Total intravenous anaesthesia with propofol or inhalational anaesthesia with isoflurane for major abdominal surgery. Recovery characteristics and postoperative oxygenation--an international multicentre study

Two hundred and ten adult patients undergoing open cholecystectomy, vagotomy or gastrectomy were included in a randomised multicentre study to compare postoperative nausea and vomiting, oxygen saturations for the first three postoperative nights, time to return of gastrointestinal function, mobilisation, and discharge from the hospital following induction and maintenance of anaesthesia with propofol and alfentanil or with thiopentone, nitrous oxide, isoflurane and alfentanil. Recovery from anaesthesia was significantly faster in the propofol group (mean (SD) times to eye opening and giving correct date of birth of 14.0 (SD 13.8) and 25.5 (SD 29.5) minutes, and 18.5 (SD 14.8) and 35.5 (SD 37.2) minutes in the propofol and isoflurane groups respectively). There was significantly less nausea in the propofol group (15.4%) than in the isoflurane group (33.7%) in the first two postoperative hours (p < 0.003) but not thereafter. There were no significant differences between the groups in any other recovery characteristics. The incidence of hypoxaemia (arterial oxygen saturation less than 93%) was close to 70% in both groups for the first three postoperative nights, indicating the need for oxygen therapy after major abdominal surgery.     

Total intravenous anaesthesia in Charcot-Marie-Tooth disease. Case report

A Total Intravenous Anaesthesia (TIVA) protocol in a case of hereditary motor-sensory neuropathy Charcot-Marie-Tooth disease in three consecutive orthopaedic surgical procedures is described. History, physical examination and sural nerve fascicular biopsy findings are reported. Problems related to the perioperative anaesthesiological management in peripheral neuropathies are discussed. Propofol and fentanyl without muscle relaxants, proved to be a safe technique, fast at reaching the level of surgical anaesthesia required, manageable for maintenance and rapidly reversible.     

Complications following major abdominal surgery in cirrhotic patients

The morbidity and mortality associated with major abdominal surgical interventions in 34 histologically proven cirrhotic patients are analyzed by the authors. The surgical interventions were carried out as urgent, absolute and elective indications. Thirty-seven general and surgical complications were observed following major abdominal surgery in 34 cirrhotics. Seven out of 34 patients died, giving a mortality rate of 21%. Suture-line insufficiency, peritonitis, sepsis and other inflammatory processes turned out to be the most common complications. Statistical analysis showed that the Child criteria, prothrombin level and white blood cell count were useful prognostic factors.     

Comparison of morphine with and without fentanyl for epidural analgesia after major abdominal surgery

Expression of fusion proteins between prepro-alpha-factor and somatostatin (SRIF) in yeast, resulted in the correct processing and secretion of the heterologous 14-amino acid SRIF peptide (1). When the chimeric genes were placed under the control of yeast acid phosphatase (PHO5) promoter, significant amount of an unglycosylated form of the fusion precursor molecule accumulated intracellularly, suggesting disruption of an endoplasmic reticulum-mediated function. We report here that the appearance of the precursor is due to an alteration in the three amino terminal residues of the chimera, i.e., Met-Arg-Phe in native prepro-alpha-factor is changed to Met-Phe-Lys in the hybrids. The unglycosylated precursor represents a population of molecules that are disrupted at an early stage of targeting to or translocation across the endoplasmic reticulum membrane. Our data demonstrate that the N-terminus plays an important role in topogenesis. Furthermore, these results show that translocation and glycosylation can be uncoupled from protein synthesis in vivo, and therefore can be posttranslational events in yeast.     

Ventilation during total intravenous anaesthesia with ketamine

In a retrospective study, we analyzed our experiences in 24 patients with acute ischemia from popliteal artery aneurysms over a period of 27 years and evaluated the value of a preoperative lytic therapy as an adjunct to surgical revascularization, compared to surgery alone. Preoperative urokinase therapy revealed a satisfactory improvement of the runoff in all cases. Follow-up angiography showed complete lysis in 6 and incomplete lysis in 3 of 9 patients. In contrast, in patients treated by surgery alone, postoperative angiography showed residual clots in all cases. The overall amputation rate was 25% (6/24) in 24 popliteal aneurysms with acute ischemia, including four patients with primary amputation for irreversible gangrene. Bypass grafting alone resulted in an early amputation rate of 9% (1/11) and occlusive complications of 45% (5/11) compared to no limb loss and no bypass complication in patients who underwent combined surgery and preoperative lysis (0/9). Our results underline the value of preoperative lytic therapy as an important factor in the management of acute ischemia in popliteal artery aneurysms.     

Cardiovascular and biochemical evidence of stress during major surgery associated with different techniques of anaesthesia

The relative merits of a potent narcotic and a spinal analgesic to affect the stress response to a standard operation have been assessed. Forty-five fit patients scheduled for abdominal hysterectomy were allocated at random to three groups, referred to as standard (i.v. anaesthesia alone), spinal (spinal plus i.v. anaesthesia) and fentanyl (fentanyl plus i.v. anaesthesia) groups. In the doses used, fentanyl produced the most effective attenuation of the cardiovascular, hormonal and metabolic responses to stress, but had the disadvantage of prolonged respiratory depression. Spinal anaesthesia gave only a modified blockade of the response to stress and did not obtund the response to intubation.     

Impaired recovery of strength in older patients after major abdominal surgery

OBJECTIVE: This study compared changes in muscle strength after major elective abdominal surgery in young and old patients, and related these changes to body composition and nitrogen balance. SUMMARY BACKGROUND DATA: The breakdown of muscle protein, erosion of lean tissue, and negative nitrogen balance are characteristic metabolic responses to surgical illness. With a substantial loss of muscle mass typical of advancing age, the authors postulated that older patients would be weaker during acute surgical illness and less able to maintain muscle function and meet metabolic demands. METHODS: Active, community-dwelling individuals undergoing major abdominal procedures who were 70 years of age or older or 50 years of age or younger were studied. Total body water (TBW) was determined preoperatively by deuterium oxide dilution. Maximal voluntary handgrip, respiratory muscle strength, and visual analog pain scores were measured preoperatively and on postoperative days 2, 4, and 6. All urine was collected postoperatively for 7 days for determination of total nitrogen, creatinine, and cortisol. RESULTS: The young (age, 36 +/- 9 years [mean +/- standard deviation]; n = 20) and old groups (age, 77 +/- 5 years; n = 20) were similar regarding weight, sex distribution, nutritional status, surgical procedures and anesthesia, and postoperative urine cortisol values. Age group, time after operation, and interaction effects were significant for each strength variable (all p < 0.005 by analysis of variance). Older patients had lower preoperative strength (29% to 41%) and mean 24-hour urine creatinine (27%). Postoperative strength was decreased most markedly on postoperative day 2, with similar proportional changes in the two age groups but lower absolute levels in the older patients. The rate of recovery of strength was substantially less rapid and complete in older patients. Older patients had less postoperative pain and received much less parenteral narcotic than younger patients. Postoperative urine nitrogen was similar in each group. Recovery of strength was not related to malignancy, preoperative strength, muscle mass (urine creatinine), lean body mass (TBW), sex, malignancy, pain, or narcotic administration. CONCLUSIONS: Older patients are weaker preoperatively than younger patients; their strength falls to lower levels after surgery and their postoperative recovery of strength is impaired. The lesser preoperative strength of older patients is due in large part but not totally to diminished muscle mass. Their impaired postoperative recovery appears to be related to more acute factors, such as muscle energetics or substrate availability.     

Alfentanil-oxygen anaesthesia for coronary artery surgery

The anaesthétic properties of alfentanil were evaluated in 15 patients undergoing coronary artery bypass grafting operations. Alfentanil was infused at a rate of 3.0mg min-1 until the patients (breathing pure oxygen) became unconscious. Additional alfentanil 2.5-5.0mg i.v. was given if systolic arterial pressure increased by 15% or more from control values. Alfentanil produced unconsciousness in 75 +/- 18s, but muscle rigidity occurred in 27% of patients. Cardiovascular dynamics were minimally altered during the induction of anaesthesia and throughout most of the operation, although 60% of patients became hypertensive during sternotomy and 73% during sternal spread. Recovery from anaesthesia was rapid with patients regaining consciousness after 1.4 +/- 0.6h and fulfilling out criteria for extubation of the trachea 4.1 +/- 1.2h after operation. No patient was aware of laryngoscopy, endotracheal intubation or any aspect of the operation.     

Intra-arterial regional anaesthesia for hand surgery with alkalinized 0.5% lignocaine

Intra-arterial regional anaesthesia (IARA) for hand surgery is an old, forgotten technique. One of the causes of low popularity may be a scalding sensation in the hand during intra-arterial injection of lignocaine, which may be caused by low pH of lignocaine's solution. In this randomized, double-blind study, normal (pH 5.2-5.3) or alkalinized (pH 7.2-7.3) preservative-free 0.5% lignocaine 1.5 mg kg-1 was injected into the radial arteries of forty adult patients to produce anaesthesia for ambulatory hand surgery. Scalding sensation in the hand during intra-arterial injection (VAS) was less pronounced with alkalinized lignocaine (P = 0.04). The time of onset and regression of analgesia was similar in both groups. Four patients in group 1 (normal lignocaine) and six patients in group 2 (alkalinized lignocaine) needed supplemental analgesia at the start of surgery (NS). Cannulation time, operating conditions, motor blockade, surgical-, and tourniquet pain scores (VAS) and patient's acceptance were similar. Three patients (two in group 1 and one in group 2) had minor systemic adverse effects after tourniquet release (NS). Nine patients in group 1 and seven in group 2 developed minor bruises after cannulation (NS). No other sequelae of intra-arterial injections were observed. We conclude that alkalinized 0.5% lignocaine was less painful on injection than normal lignocaine and should be preferred for intra-arterial anaesthesia for hand surgery.     

The addition of tenoxicam to prilocaine for intravenous regional anaesthesia

The analgesic effects of tenoxicam 20 mg added to prilocaine in a standard Bier's block (group 2) was studied in 45 patients who had their Colles' fractures reduced under intravenous regional anaesthesia, and compared both to a control group (group 1), and to a group who received a standard Bier's block combined with the same dose of tenoxicam given intravenously into the contralateral arm (group 3). Patients in group 2 obtained significantly better analgesia than group 1, as judged by a longer time before first additional analgesia was required (p < 0.05), less total analgesic consumption (p < 0.01), and lower pain scores (p < 0.01). These benefits were not obtained by patients in group 3.     

Elective appendectomy with abdominal and pelvic surgery

A series is presented of 830 patients in whom elective appendectomy was performed at the time of laparotomy for other intraabdominal disease. Special emphasis is given to 490 such procedures among 1042 patients with abdominal hysterectomy, an incidence of 47%. This increases to 57% by exclusion of patients with previous appendectomy. The contraindications to elective appendectomy are discussed, as well as its morbidity, mortality, and complications. The author concludes that an elective appendectomy should be performed with abdominal and pelvic surgery whenever the opportunity is presented, provided that the procedure is not prohibited by the contraindications discussed.     

A case report of a successful surgery for thoracoabdominal aortic aneurysm under partial cardiopulmonary bypass with selective perfusion of major abdominal branches

A 69-year-old man showed gradually developing thoracoabdominal aortic aneurysm (TAAA) after coronary artery bypass grafting. The patient underwent graft replacement of TAAA uneventfully under partial cardiopulmonary bypass with selective perfusion of major abdominal branches. The major abdominal branches and two pairs of intercostal arteries were reconstructed. The patient showed no organ failure or spinal damage postoperatively. Partial cardiopulmonary bypass with selective perfusion of abdominal branches successfully protected both the visceral organs and the spinal cord from ischemia in a TAAA surgery.     

Late results of surgery for abdominal aortic aneurysm

Little is known concerning sexually experienced and inexperienced adolescent girls' perceptions of the prevalence of condom use and sexually transmitted diseases (STDs). Girls (n = 174; 41% sexually experienced) rated the prevalence of condom use among friends and STDs among male and female friends and adolescents in general. Girls perceive the prevalence of STDs similarly across both gender and level of familiarity. For the most part, however, the girls perceived the prevalence among boys and girls more similarly than among friends and adolescents in general. No significant differences were found between sexually experienced and inexperienced girls in perceptions of condom use prevalence, but girls with a history of STD perceived condoms as used less frequently. Girls with an STD history perceived STDs as the most prevalent, followed by sexually inexperienced girls and then sexually experienced girls without a history of an STD. After an adolescent girl initiates sexual intercourse, STD experience could be a key variable in affecting her perceptions. Prevention programs can incorporate an understanding of patients' perceptions of condom use and STDs.     

Emergency reoperations in the reconstructive surgery of abdominal aorta and major arteries of the lower extremities

The experience with treatment of 564 patients who underwent 642 reoperations on the arterial vessels, including 281 emergency operation, are presented. The causes of the development of pronounced ischemia of the lower extremities and that of the extreme situation are considered. The surgical tactics for the treatment in cases of transplant infection, erosive bleeding from aortal anastomosis etc. have been developed. The original methods for surgical correction in performance of a reoperation have been suggested, the analysis of the results of treatment has been performed.