Epidural anesthesia during hysterectomy diminishes postoperative pain and urinary cortisol release

Purpose To examine the hypothesis that epidural anesthesia throughout lower abdominal surgery would depress both postoperative pain and cortisol release. Methods Forty adult patients undergoing abdominal total hysterectomy were studied. The patients were randomly assigned to two groups. Group G received general anesthesia alone (sevoflurane 1.5%–2.5%); group E received a combination of epidural anesthesia (1.5% mepivacaine) with a light plane of general anesthesia (sevoflurane<0.5%). Postoperative analgesia was obtained epidurally by patient-controlled analgesia. Postoperative pain at rest and during movement was assessed by a visual analogue scale (VAS) at 2, 24, and 48 h following surgery. The plasma concentration and urinary excretion of cortisol were measured during the perioperative period. Results VAS values were lower in group E than in group G during movement at 24h (4.6±0.5vs 6.1±0.4 cm). Urinary cortisol excretion on the first postoperative day was less in group E than in group G (192±34vs 480±120μg). Conclusions Epidural blockade prior to surgical stimuli and throughout lower abdominal surgery reduces the postoperative dynamic pain and stress response.     

硬膜外阻滞复合喉罩通气与气管插管全麻在妇科腹腔镜手术中的对比研究

目的:对比硬膜外阻滞复合喉罩通气与气管插管全麻(general anesthesia,GA)在妇科腹腔镜手术中的麻醉效果。方法:选择100例ASAⅠ级或Ⅱ级行择期妇科腹腔镜手术的患者,随机分为两组,每组50例,联合组应用硬膜外阻滞复合喉罩通气全麻,GA组麻醉维持采用丙泊酚、维库溴胺及异氟醚吸入。术式包括盆腔淋巴结清扫术、子宫全/次切除术及其他较复杂的妇科腹腔镜手术。记录全麻药物用量、术中血流动力学变化、手术时间、术毕苏醒时间及术后躁动情况。术中由手术医师对腹壁肌松度及腹腔压力或阴道松弛度进行评级,分优、良、差3级。结果:GA组术中MAP高于联合组,HR快于LGE组(P<0.05);GA组丙泊酚、维库溴胺及异氟醚用量均大于联合组(P<0.01)。结论:与单纯GA相比,硬膜外阻滞复合喉罩通气利于抑制腹腔镜术中应激反应,全麻用药量减少,术毕苏醒时间及拔管时间明显缩短,腹壁及阴道松弛度良好,是妇科腹腔镜手术麻醉的理想选择。     

Narcotrend监测下硬膜外阻滞复合全麻在老年病人腹部手术中的应用

目的比较Narcotrend监测下硬膜外阻滞复合全麻和单纯全麻用于老年病人腹部手术的临床效果,探讨老年腹部手术病人更安全合理的麻醉方式。方法 40例ASAⅡ～Ⅲ择期行腹部手术的老年病人,随机分为硬膜外阻滞复合全麻组(EGA)和单纯全麻组(GA),每组20例。两组全麻诱导用药为舒芬太尼0.4μg/kg、顺苯磺阿曲库铵0.15 mg/kg、依托咪酯0.2 mg/kg,气管插管后微泵持续输注丙泊酚、瑞芬太尼及间断静注顺苯磺阿曲库铵维持麻醉,术中行Narcotrend监测并使Narcotrend分级(NTS)维持在D0～D2之间。EGA组全麻诱导前先行硬膜外穿刺置管,注入试验剂量1.3%利多卡因3 ml,气管插管后硬膜外追加1.3%利多卡因6～8 ml,再以0.375%罗哌卡因5～8 ml/次维持硬膜外阻滞。术中监测血流动力学变化,术毕记录两组病人全麻维持用药量和病人睁眼时间、拔管时间及定位功能恢复时间等。结果 EGA组术中收缩压低于GA组(P<0.05);术中麻醉用药比较,EGA组丙泊酚及顺苯磺阿曲库铵用量少于GA组(P<0.05),EGA组瑞芬太尼用量明显少于GA组(P<0.01);恢复时间比较,EGA组病人睁眼时间、拔管时间、定位功能恢复时间均明显短于GA组(P<0.01);两组病人均无术中知晓发生。结论硬膜外阻滞复合全麻用于老年病人腹部手术血流动力学稳定,全麻药用量减少,病人恢复较快,是一种安全可行的麻醉方法,同时进行麻醉深度监测,有利于预防术中知晓。     

Effect of infraorbital nerve block under general anesthesia on consumption of isoflurane and postoperative pain in endoscopic endonasal maxillary sinus surgery

Purpose. The efficacy of infraorbital nerve block in reducing isoflurane consumption and postoperative pain was evaluated in patients undergoing endoscopic endonasal maxillary sinus surgery (ESS) under general anesthesia. Methods. Fifty patients were randomly allocated to either the block group (n = 15) or the nonblock group (n = 25). After the establishment of general anesthesia with isoflurane, nitrous oxide, and oxygen, the patients received infraorbital nerve block with 1.0 ml of either 0.5% bupivacaine (block group) or normal saline (nonblock group) administered into the soft tissue in front of the infraorbital foramen. Systolic blood pressure during anesthesia and surgery was maintained at 85–90 mmHg by adjusting the inspiratory concentration of isoflurane, and its consumption was evaluated in both groups. Pain intensity at 15 min after the end of anesthesia was also evaluated on a five-point pain scale. Results. The consumption of isoflurane under a fresh gas flow of 6 l·min⁻¹ was 17.3 ± 6.5 ml·kg⁻¹·h⁻¹ (mean ± SD) in the block group and 27.4 ± 9.4 ml·kg⁻¹·h⁻¹ in the nonblock group during surgery (P < 0.001). Nicardipine was required during surgery less frequently in the block group than in the nonblock group (P < 0.01). Postoperative pain intensity was lower in the block group than in the nonblock group (P < 0.01). Conclusion. General anesthesia combined with infraorbital nerve block is effective in reducing the consumption of isoflurane and postoperative pain intensity in ESS. Received: April 4, 2000 / Accepted: February 13, 2001     

Awake coronary artery bypass grafting under thoracic epidural anesthesia: great impact on off-pump coronary revascularization and fast-track recovery

Objective: The ultimate goal of minimally invasive coronary artery bypass grafting (CABG) is day surgery. We evaluated the potential of a new awake CABG protocol using only epidural anesthesia in realizing day surgery. Methods: Seventy-two patients who underwent awake off-pump CABG (OPCAB) in our institute from March 2003 were studied. One day before surgery, an epidural catheter was placed at the Th1–2 interspace. On the day of surgery, local anesthetics were delivered via the catheter to provide a level of epidural block from C6 to Th8. Among 1260 patients who underwent OPCAB under general anesthesia (GA) during this study period, 67 of them who matched for age and gender with the awake OPCAB group were selected as controls (GA group). Postoperative fast-track recovery was evaluated. Results: In 67 of the 72 patients (93%), awake OPCAB under consciousness and spontaneous breathing was fully accomplished. Five patients had to be administered GA. Ten patients (14.9%) were able to leave the operating room in a wheelchair. The time to drink water, the time to walk, and hospital stay were significantly shorter in awake OPCAB group than in the GA group. There were no operative and postoperative complications or deaths. Conclusions: Despite the presence of severe preoperative comorbidities in this series, good surgical outcome was obtained. Almost all the patients were able to drink water and walk very soon after surgery, suggesting the potential of this protocol as one-day or day surgery. Awake OPCAB is a promising modality of ultra-minimally invasive cardiac surgery.     

喉罩与气管插管在全麻或复合硬膜外阻滞时的心率和血压改变

目的比较喉罩与气管插管用于全麻或全麻复合硬膜外阻滞患者的HR和BP变化.方法妇科手术80例,随机分为全麻气管插管(T)组、全麻喉罩(L)组、硬膜外阻滞 全麻气管插管(ET)组、硬膜外阻滞 全麻喉罩(EL)组,每组20例.硬膜外阻滞用1%利多卡因 0.15%丁卡因.全麻诱导咪唑安定2 mg、芬太尼0.2 mg、丙泊酚1.5 mg/kg、琥珀胆碱1.5 mg/kg后插气管导管或喉罩.全麻维持50%N2O O2 异氟醚,静注阿曲库铵、芬太尼.于麻醉前(基础,入室静卧10 min后)、插管后1 min、切皮、进腹探查后5 min、拔管后1 min记录MAP、SpO2、HR、PETCO2.结果插管时HR和MAP均低于基础值,而两组喉罩HR低于插气管导管者,硬膜外复合全麻喉罩组MAP低于气管插管组.切皮时两组全麻MAP高于复合硬膜外组.探查时两组复合硬膜外者HR和MAP均低于基础值,且MAP低于单纯全麻者(P＜0.05).拔管时各组HR均显著高于基础值,MAP未复合硬膜外者显著高于基础值.结论(1)插喉罩对BP和HR的影响不如气管导管剧烈;(2)复合硬膜外阻滞时气管插管或喉罩置入应激反应轻,也可减轻探查时的BP波动.     

Nitrogen-sparing effect of epidural administration of local anesthetics in colon surgery

A nitrogen-sparing effect of epidural anesthesia has been clearly demonstrated in gynecological and lower abdominal surgery. To determine if epidural anesthesia also has a protein-sparing effect during major upper or mid-abdominal surgery, postoperative nitrogen balance and 3-methylhistidine urinary excretion (an index of skeletal muscle protein catabolism) were measured for 6 days in 28 patients who had undergone colon resection for cancer with general anesthesia (N2O-O2-1% enflurane) either supplemented with low dose fentanyl plus intermittent systemic pentazocine for postoperative pain (n = 13), or the same general anesthetic plus epidural injection of either etidocaine 1% intraoperatively and bupivacaine 0.25% postoperatively (n = 8) or meperidine (n = 7) for 48 hr after skin incision. The cumulative 6-day nitrogen balance and the cumulative 3-methylhistidine urinary excretion were significantly less after epidural injection of etidocaine intraoperatively and bupivacaine postoperatively than in the two other groups. There was a significant correlation between the daily urinary excretion of 3-methylhistidine and the daily nitrogen balance in the three groups. This study suggests that in colon surgery, epidural analgesia with local anesthetics in the postoperative period improves nitrogen balance and this effect takes place partly in the muscle.     

A comparison of intravenous-based and epidural-based techniques for anesthesia and postoperative analgesia in elderly patients undergoing laparoscopic cholecystectomy

Purpose We wished to compare the effectiveness of intravenous-based (IV) and epidural-based (EPI) techniques for anesthesia and postoperative analgesia in elderly patients undergoing laparoscopic cholecystectomy. Effectiveness was compared in terms of reduction of postoperative pain and adverse events, and achieving a high level of patient satisfaction. Methods Thirty American Society of Anesthesiologists (ASA) physical status I-II patients aged more than 65 years, scheduled for laparoscopic cholecystectomy, were enrolled in this study. The patients in the IV group (n = 15) received modified neurolept anesthesia with droperidol 0.2 mg·kg⁻¹ and pentazocine 0.15–0.3 mg·kg⁻¹ (maximum dose of 1.0 mg·kg⁻¹) and 60% nitrous oxide in oxygen, followed by postoperative intravenous infusion of 20 μg·ml⁻¹ buprenorphine, provided with a patient-controlled analgesia pump programmed to deliver a bolus of 0.5 ml with a lockout interval of 15 min and a background infusion of 0.5 ml·h⁻¹. The patients in the EPI group (n = 15) had combined epidural analgesia and general anesthesia with sevoflurane and 60% nitrous oxide in oxygen, followed by the epidural infusion of a 0.125% bupivacaine and 5 μg · ml⁻¹ buprenorphine mixture by means of an on-demand analgesic system (bolus of 2 ml, lockout interval of 60 min, and background infusion of 2 ml·h⁻¹). Results The quality of postoperative analgesia was similar in the two groups. The incidences of intraoperative hypotension and bradycardia and postoperative hypotension were significantly lower in the IV group than in the EPI group (P < 0.05). A significantly higher level of patient satisfaction was found in the IV group compared with that in the EPI group (P < 0.05). The major contributor to dissatisfaction in the EPI group was anxiety or discomfort associated with the epidural procedures. Conclusion Modified neurolept anesthesia with pentazocine and postoperative i.v. analgesia with buprenorphine were superior to epidural-based techniques, in terms of hemodynamic stability and patient satisfaction, in elderly patients undergoing laparoscopic cholecystectomy.     

A comparison of liver function after hepatectomy in cirrhotic patients between sevoflurane and isoflurane in anesthesia with nitrous oxide and epidural block

In this study, we compared postoperative liver function in patients with liver cirrhosis between isoflurane and sevoflurane anesthesia with nitrous oxide (N(2)O) and epidural block. Forty cirrhotic patients with Child-Pugh Grade A, aged 40 to 70 yr, scheduled for liver segmentectomy, had anesthesia induced with midazolam 0.1 mg/kg and fentanyl 4 micro g/kg. For maintenance, intermittent epidural administration of 1.5% lidocaine 4 to 6 mL and sevoflurane (sevoflurane group) or isoflurane (isoflurane group) with N(2)O 3 L/min in oxygen 3 L/min was used. Aspartate aminotransferase, alanine aminotransferase, total bilirubin, alkaline phosphatase, choline esterase, albumin, prothrombin time, and platelet count were measured before and 1, 3, and 7 days after surgery. Aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase increased significantly, with the peaks at 3 days after surgery in both groups. The increases in these variables were significantly larger in the isoflurane group than those in the sevoflurane group. No patient developed hepatic failure. All increases in liver enzymes were small and of questionable clinical relevance. Whether sevoflurane might be a better anesthetic when combined with N(2)O and epidural block for cirrhotic patients than isoflurane with respect to liver damage remains to be determined. IMPLICATIONS: In cirrhotic patients with Child-Pugh Grade A, isoflurane induced more of an increase in serum concentrations of liver enzymes after surgery than sevoflurane when combined with nitrous oxide and epidural block. However, the increases were small, and there was no clinical liver damage.     

Platelet activation in major surgical stress: influence of combined epidural and general anaesthesia

Platelets are activated in surgery releasing vasoactive substances such as serotonin and thromboxane. Platelets become temporarily hypoaggregable during surgery followed by a postoperative hyperaggregability. Local anaesthetics are known to inhibit platelet function but earlier reports are conflicting. In order to study the impact of the combined use of general and regional anaesthesia on platelet function during major surgery 16 otherwise healthy patients were randomised to either general anaesthesia (GA) (n = 8) or GA combined with epidural anaesthesia (GA + EPI) (n = 8) for elective upper abdominal surgery. Cyclic 3'5'adenosine monophosphate, plasma glucose, plasma Cortisol and the rate pressure product (RPP) were markers of the stress response. ADP–induced platelet aggregation and the release products β-thromboglobulin, serotonin and thromboxane 2 were measured in plasma before and during as well as for 3 days after surgery.     

不同术后镇痛方式对手术患者恢复期心肌缺血的影响

目的研究硬膜外镇痛与静脉镇痛对手术患者恢复期心肌缺血的影响。方法39例行择期腹部手术的患者随机分成两组:硬膜外镇痛组(R组),16例,术中全麻复合硬膜外麻醉,术后硬膜外镇痛;静脉镇痛组(M组),23例,术中全麻,术后静脉吗啡镇痛。维持两组Price-Henry疼痛评分≤3分。所有患者接受24 h动态心电图监测48 h。两组患者在入手术室安静平卧10 min、入SICU后2 h、术后第1天晨、术后第2天晨采集静脉血测定皮质醇浓度。结果术后48 h内,R组心肌缺血发生率比M组低(P<0.05),在术后各时点,R组的皮质醇浓度低于M组(P<0.05)。结论与静脉镇痛相比较,硬膜外镇痛明显减轻应激反应,减少术后心肌缺血发生率。     

The hemodynamic effects of newborn caudal anesthesia assessed by transthoracic echocardiography: a randomized, double-blind, controlled study

Background: Caudal anesthesia has been increasingly used in abdominal, urinary tract, and lower extremity surgery of infants. However, little was known about the hemodynamic effects of caudal anesthesia in them, especially in neonates. The purpose of this prospective study was designed to investigate the hemodynamic alterations by transthoracic echocardiography in newborn baby after caudal anesthesia with plain Bupivacaine or with epinephrine added Bupivacaine. Methods: Thirty full‐term newborn infants scheduled for lower abdominal or urinary tract surgery were randomly allocated into three groups (n = 10 each) as follows: (i) GA group: general anesthesia with sevoflurane; (ii) GA+CP group: GA with sevoflurane, combined with caudal anesthesia of plain Bupivacaine (1.25 ml·kg^?1 of 0.2%); (iii) GA+CA group: sevoflurane GA combined with caudal anesthesia of epinephrine‐added Bupivacaine (1.25 ml·kg^?1 of 0.2% Bupivacaine plus 1/200 000 epinephrine). Cardiac output (CO), arterial blood pressure, and heart rate were measured before (T‐5) and 5(T5), 10(T10), 15(T15) min after performance of caudal anesthesia. Results: In GA group, no significant hemodynamic alteration was observed in comparison with T‐5, except HR, which decreased by 7% at T15; In GA+CP group, compared with T‐5, HR decreased significantly at T5, T10 and T15, respectively, by 6%, 7% and 10%. And also CO decreased significantly at T15 by 8% compared with T‐5; In GA+CA group, no significant hemodynamic alteration was observed expect diastolic arterial blood, which decreased significantly at T15 by 10% compared with T‐5; At T15, the larger decrease of systolic arterial blood in GA+CP group and GA+CA group vs (GA) group (P < 0.05). Conclusions: The study shows the stability of hemodynamic variables during caudal anesthesia with Bupivacaine and with epinephrine‐added Bupivacaine in newborn infants.     

Intra- and postoperative heart rate changes following propofol anesthesia; a comparison with isoflurane anesthesia

Bradycardia during propofol anesthesia is well known, but bradycardia after propofol anesthesia has not been studied well. We compared perioperative heart rates in patients who had undergone gynecological surgery under lumbar epidural anesthesia supplemented with light general anesthesia using isoflurane and nitrous oxide in oxygen (Group Iso, n = 25) with those who had received lumbar epidural anesthesia supplemented with propofol (Group Prop, n = 25). The heart rates for the Group Prop were significantly lower (P < 0.05) than those for the Group Iso after the induction of anesthesia up to 2 hours after surgery. Two patients in the Group Prop developed bradycardia below 50 bpm 1 and 2 hours after surgery. In one of them intravenous atropine was necessary to treat bradycardia. We conclude that more attention should be paid to postoperative as well as intraoperative bradycardia in patients who receive propofol.     

A randomized comparative study between selective walking spinal anesthesia and general anesthesia for anorectal surgeries in outpatient settings

BackgroundSpinal anesthesia is gradually increasing in ambulatory setting. The limiting factor to the more widespread use of spinal anesthesia in the outpatient setting refers to the effect of residual block. Selective spinal anesthesia (SSA) with low dose lidocaine was compared with modern general anesthesia (GA) technique in day care anorectal surgeries.ObjectiveOur objectives in this study was to compare SSA with propofol and fentanyl based modern GA as regard to 1 – operating conditions 2 – patients’ and surgeon’s satisfaction, 3 – intraoperative, postoperative adverse events and 4 – recovery profiles in ambulatory anorectal surgeries.MethodsProspective randomized clinical study was conducted on 60 patients undergoing elective day case anorectal surgery. The patients were randomly allocated into one of two groups (GA and SSA groups) of 30 patients each. In GA group anesthesia was induced with intravenous fentanyl (2 μg/kg) and propofol (2–3 mg/kg). Airway was secured with I-gel supraglottic airway. Anesthesia was maintained by sevoflurane 1.5–2%, nitrous oxide 60% in oxygen mixture. SSA group patients received spinal anesthesia with lidocaine 20 mg and fentanyl 25 μg to a total volume of 3 ml with sterile water for injection. Intraoperative, postoperative and home adverse events, time to ambulate, time to home discharge, patients’ and surgeon’s satisfactions were statistically compared between both groups.ResultsBoth anesthetic techniques showed acceptable operating conditions and high rate of patients’ satisfaction. Low pain intensity, shorter time to ambulate and home discharge in SSA compared to GA with a p value < 0.001. Intraoperative hemodynamic stability was reported in both groups. No major postoperative or home adverse events in both groups.ConclusionsSSA with low dose lidocaine may be suitable alternative and competitive for modern GA in ambulatory anorectal surgery.     

Early postoperative renal function following renal transplantation surgery: effect of anesthetic technique

Purpose. The use of continuous epidural anesthesia in patients with chronic renal failure is rare and controversial. In this study, we compared the effects of epidural versus general anesthesia on early postoperative renal function in patients who underwent renal transplantation surgery. Methods. Sixty-eight adult patients were prospectively randomized to two groups. Group 1 (n-37) received epidural anesthesia with bupivacaine and fentanyl, and group 2 (n-31) received general anesthesia with nitrous oxide and isoflurane. The patients' renal function was compared both with qualitative scintigraphic analysis (kidney perfusion, concentration, and excretion capabilities) and biochemically [serum sodium, potassium, creatinine, and blood urea nitrogen) (BUN)] within the first postoperative week. Results. Patient demographics were similar in the two groups, and the scintigraphic and biochemical evaluations were also comparable. The time of the first appearance of Tc-99m diethylene triamine pentaacetic acid (DTPA) was within normal limits in 75.7% of patients in group 1 and 61.3% of those in group 2. The number of patients with normal peak/background activity and 20 min/peak activity were 15 (40.5%) and 19 (51.4%), respectively, in group 1, and 12 (38.7%) and 15 (48.4%) in group 2 (P > 0.05 for both). The levels of serum creatinine and urea in both groups decreased within days postsurgery compared with preoperative levels (P < 0.05), but the changes were similar in the two groups (P > 0.05). A similar number of patients in both groups were treated for acute rejection (P > 0.05). Conclusion. Our results demonstrate the safe use of both anesthetic techniques in renal transplantation surgery. Received: December 25, 2000 / Accepted: November 5, 2001     

Usefulness of epidural anesthesia in gynecologic laparoscopic surgery for infertility in comparison to general anesthesia

Background Although the advantages of epidural anesthesia in open surgery have been established, its usefulness in the setting of laparoscopic surgery remains to be studied.Methods Patients undergoing laparoscopic surgery for infertility were randomly administered epidural anesthesia (group A, n = 11) or general anesthesia (group B, n = 9). The operation was performed under 4 mmHg pneumoperitoneum and in the 20° Trendelenburg position. Respiratory function tests using a spirometer and blood gas analysis were performed during the intra- or perioperative period. Pain status was evaluated with visual analog scale scoring. The number of postoperative recovery days needed to resume daily activities was obtained by a questionnaire.Results Respiratory rate, minute volume, P_aCO₂, % vital capacity (VC), and forced expiratory volume in 1 s (FEV1) % were virtually constant throughout the study period in group A, whereas %VC was decreased immediately after operation in group B (p < 0.05). Minute volume immediately after operation was significantly increased in group B compared with group A (p < 0.01), suggesting shallow respiration in women undergoing general anesthesia. Observed pain scores on abdominal pain, shoulder pain, and dyspnea were very low during operation in group A. Pain scores immediately and 3 h after operation were also minimal in group A, whereas abdominal pain scores at these points were significantly higher in group B than those in group A (both p < 0.01). The number of days required for a half reduction in wound pain, trotting, and full recuperation for group A were less than those for group B (p < 0.05).Conclusions Epidural anesthesia, when used in laparoscppic surgery for infertility treatment, has advantages over general anesthesia in terms of analgesic effects, postoperative respiratory function, and a return to preoperative daily activities.     

Effects of sevoflurane anesthesia combined with epidural block on renal function in the elderly: comparison with isoflurane

Purpose. Renal function declines with age, but little is known about the renal effects of the inhaled anesthetic sevoflurane in the elderly. We therefore compared the renal effects of sevoflurane and isoflurane anesthesia in elderly patients. Methods. Thirteen patients aged ≥70 years undergoing gastrectomy with epidural anesthesia combined with general anesthesia were randomly assigned to receive either sevoflurane (n = 7) or isoflurane (n = 6). Dopamine (3–5 μg·kg⁻¹·min⁻¹) was administered to all patients. Blood and urine samples were collected before, during, and after anesthesia. Serum and urinary inorganic fluoride was measured, and renal function tests were performed. Results. Serum inorganic fluoride was significantly elevated in both groups. The production of inorganic fluoride was significantly greater in the sevoflurane group, but the level did not exceed 50 μmol·l⁻¹ in any patient. No abnormalities were observed in blood urea nitrogen (BUN), serum creatinine, or urine volume in either group. The albumin excretion index increased during anesthesia and decreased after anesthesia in both groups. Creatinine clearance was unchanged in the sevoflurane group but fluctuated during and after anesthesia in the isoflurane group. α₁-Microglobulin (MG), β₂-MG, and urinary N-acetyl-β-d-glucosaminidase (NAG) excretion increased up to 3 h after anesthesia, and α₁-MG and β₂-MG excretion increased on postanesthesia day 3. Conclusion. In both groups, glomerular and tubular function were transiently affected, but no abnormalities were found in routine laboratory tests, suggesting that neither isoflurane nor sevoflurane in combination with dopamine and epidural anesthesia seriously affects renal function in the elderly. Received for publication on October 23, 1998; accepted on October 27, 1999     

Comparison of local and general anesthesia in tension-free (Lichtenstein) hernioplasty: a prospective randomized trial

To compare pulmonary effects, postoperative pain and fatigue, morbidity, patient satisfaction, and cost of different anesthetic techniques for inguinal hernia repair, 50 patients were randomized to local and general anesthesia groups (LA and GA). All patients received the same premedications and the same postoperative analgesic regimen. The standardized postoperative analgesic, intramuscular pyroxicam 20 mg, was given to all patients in the recovery room and an additional 20 mg on the same day was given as requested by each patient. Pulmonary function studies and arterial blood gas analysis were performed 1 h prior to the operation and at the postoperative 8th and 24th hours. All patients underwent Lichtenstein's tension-free hernioplasty. Postoperative pain and fatigue were registered 8 h and 24 h after the operation. A questionnaire was filled out by the patients, and they were asked to give grades for the general comfort of the anesthesia and the surgical procedure (1=worst, 10=best). Postoperative pulmonary function tests were significantly poorer in the GA group both on 8th- and 24th-hour measurements (P<0.05). Patients who underwent LA had significantly lower PCO₂ and higher PO₂ at the postoperative 8th hour (P<0.05). Mean postoperative pain and fatigue scores revealed a significant difference in favor of local anesthesia at only the 8th hour (P<0.05). There were two complications, one in each group (a hematoma in LA and a urinary retention in GA). Patient satisfaction grades were not different in the two groups. We conclude that LA in inguinal hernia repair does not adversely affect pulmonary functions, patients feel less pain, and patient satisfaction is comparable to that with GA. Electronic Publication     

Early and late recovery after major abdominal surgery. Comparison between propofol anaesthesia with and without nitrous oxide and isoflurane anaesthesia

A comparison was made between early and late recovery after major abdominal surgery under intravenous anaesthesia with propofol (with and without nitrous oxide) or inhalational anaesthesia with isoflurane. Sixty patients were randomly allocated to one of three forms of anaesthesia: propofol, propofol/nitrous oxide, or isoflurane/nitrous oxide anaesthesia. All received fentanyl and vecuronium. Recovery was monitored during the first 2 h after extubation and on days 1, 2, 3, 7 and 30 after surgery. Every 30 min during the first 2 postoperative hours, the Steward recovery scale, sedation, orientation, collaboration, and comprehension were assessed by a blinded observer. Psychomotor function was evaluated by computerised simple reaction time and finger tapping speed in 32 patients. A scale of symptoms and mood check list were filled in by 35 patients on days 1, 2, 3, 7 and 30. The preoperative values for all tests were collected 1–4 days before surgery. The time between end of surgery and extubation was longer in the propofol group, but early and late recovery of psychomotor function were similar in the three groups. Patients anaethetised with isoflurane reported more vegetative symptoms than those who received propofol (P < 0.03). The addition of nitrous oxide to propofol did not change the reported degree of symptoms. The difference in vegetative symptoms between groups was most obvious on day 7. Patients anaesthetised with propofol reported better subjective control (P < 0.02) and were more socially oriented (P < 0.05) than patients anaesthetised with isoflurane. We conclude that early recovery was similar in the three groups. Patients anaesthetised with propofol reported fewer late symptoms and better mood after operation than those anaesthetised with isoflurane. The addition of nitrous oxide did not affect the results.     

Postoperative pulmonary complications: general anesthesia with postoperative parenteral morphine compared with epidural analgesia

In a prospective study, patients undergoing abdominal cancer surgery were randomly allocated to receive either general anesthesia with fentanyl intravenously and postoperative analgesia with parenteral morphine (GA group) or general anesthesia combined with epidural bupivacaine and epidural morphine for postoperative pain relief (EP group). Analgesia was tested on a visual pain scale. Pulmonary complications were evaluated by clinical complications, blood gas analysis, x-ray film changes, and pulmonary volumes (vital capacity, forced expiratory volume in 1 second). Measurements were performed on the day before the operation and on the first 5 postoperative days. In the EP group the pain relief was significantly better on the first day (p less than 0.03). Whatever the criteria used, the rates of pulmonary complications were similar in the two groups: clinical complications 21% versus 26%, radiologic complications 50% versus 64% for GA and EP groups, respectively. Postoperative PaO2 and spirometric values were similar in the two groups. Postoperative epidural analgesia may improve the patient's comfort but does not decrease the incidence of pulmonary complications.