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Comparison of invasive and less-invasive techniques of cardiac output measurement under different haemodynamic conditions in a pig model
- J. Bajorat, R. Hofmockel, D. A. Vagts, M. Janda, B. Pohl, C. Beck, G. Noeldge-Schomburg
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- Published online by Cambridge University Press:
- 23 December 2005, pp. 23-30
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Summary
Background and objective: Despite the introduction of various less-invasive concepts of cardiac output measurement, pulmonary arterial thermodilution is still the most common measurement technique. Methods: This prospective controlled study was designed to compare different methods of cardiac output measurement simultaneously. Pulmonary arterial thermodilution, transpulmonary thermodilution (PiCCO™), trans-oesophageal echo-Doppler probe (HemoSonic™) and partial carbon dioxide rebreathing technique (NICO™ monitor) were evaluated against a peri-aortic transit-time flow-probe as reference method in a clinically relevant animal model. After approval from the Local Ethics Committee on Animal Research, the investigations were conducted in nine anesthetized domestic pigs. Systemic haemodynamics were modulated systematically by the application of catecholamines, caval occlusion and exsanguination. Statistical analysis was performed with Bland–Altman and linear regression. Results: A total of 366 paired cardiac output measurements were carried out at a reference cardiac output between 0.5 and 7 L min−1. The correlation coefficients for pulmonary arterial and transpulmonary thermodilution against reference were 0.93 and 0.95, for trans-oesophageal Doppler and partial rebreathing technique 0.84 and 0.77. Pulmonary arterial thermodilution and transpulmonary thermodilution showed comparable bias and limits of agreement. Where HemoSonic™ showed an overestimation of cardiac output at a higher precision, NICO™ overestimated low and underestimated higher cardiac output values. Conclusions: Our data suggest that pulmonary arterial thermodilution and PiCCO™ may be interchangeably used for cardiac output measurement even under acute haemodynamic changes. The method described by Bland and Altman demonstrated an overestimation of cardiac output for both thermodilution methods. HemoSonic™ and NICO™ offer non-invasive alternatives and complementary monitoring tools in numerous clinical situations. Trend monitoring and haemodynamic optimizing can be applied sufficiently, when absolute measures are judged critically in a clinical context. The use of the NICO™ system seems to be limited during acute circulatory changes.
- Cited by 78
Prothrombin complex concentrates: a brief review
- C. M. Samama
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- 01 October 2008, pp. 784-789
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Prothrombin complex concentrates are haemostatic blood products containing four vitamin K-dependent clotting factors (II, VII, IX and X). They are a useful, reliable and fast alternative to fresh frozen plasma for the reversal of the effects of oral anticoagulant treatments (vitamin K antagonists). They are sometimes used for factor II or factor X replacement in patients with congenital or acquired deficiencies. They are widely prescribed in Europe. Several retrospective and prospective studies have demonstrated their efficacy in normalizing coagulation and in helping to control life-threatening bleeding. Few side-effects, mainly thromboembolic events, have been reported. The link between these events and prothrombin complex concentrate infusion has, however, often been brought into question. The use of prothrombin complex concentrates in new promising indications such as the management of massive bleeding requires prospective studies providing a high level of evidence in a high-risk setting.
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The efficacy and neurotoxicity of dexmedetomidine administered via the epidural route
- S. Konakci, T. Adanir, G. Yilmaz, T. Rezanko
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- 01 May 2008, pp. 403-409
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Background
α2-Adrenoceptor agonists administered into the intrathecal and epidural space have been found to be effective in the treatment of chronic pain. Moreover, it was shown that they increase the analgesic effects of local anaesthetics and provide sedation, anxiolysis and haemodynamic stability. Dexmedetomidine, a potent and highly selective α2-adrenoceptor agonist, is in current clinical use, particularly in the intensive care unit. Our aim was to investigate whether dexmedetomidine produced motor and sensory blockade and neurotoxic effects when administrated via the epidural catheter in rabbits.
MethodsTwenty-one New Zealand white rabbits were included in the study. Animals were randomized into three groups. In Group L: lidocaine (2%), in Group LD: lidocaine (2%) + dexmedetomidine (5 μg) and in Group D: dexmedetomidine (10 μg) were administered by epidural catheter. Motor and sensory blockade were evaluated. After the evaluation of block, the animals were euthanized and their spinal cords removed for neuropathological evaluations.
ResultsMotor and sensory blockade were lower in Group D than in Group L and Group LD (P < 0.01). Although there were no differences between the groups for ischaemia of the medulla spinalis, evidence of demyelinization of the oligodendrocytes in the white matter in Group D was significantly higher than in Group L (P = 0.035).
ConclusionsWe observed that dexmedetomidine does not have motor and sensory effects, but it may have a harmful effect on the myelin sheath when administered via the epidural route.
- Cited by 78
The midazolam-induced paradox phenomenon is reversible by flumazenil. Epidemiology, patient characteristics and review of the literature
- A. A. Weinbroum, O. Szold, D. Ogorek, R. Flaishon
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- 16 August 2006, pp. 789-797
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Background and objective Midazolam may occasionally precipitate hostility and violence instead of tranquillity. We characterized these episodes, their rate of occurrence, the potential paradoxical responders and possible predisposing circumstances among patients undergoing lower body surgery under spinal or epidural anaesthesia and midazolam sedation.
Patients and methods Fifty-eight patients who fulfilled the study entry criteria and who underwent surgery within a 3-month period in a large metropolitan, university-affiliated hospital were enrolled. Sedation and restlessness in all patients were controlled by midazolam administered intravenously by the attending anaesthesiologist; these parameters were later objectively confirmed by recorded actigrams. If ‘paradoxical’ events occurred, flumazenil 0.1 mg 10 s−1 was injected until the aberrant behaviour ceased. Patients with paradoxical reactions were later compared with matched control patients selected from the study group to identify epidemiological characteristics.
Results The incidence of paradoxical events was 10.2% (six out of 58 patients, confidence limits 2.3–18.3%) and they occurred 45–210 min after sedation started; the only independent predictor was an age older than that of the entire study group. The mean cumulative and per weight doses of midazolam were similar for both the experimental and the study groups of patients: 7.3 ± 2.8 to 10.1 ± 3.6 mg, and 0.1 ± 0.04 to 0.12 ± 0.05 mg kg−1. Flumazenil 0.2–0.3 mg (range 0.1–0.5 mg) effectively stopped the midazolam-induced paradoxical activity within 30 s and surgery continued uneventfully.
Conclusions Flumazenil completely reverses midazolam-induced paradoxical reactions and they are more frequent in older patients.
- Cited by 77
Venous thromboembolism prevention in surgery and obstetrics: clinical practice guidelines
- C. M. Samama, P. Albaladejo, D. Benhamou, M. Bertin-Maghit, N. Bruder, J. D. Doublet, S. Laversin, S. Leclerc, E. Marret, P. Mismetti, E. Samain, A. Steib
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- 20 January 2006, pp. 95-116
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Summary
Background and objective: To produce up-to-date clinical practice guidelines on the prevention of venous thromboembolism in surgery and obstetrics. Methods: A Steering Committee defined the scope of the topic, the questions to be answered, and the assessment criteria. Eight multidisciplinary working groups (total of 70 experts) performed a critical appraisal of the literature in the following disciplines: pharmacology of antithrombotic agents, orthopaedics; general surgery (gastrointestinal (GI) and varicose vein surgery); urology; gynaecology and obstetrics; thoracic, cardiac and vascular surgery; surgery of the head, neck and spine; and surgery of burns patients. The resultant reports and guidelines were submitted for comment and completion of the Appraisal of Guidelines Research & Evaluation questionnaire to a total of 150 peer reviewers, before producing definite guidelines. Results: The report answers the following questions for each type of surgery: (i) What is the venous thromboembolism incidence according to clinical and/or paraclinical criteria in the absence of prophylaxis? (with stratification of venous thromboembolism risk into low, moderate and high categories); (ii) What is the efficacy and safety of the prophylactic measures used? (iii) When should prophylaxis be introduced and how long should it last? (iv) Does ambulatory surgery affect efficacy and safety of prophylaxis? Conclusions: Apart from answering the above questions, the guidelines provide a summary table for each discipline. This table stratifies types of surgery into the three risk categories, specifies the recommended prophylaxis for venous thromboembolism (pharmacological and/or mechanical) and grades each recommendation. In addition, whenever appropriate, the recommended prophylaxis is adjusted to low- and high-risk patients.
- Cited by 76
Magnesium infusion reduces perioperative pain
- H. Kara, N. Şahin, V. Ulusan, T. Aydoğdu
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- 16 August 2006, pp. 52-56
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Background and objective: Magnesium has antinociceptive effects in animal and human models of pain. These effects are primarily based on the regulation of calcium influx into the cell. The aim of this study was to determine whether perioperative infusion of magnesium would reduce postoperative pain and anxiety.
Methods: Twenty-four patients, undergoing elective hysterectomy, received a bolus of 30 mg kg−1 magnesium sulphate or the same volume of isotonic sodium chloride solution intravenously before the start of surgery and 0.5 g h−1 infusion for the next 20 h. Intraoperative and postoperative analgesia were achieved with fentanyl and morphine respectively. Patients were evaluated pre- and postoperatively for anxiety.
Results: Fentanyl consumption and total morphine requirements were significantly decreased in the magnesium group compared to the control group. Postoperative anxiety scores and sedation were similar between groups.
Conclusions: Continuous magnesium infusion, including the pre-, intra-, and postoperative periods reduces analgesic requirements. These results demonstrate that magnesium can be an adjuvant for perioperative analgesic management.
- Cited by 76
A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery
- A. Casati, P. Alessandrini, M. Nuzzi, M. Tosi, E. Iotti, L. Ampollini, A. Bobbio, E. Rossini, G. Fanelli
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- Published online by Cambridge University Press:
- 07 July 2006, pp. 999-1004
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Summary
Background: The aim of this prospective, randomized, blinded study was to compare analgesic efficacy of continuous paravertebral and epidural analgesia for post-thoracotomy pain. Methods: Forty-two ASA physical status II–III patients undergoing lung resection surgery were randomly allocated to receive post-thoracotomy analgesia with either a thoracic epidural (group EPI, n = 21) or paravertebral (group PVB, n = 21) infusion of 0.2% ropivacaine (infusion rate: 5–10 mL h−1). The degree of pain at rest and during coughing, haemodynamic variables and blood gas analysis were recorded every 12 h for the first 48 h. Results: The area under the curve of the visual analogue pain score during coughing over time was 192 (60–444) cm h−1 in group EPI and 228 (72–456) cm h−1 in group PVB (P = 0.29). Rescue morphine analgesia was required in four patients of group EPI (19%) and five patients of group PVB (23%) (P = 0.99). The PaO2/FiO2 ratio reduced significantly from baseline values in both groups without between-group differences. The median (range) percentage reduction of systolic arterial pressure from baseline was −9 (0 to −9)% in group PVB and −17 (0 to −38)% in group EPI (P = 0.02); while clinically relevant hypotension (systolic arterial pressure decrease >30% of baseline) was observed in four patients of group EPI only (19%) (P = 0.04). Patient satisfaction with the analgesia technique was 8.5 (8–9.8) cm in group EPI and 9 (7.5–10) cm in group PVB (P = 0.65). Conclusions: Continuous thoracic paravertebral analgesia is as effective as epidural blockade in controlling post-thoracotomy pain, but is associated with less haemodynamic effects.
- Cited by 75
Cardiac protection by volatile anaesthetics: a multicentre randomized controlled study in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass
- L. Tritapepe, G. Landoni, F. Guarracino, F. Pompei, M. Crivellari, D. Maselli, M. De Luca, O. Fochi, S. D’Avolio, E. Bignami, M. G. Calabrò, A. Zangrillo
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- 01 April 2007, pp. 323-331
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Background and objectives
To evaluate the effects of total intravenous anaesthesia vs. volatile anaesthesia on cardiac troponin release in coronary artery bypass grafting with cardiopulmonary bypass, we performed a multicentre randomized controlled study to compare postoperative cardiac troponin release in patients receiving two different anaesthesia plans.
MethodsWe randomly assigned 75 patients to propofol (intravenous anaesthetic) and 75 patients to desflurane (volatile anaesthetic) in addition to an opiate-based anaesthesia for coronary artery bypass grafting. Peak postoperative troponin I release was measured as a marker of myocardial necrosis.
ResultsThere was a significant (P < 0.001) difference in the postoperative median (25th–75th percentiles) peak of troponin I in patients receiving propofol 5,5 (2,3–9,5) ng dL−1 when compared to patients receiving desflurane 2,5 (1,1–5,3) ng dL−1. The median (interquartile) troponin I area under the curve analysis confirmed the results: 68 (30.5–104.8) vs. 36.3 (17.9–86.6) h ng dL−1 (P = 0.002). Patients receiving volatile anaesthetics had reduced need for postoperative inotropic support (24/75, 32.0% vs. 31/75, 41.3%, P = 0.04), and tends toward a reduction in number of Q-wave myocardial infarction, time on mechanical ventilation, intensive care unit and overall hospital stay.
ConclusionsMyocardial damage measured by cardiac troponin release could be reduced by volatile anaesthetics in coronary artery bypass surgery.
- Cited by 74
Gabapentin attenuates late but not acute pain after abdominal hysterectomy
- A. Fassoulaki, E. Stamatakis, G. Petropoulos, I. Siafaka, D. Hassiakos, C. Sarantopoulos
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- Published online by Cambridge University Press:
- 20 January 2006, pp. 136-141
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Summary
Background and objective: Gabapentin has been suggested to decrease acute postoperative pain. We evaluated the effect of gabapentin on pain after abdominal hysterectomy. Methods: Sixty patients scheduled for abdominal hysterectomy were randomized to receive orally gabapentin 400 mg 6 hourly or placebo. Treatment started 18 h preoperatively and continued for 5 postoperative days. Pain (visual analogue score) and consumption of morphine for 48 h and of oral paracetamol/codeine were recorded after 2, 4, 8, 24 and 48 h and on days 3–5 postoperatively. After 1 month, patients were interviewed by phone for pain, and analgesic intake after hospital discharge. Results: Morphine consumption (mean ± SD) was 35 ± 15.7 mg in the control and 28 ± 12.1 mg in the gabapentin group (P = 0.21). Median number (range) of paracetamol 500 mg/codeine 30 mg tablets taken during days 3–5 was 1.0 (0–6) in the control and 2.0 (0–9) in the gabapentin group (P = 0.35). The visual analogue scores at rest and after cough did not differ between the two groups (F = 0.92, df = 1, P = 0.34 and F = 0.56, df = 1, P = 0.46, respectively). One month after surgery, 22/27 (81%) of the control group and 9/25 (36%) of the gabapentin group reported pain in the surgical area (χ2 = 11.15, P = 0.002), while 11/27 (41%) of controls and 7/25 (28%) of gabapentin patients consumed analgesics for pain (χ2 = 0.93, P = 0.39). The intensity of pain was decreased in the gabapentin group (χ2 = 12.6, P = 0.003). Conclusions: Gabapentin has no effect on immediate pain after abdominal hysterectomy but decreases pain 1 month postoperatively.
- Cited by 73
The plasma elimination rate and urinary secretion of procalcitonin in patients with normal and impaired renal function
- M. Meisner, T. Lohs, E. Huettemann, J. Schmidt, M. Hueller, K. Reinhart
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- 16 August 2006, pp. 79-87
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Background and objective The amount of procalcitonin eliminated in the urine and the plasma disappearance rate of procalcitonin were evaluated in patients with normal and impaired renal function, because patients with sepsis are a main target group for procalcitonin measurement, and these patients often develop renal dysfunction.
Methods Elimination of procalcitonin in the urine (μg 12 h−1) was measured in 76 patients. In another 67 patients, the 50% plasma disappearance rate (t½, h) was evaluated 48 h after peak concentrations (procalcitonin >2 μg L−1). Renal function was assessed by creatinine clearance.
Results Procalcitonin elimination in the urine was significantly reduced in patients with severe renal dysfunction. However, the plasma disappearance rate correlated only weakly with renal dysfunction (Spearman's rank correlation R = −0.36, P = 0.004, regression t½ = 49.87−0.15 creatinine clearance). The 25% quartile and median were 25.2 h and 30.0 h in patients with normal renal function, and 36.3 h and 44.7 h in patients with severely impaired renal function (creatinine clearance <30 mL min−1).
Conclusions Renal elimination of procalcitonin is not a major mechanism for procalcitonin removal from the plasma. Although the plasma disappearance rate may be prolonged up to 30–50% in some patients with renal dysfunction, clinical diagnostic decisions may not be severely influenced by this moderate prolongation of procalcitonin elimination. We conclude that procalcitonin can be used diagnostically in patients with renal failure as well as in those with normal renal function.
- Cited by 72
Endocrine stress response and inflammatory activation during CABG surgery. A randomized trial comparing remifentanil infusion to intermittent fentanyl
- M. Winterhalter, K. Brandl, N. Rahe-Meyer, A. Osthaus, H. Hecker, C. Hagl, H. A. Adams, S. Piepenbrock
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- 01 April 2008, pp. 326-335
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Background and objective
Our aim was to compare a continuous infusion of remifentanil with intermittent boluses of fentanyl as regards the perioperative hormonal stress response and inflammatory activation in coronary artery bypass graft patients under sevoflurane-based anaesthesia.
MethodsIn all, 42 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass were prospectively randomized to a fentanyl group (n = 21, total fentanyl dose 2.6 ± 0.3 mg), or a remifentanil group (n = 21, infusion rate 0.25 μg kg−1 min−1). Haemodynamics, plasma levels of epinephrine, norepinephrine, antidiuretic hormone, adrenocorticotropic hormone, cortisol, complement activation (C3a, C5b-9), interleukin (IL)-6, IL-8 and tumour necrosis factor-α were measured at T1: baseline, T2: intubation, T3: sternotomy, T4: 30 min on cardiopulmonary bypass, T5: end of surgery and T6: 8 h postoperatively. Troponin T and creatine kinase-MB were measured postoperatively.
ResultsPatients in the remifentanil group were extubated significantly earlier than fentanyl patients (240 ± 182 min vs. 418 ± 212 min, P = 0.006). Stress hormones 30 min after start of cardiopulmonary bypass showed higher values in the fentanyl group compared to the remifentanil group (antidiuretic hormone (ADH): 39.94 ± 30.98 vs. 11.7 ± 22.8 pg mL−1, P = 0.002; adrenocorticotropic hormone: 111.5 ± 116.8 vs. 21.81 ± 24.71 pg mL−1, P = 0.01; cortisol 185 ± 86 vs. 131 ± 82 ng mL−1, P = 0.04). The interleukins were significantly higher at some perioperative time points in the fentanyl group compared to the remifentanil group (tumour necrosis factor: T5: 3.57 vs. 2.37; IL-6: T5: 4.62 vs. 3.73; and IL-8: T5: 4.43 vs. 2.65 and T6: 2.61 vs. 1.13). However, cardiopulmonary bypass times and aortic cross-clamp times were longer in the fentanyl group, which may to some extent account for the differences.
ConclusionsThe perioperative endocrine stress response was attenuated in patients supplemented with continuous remifentanil infusion as compared to intermittent fentanyl.
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Acute pain management: analysis, implications and consequences after prospective experience with 6349 surgical patients
- G. Brodner, N. Mertes, H. Buerkle, M. A. E. Marcus, H. Van Aken
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- 16 August 2006, pp. 566-575
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An acute pain service (APS) was set up to improve pain management after operation. We attempted to reduce the length of stay in the intensive care unit (ICU) of patients undergoing major surgery and to improve their homeostasis and rehabilitation using a multimodal approach (pain relief, stress reduction, early extubation). Patient-controlled epidural analgesia (PCEA) was a keystone of this approach. If PCEA was not applicable, patients received patient-controlled intravenous analgesia (PCIA) instead. Brachial plexus blockade (BPB) was used for surgery of the upper limbs. A computer based documentation system was used to help evaluate prospectively (a) the quality of analgesia, (b) adverse effects and risks of the special pain management techniques, and (c) cost-effectiveness.
Patients receiving PCEA (n = 5.602) received a patient-titrated continuous infusion into the epidural space of either bupivacaine 0.175% or ropivacaine 0.2%, with 1 μg sufentanil mL−1 added, followed by patient-controlled boluses of 2 mL (lockout time 20 min). For patients receiving PCIA (n = 634) an initial bolus of 7.5–15 mg piritramide was given, and the subsequent bolus was 2 mg (lockout time 10 min). A continuous infusion of bupivacaine 0.25% was administered to patients receiving BPB (n = 113). The dose was titrated to a dynamic visual analogue scale (VAS) scores < 40.
The mean treatment periods were: BPB = 4.33 days, PCEA = 5.6 days, PCIA = 5.0 days. In the case of PCEA, the quality of pain relief, vigilance and satisfaction were superior compared with the PCIA method, which resulted in greater sedation and nausea. Although personal supervision was higher for the PCEA-treated patients, cost analysis revealed final savings of €91 620 for the year 1998 obviating the need for an ICU stay totalling 433 days.
Provided that PCEA is part of a fast-track protocol employing early tracheal extubation and optimal perioperative management, the associated initial higher costs will be recouped by the benefits to patients of better pain relief after surgery and fewer days subsequently spent in the ITU.
- Cited by 71
Melatonin vs. midazolam premedication in children: a double-blind, placebo-controlled study
- A. Samarkandi, M. Naguib, W. Riad, A. Thalaj, W. Alotibi, F. Aldammas, A. Albassam
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- 19 April 2005, pp. 189-196
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Summary
Background and objective: Unlike midazolam, melatonin premedication is not associated with cognitive impairment in adults despite its anxiolytic properties. The use of melatonin as a premedicant in children has not been reported. This randomized, double-blind, placebo-controlled study compared the perioperative effects of different doses of melatonin and midazolam in children.
Methods: Seven groups of children (n = 15 in each) were randomly assigned to receive one of the following premedicants. Midazolam 0.1, 0.25 or 0.5 mg kg−1 orally, melatonin 0.1, 0.25 or 0.5 mg kg−1 orally each mixed in 15 mg kg−1 acetaminophen, or placebo only (15 mg kg−1 acetaminophen). Anxiety and temperament were evaluated before and after administration of the study drug, on separation from parents and on the introduction of the anaesthesia mask. At week 2 postoperatively, the behaviour of the children was measured by the Post Hospitalization Behaviour Questionnaire.
Results: Melatonin or midazolam each in doses of 0.25 or 0.5 mg kg−1 were equally effective as premedicants in alleviating separation anxiety and anxiety associated with the introduction of the anaesthesia mask. A trend was noted for midazolam to prolong recovery times as the dosage increased. The use of melatonin was associated with a lower incidence (P = 0.049) of excitement at 10 min postoperatively, and a lower incidence (P = 0.046) of sleep disturbance at week 2 postoperatively than that observed with midazolam and control groups. No postoperative excitement was noted in the melatonin groups at 20, 30 and 45 min.
Discussion: Melatonin was not only as effective as midazolam in alleviating preoperative anxiety in children, but it was also associated with a tendency towards faster recovery, lower incidence of excitement postoperatively and a lower incidence of sleep disturbance at week 2 postoperatively.
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Safety of HES 130/0.4 (Voluven®) in patients with preoperative renal dysfunction undergoing abdominal aortic surgery: a prospective, randomized, controlled, parallel-group multicentre trial
- G. Godet, J.-J. Lehot, G. Janvier, A. Steib, V. De Castro, P. Coriat
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- 01 December 2008, pp. 986-994
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Background and objective
Patients with impaired renal function are at risk of developing renal dysfunction after abdominal aortic surgery. This study investigated the safety profile of a recent medium-molecular-weight hydroxyethyl starch (HES) preparation with a low molar substitution (HES 130/0.4) in this sensitive patient group.
MethodsSixty-five patients were randomly allocated to receive either 6% hydroxyethyl starch (Voluven®; n = 32) or 3% gelatin (Plasmion®; n = 33) for perioperative volume substitution. At baseline, renal function was impaired in all study patients as indicated by a measured creatinine clearance < 80 mL min−1. The main renal safety parameter was the peak increase in serum creatinine up to day 6 after surgery.
ResultsBoth treatment groups were compared for non-inferiority (pre-defined non-inferiority range hydroxyethyl starch < gelatin + 17.68 μmol L−1 or 0.2 mg dL−1). Other renal safety parameters included minimum postoperative creatinine clearance, incidence of oliguria and adverse events of the renal system. Baseline characteristics, surgical procedures and the mean total infusion volume were comparable. Non-inferiority of hydroxyethyl starch vs. gelatin could be shown by means of the appropriate non-parametric one-sided 95% CI for the difference hydroxyethyl starch − gelatin [−∞, 11 μmol L−1]. Oliguria was encountered in three patients of the hydroxyethyl starch and four of the gelatin treatment group. One patient receiving gelatin required dialysis secondary to surgical complications. Two patients of each treatment group died.
ConclusionAs we found no drug-related adverse effects of hydroxyethyl starch on renal function, we conclude that the choice of the colloid had no impact on renal safety parameters and outcome in patients with decreased renal function undergoing elective abdominal aortic surgery.
- Cited by 70
Voltage-dependent block of neuronal and skeletal muscle sodium channels by thymol and menthol
- G. Haeseler, D. Maue, J. Grosskreutz, J. Bufler, B. Nentwig, S. Piepenbrock, R. Dengler, M. Leuwer
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- 16 August 2006, pp. 571-579
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Background and objective: Thymol is a naturally occurring phenol derivative used in anaesthetic practice as a stabilizer and preservative of halothane, usually at a concentration of 0.01%. Although analgesic effects have long been described for thymol and its structural homologue menthol, a molecular basis for these effects is still lacking. We studied the blocking effects of thymol and menthol on voltage-activated sodium currents in vitro as possible molecular target sites.
Methods: Whole cell sodium inward currents via heterologously (HEK293 cells) expressed rat neuronal (rat type IIA) and human skeletal muscle (hSkM1) sodium channels were recorded in the absence and presence of definite concentrations of either thymol or menthol.
Results: When depolarizing pulses to 0 mV were started from a holding potential of-70 mV, halfmaximum blocking concentrations (IC50) for the skeletal muscle and the neuronal sodium channel were 104 and 149 µmol for thymol and 376 and 571 µmol for menthol. The blocking potency of both compounds increased at depolarized holding potentials with the fraction of inactivated channels. The estimated dissociation constant K d for thymol and menthol from the inactivated state was 22 and 106 µmol for the neuronal and 23 and 97 µmol for the skeletal muscle sodium channel, respectively.
Conclusions: The results suggest that antinociceptive and local anaesthetic effects of thymol and menthol might be mediated via blockade of voltage-operated sodium channels with the phenol derivative thymol being as potent as the local anaesthetic lidocaine.
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Dexmedetomidine and postoperative shivering in patients undergoing elective abdominal hysterectomy
- E. G. Elvan, B. Öç, Ş. Uzun, E. Karabulut, F. Coşkun, Ü. Aypar
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- 01 May 2008, pp. 357-364
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Background
Post-anaesthetic shivering is one of the most common complications, occurring in 5–65% of patients recovering from general anaesthesia and 33% of patients receiving epidural anaesthesia. Our objective was to investigate the efficacy of intraoperative dexmedetomidine infusion on postoperative shivering.
MethodsNinety female patients, ASA I-II, 35–60 yr old, scheduled for elective total abdominal hysterectomy with or without bilateral salpingo-oophorectomy were randomized into two groups. After endotracheal intubation one group received normal saline infusion and the other received dexmedetomidine as a loading dose of 1 μg kg−1 for 10 min followed by a maintenance infusion of 0.4 μg kg−1 h−1. In the recovery room, pain was assessed using a 100 mm visual analogue scale and those patients who had a pain score of more than 40 mm were administered 1 mg kg−1 intramuscular diclofenac sodium. Patients with shivering grades more than 2 were administered 25 mg intravenous meperidine. Patients were protected with passive insulation covers.
ResultsPost-anaesthetic shivering was observed in 21 patients in the saline group and in seven patients in the dexmedetomidine group (P = 0.001). Shivering occurred more often in the saline group. The Ramsay Sedation Scores were higher in the dexmedetomidine group during the first postoperative hour. Pain scores were higher in the saline group for 30 min after the operation. The need for intraoperative atropine was higher in the dexmedetomidine group. Intraoperative fentanyl use was higher in the saline group. Perioperative tympanic temperatures were not different between the groups whereas postoperative measurements were lower in the dexmedetomidine group (P < 0.05).
ConclusionIntraoperative dexmedetomidine infusion may be effective in the prevention of post-anaesthetic shivering.
- Cited by 69
The effects of sevoflurane, isoflurane and desflurane on QT interval of the ECG
- H. Yildirim, T. Adanir, A. Atay, K. Katircioğlu, S. Savaci
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- 23 December 2004, pp. 566-570
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Summary
Background and objective: To determine if there is any significant difference between the effects of desflurane, isoflurane and sevoflurane on the QT interval, QT dispersion, heart rate corrected QT interval and QTc dispersion of the electrocardiogram.
Methods: The study was conducted in a prospective, double blind and randomized manner in a teaching hospital. Ninety ASA I patients, aged 16–50 yr, undergoing general anaesthesia for noncardiac surgery were studied.
Results: There was no significant change in QT intervals during the study in any group (P > 0.05). QT dispersion in the sevoflurane group 49 ± 14 ms vs. 37 ± 10 ms; in the desflurane group 55 ± 16 and 62 ± 21 ms vs. 35 ± 14 ms and in the isoflurane group 54 ± 26 and 59 ± 24 ms vs. 42 ± 19 ms were significantly increased at 3 and 10 min after 1 MAC of steady end-tidal anaesthetic concentration compared with baseline values (P < 0.05). QTc values in the sevoflurane group were 444 ± 24 and 435 ± 21ms vs. 413 ± 19 ms (P < 0.05), in the isoflurane group were 450 ± 26 and 455 ± 34 ms vs. 416 ± 34 ms (P < 0.05), in the desflurane group were 450 ± 26 and 455 ± 34 ms vs. 416 ± 34 ms (P < 0.05) at 3 and 10 min after reaching 1 MAC of anaesthetic concentration and significantly increased compared with baseline values. QTc dispersion increased significantly with sevoflurane 62 ± 14 ms vs. 45 ± 16 ms (P < 0.05); isoflurane 70 ± 36 ms at 3 min and 75 ± 36 ms at 10 min after reaching 1 MAC of anaesthetic concentration vs. 50 ± 24 ms (P < 0.05); desflurane 67 ± 25 ms at 3 min and 74 ± 27 ms at 10 min after 1 MAC concentration vs. 41 ± 22 ms (P < 0.05).
Conclusion: Sevoflurane, isoflurane and desflurane all prolonged QTd, QTc and QTcd but there were no significant intergroup differences.
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Malignant hyperthermia
- F. Wappler
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- Published online by Cambridge University Press:
- 16 August 2006, pp. 632-652
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Malignant hyperthermia is an autosomal-dominant inherited disorder of the skeletal muscle cell characterized by a hypermetabolic response to all commonly used inhalational anaesthetics and depolarizing muscle relaxants. The clinical syndrome includes muscle rigidity, hypercapnia, tachycardia and myoglobinuria as result of increased carbon dioxide production, oxygen consumption and muscle membrane breakdown. In human beings and animals susceptible to malignant hyperthermia, it is generally accepted that an increase in the level of myoplasmic free calcium is the cause of the syndrome. Various hypotheses have been proposed to account for the increase of intracellular calcium levels, e.g. a defect in the calcium release channel of the sarcoplasmic reticulum (ryanodine receptor), an abnormality of the excitation-contraction coupling mechanisms, or alterations in second messenger systems of skeletal muscles. This review gives an overview of the main features of this disease and recent advances in research including pathophysiology, treatment, diagnosis and genetics as well as association with other disorders.
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Preload and haemodynamic assessment during liver transplantation: a comparison between the pulmonary artery catheter and transpulmonary indicator dilution techniques
- G. Della Rocca, M. G. Costa, C. Coccia, L. Pompei, P. Pietropaoli
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- Published online by Cambridge University Press:
- 16 August 2006, pp. 868-875
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Background and objective: Liver transplantation is characterized by several changes in intravascular blood volume due to vasodilatation based on neurohumoral mediators, intraoperative bleeding and anaesthesia technique effects. Today, with the transpulmonary indicator dilution technique, cardiac index (CIart) can be evaluated and preload assessed in terms of the intrathoracic blood volume index (ITBVI). The aim was to analyse in patients undergoing liver transplantation two preload variables, pulmonary artery occlusion pressure (PAOP) and ITBVI with respect to cardiac index (CIpa) and stroke volume index (SVIpa), the correlation between ITBVI and PAOP, and secondary the relationship between the changes (Δ) of ITBVI and PAOP and the changes of CIpa and SVIpa, and the relationships between ΔITBVI and ΔPAOP. The reproducibility and precision of all CIart and CIpa measurements were also evaluated.
Methods: A prospective study was performed in 60 patients monitored with a pulmonary artery catheter and with the PiCCO® system. The variables were evaluated with a linear regression model.
Results: Linear regression analysis between ITBVI-CIpa and ITBVI-SVIpa were r2 = 0.47 (P < 0.0001) and r2 = 0.55 (P < 0.0001) respectively, while PAOP poorly correlated to CIpa (r2 = 0.02), SVIpa (r2 = 0.015) and ITBVI (r2 = 0.002). Only changes in ITBVI were correlated with changes in CIpa (Δ1, r2 = 0.37; Δ2, r2 = 0.32), and SVIpa (Δ1, r2 = 0.60; Δ2, r2 = 0.47). The mean bias between CIart and CIpa was 0.13 L min−1 m−2 (2 SD = 1.04 L min−1m−2) (r2 = 0.86, P < 0.0001).
Conclusions: In comparison with PAOP, ITBVI seems a more reliable indicator of cardiac preload in patients undergoing liver transplantation.
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Effects of different anaesthetic agents on immune cell function in vitro
- C. E. Schneemilch, T. Hachenberg, S. Ansorge, A. Ittenson, U. Bank
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- Published online by Cambridge University Press:
- 28 July 2005, pp. 616-623
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Summary
Background and objective: Anaesthesia may affect the regulatory balance of postoperative immune response. The aim of this study was to investigate the effects of different volatile and non-volatile anaesthetic agents and particularly of clinically used agent combinations on the proliferation capacity and cytokine production of immune cells. Methods: Peripheral blood mononuclear cells from healthy donors were PHA-activated in the presence or absence of various concentrations of thiopental, propofol, fentanyl, sufentanil, sevoflurane, nitrous oxide and combinations of these anaesthetics. Cell proliferation was assessed by tritiated thymidine uptake. Interleukin-2 production and release of the soluble IL-2 receptor were determined by enzyme immunoassays and used as measures of lymphocyte activation. Results: Thiopental inhibited cell proliferation in a dose dependent manner (P < 0.001) and reduced sIL-2R release (2090–970 pg mL−1; P < 0.05). Propofol reduced sIL-2R release at the high concentration of 10 μg mL−1 (2220 pg mL−1–1780 μg mL−1; P < 0.05). Fentanyl and sufentanil did not compensate for or enhance the inhibitory effects of thiopental. Nitrous oxide, but not sevoflurane, reduced the proliferation of human peripheral blood mononuclear cells (P < 0.05). In combinations with thiopental or nitrous oxide, sevoflurane compensated the inhibitory effects of these two agents. Fentanyl, sufentanil, sevoflurane and nitrous oxide did not affect PHA-induced IL-2 and sIL-2 receptor release by human peripheral blood mononuclear cells. Conclusion: Thiopental and nitrous oxide have immunosuppressive activity. In contrast, sevoflurane may have a beneficial effect by alleviating the immunosuppressive effects of both substances.