Potency and hourly maintenance requirement of combinations of mivacurium and pancuronium in adults

Purpose

To evaluate the dose-response and maintenance requirements of a combination of mivacurium and pancuronium (cMP) in clinical practice.

Methods

In a randomised, open clinical study, 70 patients, 17–50 yr of age, were anaesthetised with propofol, alfentanil and nitrous oxide in oxygen. Thirty patients received mivacurium and 20 patients received pancuronium to establish dose-response curves for these agents. Hourly maintenance requirements of mivacurium and pancuronium to maintain 90–95% neuromuscular blockade (NMB) were determined. Thereafter, 20 additional patients received cMP in incremental doses to establish a cumulative dose-response curve for cMP followed by maintenance doses of cMP NMB was recorded by adductor pollicis electromyography.

Results

The ED₉₅ values for mivacurium and pancuronium were 100 and 66μg·kg^?1, respectively; and for the cMP 2:1 (in mg:mg basis), 32 μg·kg^?1 mivacurium together with 16 μg·kg^?1 pancuronium. This cMP was 1.8 times more potent than one parent agent (P < 0.0001 ). When cMP 2:1 was used, 60% of normal maintenance requirement of pancuronium reduced the requirement of mivacurium by > 90%. If cMP 20:1 was used, then 20% of normal maintenance requirement of pancuronium reduced the requirement of mivacurium by > 70%. Neostigmine 35 μg·kKg^?1 given at T₁ 10% recovery following cMP reversed the NMB to a TOF ratio of 0.70 in 9.5 ±3.9 min.

Conclusion

These results reflect considerable synergism between mivacurium and pancuronium. The cMP is near intermediate-acting and the NMB is easily reversed with neostigmine. By using cMR it may be possible to save some pharmacological costs during maintenance of anaesthesia.     

Recovery of post-tetanic and train-of-four responses at the first dorsal interosseous and adductor pollicis muscles in patients receiving vecuronium

Purpose

To compare recovery of accelographical responses to post-tetanic twitch (PTT) and train-of-four (TOF) stimuli obtained at the first dorsal interosseous muscle (DI) with those at the adductor pollicis muscle (AP) after administration of vecuronium 70 μg · kg^?1.

Methods

Sixty adult patients were randomly assigned to one of four groups: PTT-DI (n = 15), PTT-AP (n = 15), TOF-DI (n = 15), or TOF-AP (n = 15) group. In PTT-DI and PTT-AP groups, responses to PTT were measured accelographically at the DI and at the AP, respectively. In TOF-DI and TOF-AP groups, responses to TOF were measured at the DI and at the AP, respectively.

Results

The T₁/T₀ (T₀ = control) was greater in the TOF-DI than in TOF-AP group throughout recovery (P < 0.05), and the T₄/T₁ was greater in the TOF-DI than in TOF-AP group during the 30–40 min after vecuronium injection (P < 0.05). Time to the return of the first response to PTT (post-tetanic count₁, PTC₁) was less in the PTT-DI than in the PTT-AP group (17.7 ± 4.2 vs 21.7 ± 5.6 min, mean ± SD, P = 0.0341). The post-tetanic count PTC (number of single twitch stimuli in response to PTT) was greater in the PTT-DI than in the PTT-AP group during the 10–30 min after vecuronium (P < 0.05). Time to the return of T₁ was less in the TOF-DI than in the TOF-AP group (23.1 ± 6.0 vs 27.6 ± 4.9 min, P = 0.0334).

Conclusion

Recovery of responses to PTT and TOF stimuli occurred earlier at the DI than at the AP.     

Sugammadex Allows Fast-Track Bariatric Surgery

Background

Morbidly obese (MO) patients are at increased risk for postoperative anesthesia-related complications. We evaluated the role of sugammadex versus neostigmine in the quality of recovery from profound rocuronium-induced neuromuscular blockade (NMB) in patients with morbid obesity.

Methods

We studied 40 female MO patients who received desflurane and remifentanil anesthesia for laparoscopic removal of adjustable gastric banding. NMB was achieved with rocuronium. At the end of the surgical procedure, complete reversal of NMB was obtained with sugammadex (SUG group, n?=?20) or neostigmine plus atropine (NEO group, n?=?20) in the presence of profound NMB.

Results

No difference in surgical time or anesthetic drugs was found between the groups. Anesthesia time was significantly greater in the NEO group than in the SUG group (95?±?21 vs. 47.9?±?6.4 min, p?<?0.0001), which was mainly due to a longer time to reach a train-of-four ratio (TOFR)?≥?0.9 in the NEO group (48.6?±?18 vs. 3.1?±?1.3 min, p?<?0.0001) during reversal of profound NMB. Upon admission to the postanesthesia care unit, level of SpO₂ (p?=?0.018), TOFR (p?<?0.0001), ability to swallow (p?=?0.0027), and ability to get into bed independently (p?=?0.022) were better in the SUG group than in the NEO group. Patients in the SUG group were discharged to the surgical ward earlier than patients in the NEO group were (p?=?0.013).

Conclusions

Sugammadex allowed a safer and faster recovery from profound rocuronium-induced NMB than neostigmine did in patients with MO. Sugammadex may play an important role in fast-track bariatric anesthesia     

Effects of tidal volume and PEEP on arterial blood gases and pulmonary mechanics during one-lung ventilation

Purpose

The main problem of one-lung ventilation (OLV) is hypoxemia. The use of a high tidal volume for preventing hypoxemia during OLV is controversial. We compared the effects of a high tidal volume versus a low tidal volume with or without PEEP on arterial oxygen tension (PaO₂) and pulmonary mechanics during OLV.

Methods

Sixty patients (age range, 16–65?years; ASA I, II) who underwent wedge resection with video-assisted thoracostomy during OLV were assigned to three groups: group I received a high tidal volume (10?ml/kg) (n?=?20), group II received a low tidal volume (6?ml/kg) (n?=?20), and group III received a low tidal volume (6?ml/kg) with PEEP (5?cmH₂O) (n?=?20). Patient hemodynamics, pulmonary mechanics, and arterial blood gases were measured before (T₀) OLV and 5 (T₁), 15 (T₂), 30 (T₃), and 45?min (T₄) after OLV.

Results

The PaO₂/FiO₂ ratios of group II and III were significantly decreased and the incidence of hypoxemia was significantly higher in groups II and III than in group I (P?Conclusion During OLV, mechanical ventilation with a low tidal volume with or without PEEP increased hypoxemia as compared to that when performing OLV with a high tidal volume.     

Optimum time for neostigmine reversal of atracurium-induced neuromuscular blockade

Purpose

The aim of the study was to determine the optimum time for administration of neostigmine during recovery from atracurium-induced neuromuscular blockade.

Methods

The study comprised 103 patients anaesthetised with midazolam, fentanyl, thiopentone, halothane, and nitrous oxide. Relaxation was induced with atracurium 0.5 mg·kg^?1 and maintained with supplements of 0.15 mg·kg^?1. The ulnar nerve was stimulated with train-of-four (TOF) and double burst stimulation (DBS). Evoked MMG responses were recorded. Patients were randomized to spontaneous recovery (n = 20) or to assisted recovery by neostigmine (0.07 mg ·kg^?1) at varying intervals (6–50 min) from the last atracurium dose (n = 83).

Results

The reversal time (time from administration of neostigmine to TOF ratio 0.7) was always < 13 min, when T₁ (first twitch in TOF) was detectable or when D₁ (first twitch in DBS) was > 5%. Total assisted recovery time (time from last supplemental atracurium dose to TOF ratio 0.7) increased with increasing T₁ and D₁ twitch heights (P < 0.05). The curve fitted to the scattergram with total assisted recovery time vs time from last atracurium supplement to neostigmine administration decreased to reach a minimum after which it increased to approach the line of identity. The minimum of the curve (total assisted recovery time 30.7 min) was reached when neostigmine was given 18.6 min after last atracurium supplement. At this time the T₁ and D₁ twitch height averaged 4 and 8% respectively. If prolongation of the minimum total recovery time of 2.5% is accepted, neostigmine can be given at T₁ and D₁ twitch height values of 0 to 8% and 4 to 15%, respectively.

Conclusion

The optimum time for neostigmine administration, taking both the reversal time and total recovery time into consideration, is when 0 < T₁ < 8% or when 5 < D₁ < 15%. Giving neostigmine at more profound degrees of blockade prolongs reversal time, while giving neostigmine later in the recovery phase prolongs total recovery time.     

Pharmacodynamics of doxacurium during cardiac surgery with hypothermic cardio-pulmonary bypass

Purpose

To determine the characteristics of neuromuscular block produced by two and three times the 95% effective dose (ED₉₅) of doxacurium in patients undergoing coronary artery surgery with hypothermic cardiopulmonary bypass.

Methods

In a prospective non randomized study, ten patients received doxacurium 0.05 mg·kg^?1 (Group 1) and ten others received 0.075 mg · kg^?1 (Group 2) with midazolam and sufentanil. The mechanomyographic response of the adductor pollicis muscle after supramaximal train-of-four (TOF) stimulation of the ulnar nerve was recorded intraoperatively and postoperatively. Additional doxacurium (10% of the initial dose) was administered until sternal closure whenever the first twitch (T₁) had recovered to 25% of control.

Results

The onset time (time to maximal T₁ depression) of doxacurium was 390 ± 148 sec in Group 1 and 370 ± 74 sec in Group 2 (P = 0.71). The clinical duration of neuromuscular block (time to 25% T₁ recovery) was 165 ± 90 min in Group 1 and 258 ± 86 min in Group 2 (P = 0.03). On arrival to recovery room the mean T₁ was 57 ± 23% in Group 1 and 24 ± 21% in Group 2(P = 0.003); the mean T₄/T₁ ratio was 0.25 ± 0.15 for five patients of Group 1 with four responses to TOF stimulation and 0.10 for the only patient of Group 2 with four twitches.

Conclusion

In contrast with findings in patients without cardiac disease, this study shows comparable onset times of doxacurium with doses of two and three times ED₉₅. The clinical duration of doxacurium is 60 to 100% longer than previously reported in noncardiac surgery.     

No exacerbation of perihematomal edema with intraclot urokinase in patients with spontaneous intracerebral hemorrhage

Background

Perihematomal edema (PHE) can worsen patient outcomes after spontaneous intracerebral hemorrhage (ICH). Minimally invasive surgery (MIS) in combination with thrombolytic removal of hematoma has been proven to be a promising treatment strategy. However, preclinical studies have suggested that intraclot thrombolysis may exacerbate PHE after ICH. Herein, we investigated the effects of MIS and urokinase on PHE.

Methods

ICH patients were retrospectively identified from our institutional ICH database. Computerized volumetric analysis was applied to assess changes in both ICH and PHE volumes using computed tomographic (CT) scans of T₁ (pre-MIS) and T₂ (post-MIS) time points. Relative PHE (rPHE) was calculated as a ratio of PHE and T₁ ICH volume.

Results

Data from 60 MIS plus urokinase (MIS + U), 20 MIS aspiration only (MO), and 30 control patients were analyzed. The ICH volume, PHE volume and rPHE on T₂ CT in both MIS + U and MO groups significantly decreased as compared with the control group (ICH volume, 13.7?±?5.7 ml, 17.0?±?10.5 ml vs. 30.5?±?10.3 ml, P?vs. 45.4?±?16.0 ml, P?P?2 trended towards similarity, but was not significant (P?=?0.09, P?=?0.40, P?=?0.43). Furthermore, we found a significant correlation between the percent of ICH removal and PHE reduction (r?=?0.59, P?2 PHE volume (r?=?0.19; P?=?0.16) or T₂ rPHE (r?=?-0.12; P?=?0.37).

Conclusions

Hematoma evacuation using MIS leads to a significant reduction in PHE. Furthermore, the use of urokinase does not exacerbate PHE, making its hypothesized proedematous effects unlikely when the thrombolytic is administered directly into the clot.     

Pharmacokinetics of propofol in patients undergoing total hip replacement

Objective

The aim of the study was to investigate the effects of acute hypervolemic hemodilution (HHD) on the pharmacokinetics of propofol in patients undergoing total hip replacement.

Methods

A total of 16 patients undergoing elective surgery for total hip replacement under general anesthesia in combination with epidural analgesia were randomly assigned to 2 groups: the control group (n?=?8) or the HHD group (n?=?8). All patients in both groups received lactated Ringer??s solution before induction of general anesthesia. In the control group the conventional fluid replacement protocol was used. In the HHD group 4% succinylated gelatin was infused at the rate of 20?ml?kg^?1BW?h^?1 with a targeted hematocrit of 30. Anesthesia was induced with midazolam 0.04?mg?kg^?1, fentanyl 4???g?kg^?1 and propofol 1.5?mg?kg^?1. Tracheal intubation was facilitated by infusion of succinylcholine 2?mg?kg^?1. Anesthesia was maintained with isoflurane, fentanyl, vecuronium and epidural analgesia. Electrocardiogram (ECG), blood pressure (BP), blood oxygen saturation (SpO₂), partial pressure of end-tidal carbon dioxide (P_ETCO₂) and central venous pressure (CVP) were monitored continuously. Blood samples were taken at 1, 2, 4, 6, 10, 15, 30, 45, 60, 75, 90, 120, 150, 180, 240, 300 and 360?min after propofol administration to determine plasma concentrations of propofol by high performance liquid chromatography (HPLC).

Results

Plasma propofol concentrations were significantly lower in the HHD group than in the control group at 1, 2, 4, 6 and 10?min after propofol administration (p??>?0.05). In the HHD group the volume of distribution of the central compartment (V_C) increased significantly, elimination half-life (T_{1/2 ??}) was significantly prolonged, the elimination rate constant (K₁₀) and the whole-body clearance (CL) were significantly decreased compared with the control group (p?1/2 _??), half-life of the slower distribution phase (T_{1/2 ??}), K₁₂, K₂₁, K₁₃, K₃₁ and the area under the curve (AUC) (p?>?0.05). The pharmacokinetic profile of propofol is best described by a three-compartment model in both groups using minimal Akaike information criteria (AIC).

Conclusion

Acute HHD increases V_C, prolongs the T_{1/2 ??}, and decreases K₁₀ and CL, which suggests that care must be taken when propofol is used in patients undergoing HHD. The induction dose should be increased, but the maintenance dose should be decreased. The time to emergency from anesthesia will likely be prolonged, especially in patients receiving prolonged continuous infusions.     

Arthroscopic shoulder surgery under general anesthesia with brachial plexus block

Objective

Changes in respiratory parameters and pulmonary function tests were evaluated after shoulder arthroscopic surgery with brachial plexus block (BPB). The purpose of this study was to identify the mechanism of respiratory dysfunction after this type of surgery.

Methods

Patients undergoing arthroscopic rotator cuff repair under general anesthesia (GA) with BPB were enrolled in the arthroscopy group (n?=?30) while those undergoing open reduction of a clavicle or humerus fracture under GA were enrolled in the control group (n?=?30). Forced vital capacity (FVC) and forced expiratory volume 1 s (FEV₁) were measured at the outpatient clinic stage (#1) before (#2) and 20 min after BPB (#3) and 1 h after extubation (#4). Respiratory variable measurements along with the cuff leak test were performed 5 min after surgical positioning (T1) and at the start of skin closure (T2). Respiratory discomfort was evaluated after extubation. The upper airway diameters and soft tissue depth of chest wall were also measured by ultrasonography at stages #3 and #4.

Results

Static compliance decreased significantly at T2 in the arthroscopy group (50?±?11 at T1 vs. 44?±?9 ml/cm H₂O at T2, p?=0.035) but not in the control group. The incidence of positive cuff leak tests at T2 was significantly higher in the arthroscopy group than in the control group (47% in the arthroscopy group vs. 17% in controls, p?=0.010). While FEV₁ and FVC remained stable at stages #1 and #2, FVC and FEV₁ decreased at stages #3 and #4 only in the arthroscopy group (FVC in arthroscopy group, #2: 3.26?±?0.77 l; #3: 2.55?±?0.63 l, p?=0.015 vs. #2; #4: 2.66?±?0.41 l, p?=0.040 vs. #2). The subglottic diameter decreased at #4 in the arthroscopy group, while no changes occurred in the control group (0.70?±?0.21 cm vs. 0.85?±?0.23 cm in the arthroscopy and control groups, respectively, p?=0.011). Depth of skin to pleura increased at both intercostal spaces 1–2 and 3–4 in the arthroscopy group. There were three cases of hypoxia (S_pO₂?<?95%) with room air in the arthroscopy group while none occurred in the controls.

Conclusion

Shoulder arthroscopic surgery under GA with BPB induced both restrictive and obstructive pathologies. It is important to maintain a high level of awareness for the potential negative respiratory effects of this surgery especially for subjects with pre-existing cardiopulmonary disease. The measurements in this study would be useful to monitor the risk of respiratory dysfunction in these patients.     

Effect of parathyroid hormone on hypogonadism induced bone loss of proximal femur of orchiectomized rat

Purpose

Management of hypogonadism-induced osteoporosis in elderly men is still a challenge. We investigated the short-term effects of parathyroid hormone (PTH) treatments on strength, micro-architecture, and mineral density of trochanteric region of orchiectomized rat femur.

Methods

Eight-month-old male Sprague?CDawley rats (n?=?44) were divided into two groups: (1) orchiectomized (ORX) and (2) sham group. Twelve weeks after orchiectomy, half of the orchiectomized animals were treated with daily subcutaneously injected PTH (0.040?mg/kg/BW) (ORX-PTH) for 5?weeks. The other half remained untreated (ORX). The sham-operated group was divided and treated in the same way (sham, sham-PTH). After 5?weeks, both femurs were excised for biomechanical and histomorphometric analysis, trabecular measurements, mineral content assessment, and immunofluorescence analysis.

Results

The femoral trochanteric strength after PTH treatment was enhanced in the breaking test (ORX-F_max?=?158.7?N vs. ORX?+?PTH-F_max?=?202?N). Stiffness of treated ORX animals reached nearly the levels observed in untreated sham rats. PTH therapy improved the trabecular connectivity, width, and area (ORX-Tb.Ar?=?47.79% vs. ORX?+?PTH-Tb.Ar?=?68.47%, P?<?0.05) in the proximal femur. The treated rats showed significantly improved mineral content in ashed femurs (ORX-mineral content?=?43.73% vs. ORX?+?PTH-mineral content?=?49.49%) when compared to the untreated animals. A comparison of widths of fluorescence bands in cortical bone of the subtrochanteric cross-sections showed a significant increase in oppositions after the PTH therapy.

Conclusions

Our finding supports the hypothesis that PTH therapy seems to be a rational therapy in patients with hypogonadism induced bone loss and improves the bone strength of trochanteric region of rat femur.     

Komplikationsraten bei der Karotis-TEA

Background

The gold standard for carotid stenosis is carotid endarterectomy. In this study perioperative and postoperative results were compared between consultants and residents in vascular surgery.

Objectives

The primary endpoints of the study were perioperative stroke and mortality rates. Further endpoints were postoperative general and local complication rates as well as duration of surgery and clamping time of the carotid artery.

Methods

In a retrospective study data from 496 patients undergoing carotid endarterectomy were analyzed. Two groups were formed: surgery by a vascular surgeon (group A, n?=?337 patients) and surgery by a resident in vascular surgery (group B, n?=?159 patients).

Results

Surgery was performed significantly more often by a vascular surgeon in symptomatic patients. The duration of surgery was significantly longer when performed by residents in vascular surgery assisted by a vascular surgeon whereas there were no significant differences between clamping times in both groups. Combined perioperative stroke and mortality rates were 1.17?% in group A and 0.63?% (p?=?1) in group B. Postoperative general complication, local complication and wound infection rates were 2.37, 2.67 and 0.3?% in group A and 3.77, 2.52 and 0?% in group B, respectively and showed no statistically significant differences (p?=?0.36). Overall there was a total perioperative and postoperative complication rate of 6.52?% in group A and of 6.92?% in group B. There were no statistically significant differences between the complication rates (p?=?0.39) and restenosis (p?=?0.8).

Conclusion

Residents in vascular surgery obtained comparable results for perioperative and postoperative complication rates when performing carotid endarterectomy supervised by a vascular surgeon even though the duration of surgery was longer.     

Stumpfverschluss bei der laparoskopischen Appendektomie

Background

Even though laparoscopic appendectomy is one of the most frequent procedures in abdominal surgery, the technique of appendiceal stump closure is still not standardized. The aim of this retrospective study was to analyze the effect of the use of endoloops or linear staplers for appendiceal stump closure concerning surgical site infections (SSI) and intra-abdominal abscesses (IAA).

Patients and methods

All laparoscopic appendectomies between January 1st 2007 and May 31st 2010 were split into an endoloop group (ELG) and a linear stapler group (LSG). The groups were compared with respect to the outcome parameters SSI and IAA.

Results

A total of 430 appendectomies were performed in the study period of which 105 operations were conducted laparoscopically. In this study 47.6?% (n?=?50) were alloted to the LSG and 52.4?% (n?=?55) to ELG. In LSG 3.1?% (n?=?1) developed an SSI versus 10.0?% (n?=?4, p?=?0.254) in ELG. No IAAs occurred in LSG compared to 2 (5.1?%, p?=?0.499) in ELG.

Conclusion

The use of EL for appendiceal stump closure is safe and cost effective for low-grade appendicitis but high-grade appendicitis should be treated with LS.     

Train-of-four and double burst stimulation fade at the great toe and thumb

Purpose

We compared probabilities of tactile detection of fade in response to train-of-four (TOF). double burst stimulation,_3,3 (DBS_3,3). and DBS_3,3 at the great toe with those at the thumb.

Methods

One hundred and thirty adult patients anaesthetized with nitrous oxide, oxygen, isoflurane, and fentanyl were studied. At varying degrees of neuromuscular block caused by vecuronium. an observer determined the presence or absence of fade m response to TOF, DBS_3,3, or DBS_3,2 at the great toe and that at the thumb. The relationship between TI /TO or TOF ratio (T4/T1) measured at the great toe and that at the thumb was also examined.

Results

When TOF ratios were 0-0,10, 0.11–0.20, 0.21–0.30, 0.31–0.40, 0.41–0.50, 0.51–0.60. 0.61–0.70. and 0.71-1,00. the probabilities of detection of fade in response to TOF at the great toe (thumb) were 77 (100), 66 (100), 58 (96), 52 (77), 39 (38), 26 (23), 2 (4), and 0 (0) %, respectively (P< 0.05 at TOF ratio 0–0.40). Similarly, the probabilities of detection of fade in response to DBS_3,3 at the great toe were lower than at the thumb when TOF ratios were 0.21–0.80. and those in response to DBS_3,3 at the great toe were lower than at the thumb when TOF ratios were 0.61–0.80. A dose relationship was observed between T1 /T0 or TOF ratio at the great toe and that at the thumb.

Conclusion

This study suggests that the probability of tactile detection of fade in response to TOF, DBS_3,3, or DBS_3,2 at the great toe is less than that at the thumb. The present results may be because the flexor hallucis brevis muscle is more resistant to non-depolanzmg neuromuscular relaxant than the adductor pollicis muscle and that the ratio of fade m response to neurostimulation at the great toe is higher than at the thumb.     

Einfluss der akuten normovolämischen Hämodilution auf die primäre Hämostase

Background

Acute normovolemic hemodilution (ANH) is performed with the intention to reduce the requirement for allogeneic blood transfusions. After preoperative withdrawal of whole blood, corresponding amounts of crystalloids and/or colloids are infused to maintain normovolemia. The main benefit of ANH is the availability of whole blood containing red blood cells, clotting factors and platelets for reinfusion after removal during the dilution process. Until retransfusion whole blood components are stored at the patient’s bedside in the operating theatre.

Aim

It was the aim of the present investigation to analyze potential changes in ex vivo induced platelet aggregation in stored blood components.

Material and methods

After obtaining approval 15 patients undergoing complex cardiac surgery were enrolled into this prospective observational study. Acute normovolemic hemodilution (ANH) was routinely performed in this collective based on institutional standards. Besides analyses of pH and plasma concentrations of ionized calcium and hemoglobin, hematological analyses included aggregometric measurements using multiple electrode aggregometry (MEA, Multiplate®, Roche, Grenzach, Germany). Ex vivo platelet aggregation was induced using arachidonic acid (ASPI test), as well as thrombin receptor activating peptide (TRAP test) and adenosine diphosphate (ADP test). Laboratory analyses were performed before beginning ANH (baseline), as well as immediately (T₁), 30 min (T₂), 60 min (T₃), 90 min (T₄), 120 min (T₅), 150 min (T₆) and 180 min (T₇) after beginning of storage. The areas under the aggregation curves (AUC) in the MEA were defined as primary (ASPI test) and secondary endpoints (ADP test, TRAP test).

Results

As compared to baseline, arachidonic acid induced platelet aggregation was significantly reduced at T₁ [77 U (68/94 U) vs. 53 U (25/86 U), p?=?0.003] and each consecutive measuring point. As compared to T₁ (begin of storage), arachidonic acid induced platelet aggregation was significantly reduced at T₄ [26 U (14/54 U); p?=?0.002], T₅ [30 U (21/36 U); p?=?0.007], T₆ [25 U (17/40 U); p?=?0.004] and T₇ [28 U (17/39 U); p?<?0.001]. The extent of ex vivo induced platelet aggregation in the TRAP test and ADP test remained unchanged during the study period. The pH as well as the concentrations of ionized calcium and hemoglobin remained unchanged in the blood component during storage.

Conclusion

The results of the present study indicate that disturbances of platelet aggregation may occur during storage of whole blood components prepared for the purpose of ANH. Further investigations are needed to analyze whether the observed phenomena are of hemostatic relevance.     

Levator–sphincter reinforcement after ultralow anterior resection in patients with low rectal cancer: the surgical method and evaluation of anorectal physiology

Purpose

To determine whether ultralow anterior resection with levator–sphincter reinforcement (uLAR-LSR), which is first introduced in the current study, offers functional preservation in patients with low rectal cancer.

Methods

We assessed the functional outcomes in 56 of 61 consecutively enrolled patients who underwent uLAR-LSR. After rectal resection, levator–sphincter reinforcement (LSR) was performed by approximation of the dissected muscles. The functional outcomes were assessed preoperatively, and then 3, 12, and 24?months postoperatively.

Results

There were no significant differences in the sphincter or high-pressure zone length between the preoperative and postoperative periods in the uLAR-LSR group (P?=?0.298–0.981), which indicated functional preservation by the LSR. The percentage of patients with moderate to severe incontinence (>10 using the Wexner score) was significantly decreased at 24?months as compared to 3?months postoperatively (15.7 vs, 39.6%, P?Conclusion The uLAR-LSR method is a novel technical option, which maintains the anorectal function as well as accomplishing oncological safety during a short-term evaluation.     

Flurbiprofen axetil provides a prophylactic benefit against mesenteric traction syndrome associated with remifentanil infusion during laparotomy

Purpose

Mesenteric traction syndrome (MTS) is caused by PGI₂ release during abdominal procedures and is often observed during abdominal surgery. We have demonstrated that MTS occurs more frequently in cases using remifentanil than in those that are not. The aim of this study was to assess the prophylactic benefit of flurbiprofen axetil on MTS in patients undergoing abdominal surgery using remifentanil.

Methods

Thirty ASA physical status I and II patients were enrolled. They were scheduled to undergo abdominal surgery under general anesthesia with remifentanil and were randomly assigned to receive flurbiprofen axetil (group F) or saline (group C) preoperatively (n?=?15 each). MTS was defined according to our simplified diagnostic criteria. Arterial blood pressure and heart rate were recorded, and the plasma 6-keto-PGF_1α (a stable metabolite of PGI₂) concentration was measured just before skin incision and at 20 and 60?min after skin incision (T₀, T₂₀, T₆₀) to confirm the diagnosis of MTS.

Results

Twelve of 15 (80%) patients developed MTS in group C, whereas only 1 of 15 (6.7%) patients in group F developed MTS. At T₂₀, the group C patients showed significantly lower arterial blood pressure (P?P?1α concentration was significantly elevated in group C at T₂₀ (P?1α level remained low throughout the observation period in group F.

Conclusions

We found that preoperative administration of flurbiprofen axetil reduced the incidence of MTS during abdominal surgery with remifentanil analgesia.     

Reduction of pain on injection of propofol: combination of nitroglycerin and lidocaine

Purpose

Pain on propofol injection is a common adverse effect. This study examined the effect of a combination of nitroglycerin and lidocaine on pain during propofol injection compared to lidocaine alone.

Methods

In a double-blind, prospective trial, 90 patients scheduled to undergo elective plastic surgery were allocated randomly to three groups, to receive lidocaine 20?mg (n?=?30), a combination of lidocaine 20?mg and nitroglycerin 0.1?μg/kg (n?=?30), or normal saline as a placebo (n?=?30), with venous occlusion for 1?min, followed by the administration of 25?% of the total calculated dose of propofol (2?mg/kg) into a dorsal hand vein. The pain intensity during the propofol injection was assessed using a four-point scale (0?=?none, 1?=?mild, 2?=?moderate, 3?=?severe). Hemodynamic variables–mean arterial pressure and heart rate–were measured during the preoperative and intraoperative periods.

Results

A significantly higher proportion of patients in the placebo group (83?%) experienced pain compared to the lidocaine and combination groups (43 and 7?%, respectively; both, P?<?0.01). The incidence of pain in the combination group was lower than that in the lidocaine group (P?<?0.01). The pain score (median) was lower in the lidocaine (0) and combination (0) groups than in the placebo group (2); (P?<?0.01). The hemodynamic variables were similar in the three groups.

Conclusion

A combination of nitroglycerin 0.1?μg/kg and lidocaine 20?mg with venous occlusion for 1?min was more effective than lidocaine 20?mg alone in decreasing pain during propofol injection.     

Target controlled remifentanil infusion for smooth laryngeal mask airway removal during emergence from desflurane–remifentanil anesthesia

Purpose

Administration of remifentanil can be a reliable method for preventing airway reflex responses during emergence. We therefore investigated the effect of maintaining target controlled infusion (TCI) of remifentanil for smooth cLMA removal during emergence from desflurane?Cremifentanil anaesthesia.

Methods

Forty-one patients undergoing uretero-renoscopy under general anesthesia with desflurane and at 1?C4?ng/ml TCI remifentanil infusion were randomly assigned to a control group (n?=?20) or a remifentanil group (n?=?21). At the end of the surgery, desflurane and remifentanil infusion were stopped in group C and remifentanil was maintained at the effect-site concentration of 1.5?ng/ml TCI in group R. When LMA removal was accomplished without coughing, teeth clenching, gross purposeful movements, breath holding, laryngospasm, and desaturation to SpO₂ less than 90%, removal was regarded as smooth (successful). The emergence and recovery profiles were also evaluated.

Results

The incidence and number of complications (coughing, teeth clenching, gross purposeful movements, breath holding, laryngospasm, desaturation to SpO₂ <90%) were significantly higher in the control group than in the remifentanil group (p?=?0.002).

Conclusion

Maintaining effect-site TCI of remifentanil at 1.5?ng/ml during emergence from anaesthesia enabled smooth removal of cLMA without any delay in recovery time.     

Sevoflurane and isoflurane impair edrophonium reversal of vecuronium-induced neuromuscular block

Purpose

A dose-response relationship study for edrophonium to examine the modification of volatile anaesthetics on reversal of vecuronium block.

Methods

One hundred and twenty ASA (I–II) patients were anaesthetized with sevoflurane, isoflurane (I minimum alveolar anaesthetic concentration [MAC] end-tidal concentration), or fentanyl-diazepam anaesthesia, in combination with 66% nitrous oxide (n = 40 for each group). The evoked electromyogram (EMG) response of the abductor digiti minimi was monitored at 20 sec intervals following train-of-four (TOF) stimulation of the ulnar nerve. The initial neuromuscular block was produced by vecuronium 100 μg · kg^?1. When the amplitude of the first response (T₁) had spontaneously recovered to 10% of the control, edrophonium (0, 125, 400, 700 or 1000 μg · kg^?1; eight patients each) was randomly administered, and the ratio of the fourth TOF to the first response (TOFR ) was monitored at one minute intervals for 10 min.

Results

Sevoflurane and isoflurane impaired the edrophonium-assisted TOFR recovery in an edrophonium dose and time dependent manner. The dose-response curves at 10 min exhibited a greater shift to the right in the sevoflurane and isoflurane groups than in the fentanyl-diazepam-nitrous oxide group (P < 0.05). Higher ED₅₀ values (the edrophonium dose required to obtain TOFR value of 50%) in the sevoflurane (> 1000 μg · kg^?1) and isoflurane groups (851 · μg · kg^?1) were observed than in the fentanyl-diazepam-nitrous oxide group (339 μg · kg^?1) (P < 0.05).

Conclusion

One MAC sevoflurane and isoflurane anaesthesia impair edrophonium reversal of vecuronium block to a similar degree.     

Radical cystectomy for clinically muscle invasive bladder cancer: does prior non-invasive disease affect clinical outcomes?

Purpose

To compare clinical and pathologic outcomes of radical cystectomy for muscle invasive bladder cancer in relation to prior history of non-invasive urothelial carcinoma.

Materials and methods

Retrospective data collected from 1,150 patients managed by radical cystectomy for urothelial carcinoma of the bladder from the Canadian Bladder Cancer Network were analysed. Patients with clinical stage T2 or more were included and divided into two groups: (Group 1) patients with prior history of non-invasive urothelial carcinoma (N?=?365) and (Group 2) patients with clinical muscle invasive cancer de novo (N?=?785). Variables analysed included patient age, gender, pathologic stage, adjuvant chemotherapy, recurrence and mortality.

Results

Both groups were nearly equal in mean age and gender distribution, with mean ages of 67.2 and 66.7?years, and 79.7 and 79.5%, respectively (P?=?0.4 and 0.9, respectively). The presence of preoperative hydronephrosis was 20.8 and 32.6% (P?=?0.0007) for groups 1 and 2, respectively. The rate of higher pathological stage (T3 or T4) was 36.3 and 58% (P?<?0.0001), positive lymph nodes were 20.1 and 28.8% (P?=?0.002), and lymphovascular invasion was 31.7 and 46.2% (P?=?0.0001) for groups 1 and 2, respectively. The rate of adjuvant chemotherapy was 15.5 and 23.3% (P?=?0.002) for groups 1 and 2, respectively. None of the sampled patients received neoadjuvant chemotherapy. The overall survival (OS) and disease-specific survival (DSS) rates at 5?years were 62 and 70% for group 1 and 51 and 60% for group 2, respectively, while at 10?years, OS and DSS were 46 and 66% for group 1 and 35 and 49% for group 2, respectively (P?=?0.0001 and 0.0002, respectively). Using multivariate analysis examining factors affecting recurrence and survival, we found that previous non-invasive bladder tumour history was associated with a significantly reduced risk of mortality and recurrence (Hazard ratio of 0.7 for all risks, P?=?0.0002).

Conclusion

Our retrospective study suggests that patients with non-invasive urothelial carcinoma of the bladder that progress to muscle invasion and require radical cystectomy appear to have better pathologic and clinical outcome than patients presenting with clinical muscle invasive disease de novo.