Postoperative analgesia with intramuscular morphine at fixed rate versus epidural morphine or sufentanil and bupivacaine in patients undergoing major abdominal surgery

Hydrofluoroalkane-134a (HFA) beclomethasone dipropionate (BDP) was formulated in a metered-dose inhaler (MDI) to deliver a particle size of 1.1 microm compared with 35 microns for currently marketed chlorofluorocarbon (CFC)-BDP products. Two phase I single-dose human deposition studies were conducted using technetium 99m-radiolabelled BDP in a press-and-breathe actuator without an add-on spacer. A healthy volunteer study (n=6) showed that 55-60% of the HFA-BDP ex-actuator dose was deposited in the lungs, with 29-30% deposited in the oropharynx. CFC-BDP deposition was 4-7% in the lungs and 90-94% in the oropharynx. The pattern of deposition within the lung showed that HFA-BDP was spread diffusely throughout the lung airways, whereas CFC-BDP was confined to the central airways with little, if any, peripheral airway deposition. A second study with asthmatics (n=16) confirmed that 56% of the HFA-BDP dose was deposited in the airways, with 33% in the oropharynx. In conclusion, hydrofluoroalkane-134a-beclomethasone dipropionate deposition was much greater in the airways than chlorofluorocarbon-beclomethasone dipropionate, with a concomitant reduction in oropharyngeal deposition. The increased lung deposition efficiency of the hydrofluoroalkane propellant has led to a reduction in the amount of beclomethasone dipropionate needed to achieve a similar efficacy. The penetration of the hydrofluoroalkane to the small airways may provide asthma treatment not afforded by conventional chlorofluorocarbons.     

Caudal morphine in paediatric patients: a comparison of two different doses in children after major urogenital surgery

As we had an opportunity to take blood samples from a totally thyroidectomized patient who had attempted suicide by taking 2,000 microg of Levothyroxine (L-T4), the serum levels of thyroid hormones were sequentially measured to investigate the metabolism of circulating thyroid hormones in an athyreotic human. The serum concentrations of most thyroid hormones reached a peak on the second day, but the serum T3 level showed a peak one day later. The maximum concentrations of T4 (315 microg/l), FT4 (48.8 ng/l) and rT3 (0.80 microg/l) were very high, while the peak T3 level (1.92 microg/l) did not exceed the upper limit of the normal range. The serum T4 and rT3 levels returned to their normal range 13-17 days after the suicide attempt. The TSH level was suppressed rapidly and reached its nadir (0.044 mU/l) on the 6th day. During this period, the T1/2 and MCR of serum T4 were 10.4 days and 0.64 l/day, respectively, which values were almost equivalent to those observed during 15 days after discontinuation of the maintenance L-T4 therapy. In summary, the oral intake of a large amount of L-T4 at one time does not induce a proportional increase in the T3 level in an athyreotic person. The MCR of serum T4 is decreased and the T1/2 of serum T4 is prolonged, probably due to the lack of intrathyroidal deiodination. These findings support the conclusion that the D1 activity in the thyroid is one of the major determinants in the metabolic clearance of serum T4.     

Midazolam for caudal analgesia in children: comparison with caudal bupivacaine

In a randomized, double-blind study we have examined the analgesic efficacy of caudal administration of midazolam, bupivacaine, or a mixture of both drugs in 45 children, undergoing inguinal herniotomy. They were allocated randomly into three groups (n = 15 in each) to receive a caudal injection of either 0.25% bupivacaine 1 ml.kg-1 with or without midazolam 50 micrograms.kg-1 or midazolam 50 micrograms.kg-1 with normal saline 1 ml.kg-1. There were no differences in quality of pain relief, postoperative behaviour or analgesic requirements between the midazolam group and the other two groups. Times to first analgesic administration (paracetamol suppositories) were longer (P < 0.001) in the bupivacaine-midazolam group than in the other two groups. Further, the bupivacaine-midazolam group received fewer (P < 0.05) doses of paracetamol than the bupivacaine group. Side effects such as motor weakness, respiratory depression or prolonged sedation were not observed in patients who received caudal epidural midazolam only. We conclude that caudal midazolam in a dose of 50 micrograms.kg-1 provides equivalent analgesia to bupivacaine 0.25%, when administered postoperatively in a volume of 1 ml.kg-1 for children following unilateral inguinal herniotomy.     

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.     

Comparison of caudal block using bupivacaine and ketamine with ilioinguinal nerve block for orchidopexy in children

Forty boys weighing less than 25 kg undergoing unilateral orchidopexy were randomly allocated to receive one of two analgesic regimens. Group C received a caudal epidural block with 0.25% bupivacaine 1 ml.kg-1 and preservative-free ketamine 0.5 mg.kg-1; Group L received an ilioinguinal nerve block with 0.25% bupivacaine 0.5 ml.kg-1 and infiltration of the wound with 0.25% bupivacaine 0.5 ml.kg-1. All subjects received diclofenac sodium 1-2 mg.kg-1 as a rectal suppository. Postoperative pain was assessed by means of a modified Objective Pain Score and analgesia was administered if this exceeded a value of 4. The median duration of analgesia was 10 h (range 2.6 to > 24 h) in Group C and 2.9 h (range 0.7 to > 24 h) in Group L (p < 0.05). There were no differences between groups in the incidence of motor block, urinary retention, postoperative vomiting or postoperative sedation. Subjects in Group L required significantly more doses of postoperative analgesia than those in Group C (p < 0.05).     

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.     

Total intravenous anaesthesia with sufentanil-midazolam for major abdominal surgery

Haemodynamic and endocrine stress responses were compared during total intravenous anaesthesia with sufentanil and midazolam or fentanyl and midazolam in patients undergoing elective major abdominal surgery. Twenty-two ASA I and II patients were allocated randomly to receive sufentanil (induction 1.5 micrograms kg-1 plus infusion 1.5 micrograms kg-1 h-1) or fentanyl (induction 10 micrograms kg-1 plus infusion 10 micrograms kg-1 h-1) supplemented with 0.15 microgram kg-1 sufentanil or 1 microgram kg-1 fentanyl as necessary. Midazolam was infused to obtain plasma concentrations of 500-600 ng ml-1. Ventilation was with oxygen-enriched air. The opioid infusion was reduced post-operatively by half and benzodiazepine effects were reversed by titration with flumazenil. Mean arterial pressure, heart rate and cardiac index decreased in both groups after induction (cardiac index: sufentanil 4.94 +/- 0.45 to 2.99 +/- 0.18 litre min-1; fentanyl 4.97 +/- 0.45 to 3.71 +/- 0.36 litre min-1), but all returned to baseline during surgery. With sufentanil; mean arterial pressure was lower throughout the study period, and heart rate was lower intra-operatively. Oxygen uptake decreased in both groups after induction (sufentanil 289 +/- 29 to 184 +/- 21 ml min-1; fentanyl 318 +/- 32 to 216 +/- 32 ml min-1) and remained low with sufentanil until flumazenil was given. Adrenaline concentrations increased in both groups but there was no intergroup difference. The median noradrenaline concentration was lower intra-operatively with sufentanil (0.47 nmol litre-1 (range 0.06-6.77)) than with fentanyl (0.73 nmol litre-1 (0.07-4.58)). Cortisol, glucose and lactate concentrations increased in both groups. Bradycardia occurred in four patients with sufentanil and in three with fentanyl. There were two cases of marked thoracic rigidity with sufentanil and one with fentanyl.     

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.     

Reduced postoperative analgesic demand after inhaled anesthesia in comparison to combined epidural-inhaled anesthesia in patients undergoing abdominal surgery

A central reaction in homologous recombination is synapsis, which involves invasion of duplex DNA by a homologous single strand. A key intermediate in this process is the presynaptic filament, a protein-DNA complex composed of a "strand transferase" polymerized along the invading single strand. In this report, the organization and mechanism of assembly of the bacteriophage T4 presynaptic filament are explored. Three T4 proteins, encoded by the uvsX, uvsY and 32 genes, are involved in this process. It is demonstrated that a well-defined series of events involving multiple protein-DNA and protein-protein interactions is required to mediate a transition from an initial gene 32-DNA complex to a mature presynaptic filament in which the UvsX and UvsY proteins are in contact with the DNA and each other, while most or all of the gene 32 protein is removed from the complex.     

Metabolic alkalosis in children undergoing cardiac surgery

OBJECTIVE: To define the frequency of metabolic alkalosis and its pathogenesis in children after open-heart surgery. DESIGN: Retrospective chart review. SETTING: Multidisciplinary, tertiary, pediatric intensive care unit. PATIENTS: Fifty-six consecutive children undergoing open-heart surgery. MEASUREMENTS AND MAIN RESULTS: Metabolic alkalosis occurred in 29 (52%) of 56 patients. Seventy-two percent of patients < 12 months of age developed metabolic alkalosis as compared with 30% of patients > 12 months of age (p < .01 by chi-square). Patients developing metabolic alkalosis were younger, received more furosemide, had lower serum chloride concentrations, and underwent longer cardiopulmonary bypass times than nonmetabolic alkalosis patients. By stepwise multiple linear regression analysis, only age (p < .05) and serum chloride concentrations (p < .001) had independent correlations with the development of metabolic alkalosis; both variables had inverse correlations with arterial pH (r2 = .42). Patients with metabolic alkalosis also developed significantly (p < .01 by two tailed Student's t-test) lower serum ionized calcium concentrations (4.2 +/- 0.5 mg/dL [1.05 mmol/L]) as compared with nonmetabolic alkalosis patients (4.6 +/- 0.4 mg/dL [1.15 mmol/L]). CONCLUSIONS: Postoperative metabolic alkalosis occurs frequently in children undergoing open-heart surgery. Chloride depletion seems to be the predominant factor in the pathogenesis of metabolic alkalosis. Younger age can serve as a positive predictor for the development of metabolic alkalosis in this subset of patients.     

Urinary morphine excretion during and after morphine anaesthesia for open-heart surgery in children

The urine of 20 children undergoing complete correction of atrial septal defect (ASD) or tetralogy of Fallot (TF) were analyzed for morphine and its glucuronide conjugation product before and after induction of morphine anaesthesia, throughout the operation and for two hours post-operatively. Children with ASD had a higher, mean urine flow rate during anesthetic induction and during the entire operation than those with TF (P less than 0.01). ASD children excreted a greater percentage of the administered morphine by the time they reached the recovery room and after two hours in the recovery room than those with TF. Urinary morphine in the glucuronide form increased progressively from anaesthetic induction until the post-operative period in both groups and was more than 93% after two hours in the recovery room. Fifty-five per cent of ASD patients had respiratory dynamics that enabled them to be extubated within six hours of the end of their operation. Those that could be extubated after six hours had excreted a significantly greater percentage of morphine than those that couldn't (P less than 0.025). None of the children with TF could be extubated until the day after operation. These data demonstrate that the ability to maintain adequate spontaneous respiration after morphine anaesthesia is directly related to urinary output during anaesthesia and operation.     

A comparison of prophylactic ondansetron and metoclopramide administration in patients undergoing major neurosurgical procedures

In a prospective, randomised, double-blind trial, we assessed the relative efficacy of prophylactic ondansetron and metoclopramide administration in the reduction of postoperative nausea and vomiting in 60 patients undergoing routine major neurosurgical procedures. The patients were randomly allocated into one of two groups. Both groups received a standardised anaesthetic. When the dura mater was closed, patients in group A received an intravenous injection of metoclopramide 10 mg whilst group B received ondansetron 8 mg intravenously. Patients who received metoclopramide experienced less postoperative nausea and vomiting than those who received ondansetron in the 48 h following surgery (17 (56%) versus 9 (30%) p = 0.038). In the light of these findings, we believe that ondansetron is an inappropriate agent for the prevention of postoperative nausea and vomiting in the neurosurgical population.     

Respiratory effects of extradural analgesia after lower abdominal surgery

Blood-gas tensions, FRC and volume of trapped gas (VTG) in the lung were measured in patients on the day before lower abdominal gynaecological surgery, and twice on the day following surgery, before and after establishing lumbar extradural block (EDB) using 0.5% bupivacaine to provide analgesia after operation. FRC and VTG were measured with the closed-circuit helium-dilution technique. Mean VTG was 175 ml before operation and 275 ml after operation. PaO2 decreased significantly after operation, and the changes in FRC and VTG that occurred were related qualitatively. EDB did not significantly alter FRC, VTG or PaO2. Individual changes in FRC could not be related to changes in VTG or PaO2. Although EDB provided effective analgesia, the variables measured did not indicate that EDB conferred an immediate respiratory advantage.     

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.     

Postoperative hypoxaemia: continuous extradural infusion of bupivacaine and morphine vs patient-controlled analgesia with intravenous morphine

We carried out a randomized prospective study in 60 patients who had undergone major abdominal surgery for cancer. For postoperative pain control, 30 patients received continuous extradural infusion of 0.125% bupivacaine 12.5 mg h-1 and morphine 0.25 mg h-1 (EXI group) and 30 received patient-controlled analgesia (PCA) with intravenous morphine (1 mg bolus, 5-min lock-out and maximum dose 20 mg 4h-1). Both groups had general anaesthesia. The two groups were compared for postoperative pain scores, satisfaction, sedation and oxygen saturation. Oxygen saturation was recorded continuously the night before surgery and for two consecutive postoperative nights. Episodes of moderate desaturation (90% > SpO2 85%) were more frequent in the EXI group than in the PCA group (P < 0.05). Pain scores were lower in the EXI group compared with the PCA group at rest and while coughing (P < 0.05). No significant difference was found for patient sedation and satisfaction.     

Randomized study of two doses of didanosine in children infected with human immunodeficiency virus

2'3'-Dideoxyinosine (didanosine) is a nucleoside analog active in vitro against human immunodeficiency virus. Few data are available regarding its use for the treatment of children. In a single-center, randomized, open-label trial, we compared two dosages of didanosine (120 vs 270 mg/m2 per day) for at least 6 months in 34 children infected with human immunodeficiency virus who had become resistant to or were intolerant of zidovudine. Serum levels of didanosine 1 hour after administration were significantly different in the two groups and remained stable with time. There was a significant reduction in human immunodeficiency virus-p24 antigenemia and quantitative cellular viremia with time but no difference between the two groups. The intensity of the biologic response, however, was significantly higher in the patients who had more than 50 CD4+ cells 10(6)/L at inclusion. No pancreatic or neurologic toxic effects were observed. In five children, liver function abnormalities developed that are unusual in this setting, and the death of one child from unexplained hepatocellular failure suggests that didanosine may be hepatotoxic. Three of these five children had preexisting liver disease. Although no definite conclusion can be made as to the optimal dose, there were no major differences between the two administration schedules in terms of biologic effects and tolerability.