the times to 25 and 90% recovery of T1 (20 ± 4.5 and 33 ± 8.8 min, 21 ±3.8 and 33 ± 6.5 min, and 18 ± 4.1 and 28 ± 5.8 min respectively) were different among groups. The times to recovery of TOF ratio to 0.8 were 40 ± 10.0, 36 ± 8.5 and 29 ± 5.5 min in the sevoflurane, isoflurane and propofol groups respectively (P = 0.017 between the sevoflurane and propofol groups).ConclusionsUnder usual conditions of clinical anesthesia the potency of mivacurium was slightly enhanced during sevoflurane compared with intravenous anesthesia but the duration of action was only minimally prolonged during sevoflurane and isoflurane anesthesia.
Poblete, Beate; Van Gessel, Elisabeth F.; Gaggero, Giovanni; Gamulin, Zdravko
doi: 10.1007/bf03012511pmid: 10078400
PurposeTo determine among three currently used epidural test doses which is the most reliable for the detection of accidental intrathecal misplacement of an epidural catheter, and which clinical sign is to be used as a marker.MethodsNinety orthopedic patients were allocated to either the continuous epidural or the continuous spinal group according to age, < or > 70 yr. They received, in a randomised, double-blind fashion, one of the three solutions: 60 mg lidocaine 2% (L2%), 7.5 mg bupivacaine 0.25% (B0.25%), or 15 mg bupivacaine 0.5% (B0.5%); all three solutions contained epinephrine. Objective variables studied every two minutes over the first ten minutes after injection included: presence of a sensory level ≥ T12, presence of a motor block ≥ I, and anesthesia of segments L1, L2, S2 and S5. Subjective variables studied over the same period included paresthesias, sensation of warmth or cold, and muscle weakness.ResultsWhen using presence of motor block ≥ I on the Bromage scale, the administration of 60 mg L2% with epinephrine identified all patients having an intrathecal catheter six minutes after injection, whereas none of the patients receiving the same solution through the epidural catheter presented a motor block. This was not the case for the other two solutions studied.ConclusionLidocaine 2% with epinephrine at a dose of 60 mg is the test dose of choice to detect the intrathecal misplacement of an epidural catheter. The presence of motor block ^ I is the only reliable clinical sign.
Rajeeva, V.; Bhardwaj, N.; Batra, Y. K.; Dhaliwal, L. K.
doi: 10.1007/bf03012512pmid: 10078401
PurposeTo compare the efficacy of ondansetron-dexamethasone combination with ondansetron alone for prevention of postoperative nausea and vomiting (PONV).MethodsThis double blind, randomized study was carried out in 51 female patients, aged 20–40 yr, ASA-1 physical status undergoing gynecological diagnostic laparoscopy. Group 1 (n = 26) received 4mg ondansetroniv and group 2 (n = 25) received a combination of 4 mg ondansetron and 8 mg dexamethasoneiv soon after induction of anesthesia. Postoperatively patients were assessed hourly for four hours and then at 24 hr for nausea, vomiting, pain and post anesthetic discharge score. Vomiting occurring up to two hours was considered early vomiting and from 2–24 hr as delayed vomiting.ResultsThe postoperative nausea score was lower in patients receiving a combination of ondansetron and dexamethasone (3.76) than ondansetron alone (4.38) at 0 hr (P < 0.01), 2 hr (P < 0.05) and 24 hr (P < 0.01). In group 1, 38.5% of patients had a nausea score of ≥ 5 (major nausea) compared with only 12% of patients in group 2 (P < 0.025). The overall incidence of vomiting was greater in group 1 (35%) than in group 2 (8%) (P < 0.05). The combination group showed better control of delayed vomiting compared with the ondansetron group (4%vs 35%)(P< 0.0l).ConclusionThe combination of ondansetron and dexamethasone provides adequate control of PONV with delayed PONV being better controlled than early PONV
Roy, Louise; Ramanathan, Sivam
doi: 10.1007/bf03012515pmid: 10078404
PurposeTo evaluate myocardial contractility during ST segment depression in healthy parturients during Cesarean section (CS).MethodsForty-seven consecutive term parturients undergoing elective CS under spinal anesthesia were studied. The ST segment was recorded continuously on leads II and V5 using a Holter monitor. Myocardial performance was evaluated by measuring cardiac index (CI), heart rate (HR), pre-ejection period (PEP), ventricular ejection time (VET), systolic time ratio (STR, PEP/VET), and ejection fraction (EF) with an impedance cardiograph.ResultsFourteen patients (30%) developed ST segment depression within 15 min after delivery and the remaining 33 (70%) did not (controls). Seven patients developed a I mm change, five patients a 2 mm change and the remaining two a 3 mm change in the ST segment. Compared with pre-anesthesia values, the mean HR increased from 103 ± 10 to 116 ± 10 ( ISD) bpm (P = 0.001), CI from 4.7 ± 0.7 to 5.6 ± 1.7 L·min−1 (P = 0.01), EF from 0.58 ± 0.08 to 0.66 ± 0.05 (P = 0.01 ) and STR decreased from 0.26 ± 0.06 to 0.2 ± 0.04 (P = 0.01) during ST segment depression. At this time, CI, HR and EF were greater and STR smaller than values obtained 15 min after delivery in the control subjects.ConclusionST-segment depression occurring during CS is associated with a hyperkinetic myocardial contractile state.
Dennehy, Kevin C.; Dupuis, Jean-Yves; Nathan, Howard J.; Wynands, J. Earl
doi: 10.1007/bf03012516pmid: 10078405
PurposeTo illustrate the multiple causes of hypoxemia to be considered following cardiopulmonary bypass and how therapy given to improve oxygen delivery may have contributed to a decrease in arterial oxygen saturation to life-threatening levels.Clinical featuresA 61 yr old man with severe mitral regurgitation and chronic obstructive lung disease underwent surgery for mitral valve repair. A pulmonary artery catheter with the capacity to measure cardiac output and mixed venous oxygen saturation (SvO2) continuously was used. Two unsuccessful attempts were made to repair the valve which was finally replaced, requiring cardiopulmonary bypass of 3 17 min. Dobutamine 5 μg·kg−1·min−1 and sodium nitroprusside I μg·kg−1·min−1 were used to increase cardiac output. Soon after, the SvO2 decreased progressively from 55 to 39%. The patient became cyanotic with a RaO2 of 39 mmHg. Sodium nitroprusside was stopped and amrinone 100 mg bolus followed by 10 μg·kg−1·min−1 was given in addition to adding PEEP to the ventilation. With these measures PaO2 could be maintained at safe levels but PEEP and high inspired oxygen concentrations were needed postoperatively until the trachea could be extubated on the third postoperative day.ConclusionThe profound hypoxemia in this case was likely due to a combination of intra-and extrapulmonary shunt, both augmented by sodium nitroprusside. The desaturation of mixed venous blood amplified the effect of these shunts in decreasing arterial oxygen saturation. The interaction of these factors are analyzed in this report.
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