Spinal anesthesia versus intravenous sedation for transvaginal oocyte retrieval: reproductive outcome, side-effects and recovery profiles

Transvaginal ultrasonically guided oocyte retrieval is commonly performed as part of in vitro fertilization efforts. The impact of anesthetic management on patient outcome from this procedure has not been well characterized. At our institution, patients are offered a choice of either heavy intravenous sedation or spinal anesthesia with minimal or no sedatives. In this pilot study, we retrospectively reviewed the anesthetic management, reproductive outcome and recovery room experience for all patients having oocyte retrieval during a 2-year interval (n = 95). Fifty-one oocyte retrievals were performed under spinal anesthesia, while 44 patients received solely intravenous sedatives. Both groups had similar reproductive outcomes. The intravenous sedation group required a significantly longer period until recovery room discharge criteria were met (P = 0.03), and were more likely to have postoperative emetic episodes (46% versus 6% in the spinal anesthesia group: P < 0.01). Two unplanned hospital admissions occurred in the intravenous sedation group: both were related to uncontrolled nausea and vomiting. We conclude that spinal anesthesia may have advantages over intravenous sedation for oocyte retrieval.     

丙泊酚复合瑞芬太尼用于经阴道取卵术麻醉的药效学

目的评价丙泊酚复合瑞芬太尼用于经阴道取卵术麻醉的临床效果,根据给药时间、剂量和药代动力学模型,用计算机模拟药物浓度,建立并分析药效学模型及其特点。方法静脉麻醉下行经阴道取卵术患者42例,ASAⅠ或Ⅱ级,随机分为两组,分别静脉注射瑞芬太尼1.5μg/kg+丙泊酚1.5mg/kg(PR15组,n=24)或瑞芬太尼1.0μg/kg+丙泊酚1.0 mg/kg(PR10组,n=18)。根据患者体动反应和自诉疼痛情况,酌情追加瑞芬太尼0.5μg/kg和/或丙泊酚0.5 mg/kg。麻醉质量评价主要指标包括睫毛反射消失时间、定向力恢复时间、低氧发生率(SpO_292%)及其他不良反应。基于模拟浓度、非线性混合效应模型、采用NONMEM软件建立药效学模型。结果PR15组患者定向力恢复时间明显慢于PR10组[(4.9±1.3)min vs(3.6±1.2)min,P0.05];但两组睫毛反射消失时间[(58±14)s vs(64±13)s]、低氧(12.5%vs 16.7%)和咳嗽(16.7%vs11.1%)发生率差异无统计学意义。50%患者有效镇静的丙泊酚浓度和有效镇痛的瑞芬太尼浓度(EC_(50))分别是1.71μg/ml、2.57ng/ml;95%患者有效镇静的丙泊酚浓度和有效镇痛的瑞芬太尼浓度(EC_(95))分别为4.30μg/ml、4.57ng/ml。丙泊酚1.0 mg/kg产生的峰效应位浓度低于EC_(50),而1.5mg/kg产生的峰效应位则高于EC_(50);但瑞芬太尼1.0、1.5μg/kg产生的峰效应位浓度均高于EC_(50),后者接近EC_(95)。结论基于患者恢复时间,经阴道取卵术麻醉时瑞芬太尼1.0μg/kg复合丙泊酚1.0mg/kg较为合适。     

Comparison of conscious sedation for oocyte retrieval between low-anxiety and high-anxiety patients

STUDY OBJECTIVE: To investigate the correlation among the level of anxiety, the intravenous propofol requirement for conscious sedation, and recovery profile in in vitro fertilization patients. DESIGN: Prospective, randomized, double-blinded study. SETTING: Operating room of tertiary-care university hospital. PATIENTS: One hundred fifty consecutive women scheduled for oocyte retrieval under conscious sedation. INTERVENTIONS: Anxiety scores were separately measured by an anesthesiologist who was not involved in sedation. The patients were divided into 2 groups, high-anxiety and low-anxiety, as determined by using the median of anxiety VAS scoring for assessment of preoperative anxiety (4.0 cm). The subjects were collected, 76 in high-anxiety group and 74 in low-anxiety group. MEASUREMENTS: An infusion of propofol with a preset target concentration of 2.5 microg/mL(-1) was started until the patient had reached and maintained a sedation level of 3 on a 5-point sedation scale. Hemodynamic variables were recorded by using standard monitors. The scorings of sedation, operability, and satisfaction were assessed by one of the investigator-anesthesiologists. Data of induction quality and concentration of propofol were obtained from Target-Controlled Infusion system that runs on a microcomputer connected to an infusion pump (Becton-Dickinson infusion system, Le Grande chemin, France). Recovery data were measured in the recovery room. MAIN RESULTS: The high-anxiety group required more for the induction of sedation and a larger amount of total dosage of propofol for sedation, as compared with the low-anxiety group. The concentrations of propofol on the Target-Controlled Infusion at sedation level 3 of the high-anxiety group were significantly higher than those of the low-anxiety group. Context-sensitive half time of high-anxiety group was also longer than that of the low-anxiety group. The postoperative pain score of the high-anxiety group was higher than that of the low-anxiety group. Increased preoperative anxiety was significantly correlated with postoperative wound pain (r = 0.240, P = 0.009) and previously experienced pain on same procedure (r = 0.252, P = 0.031), but not with pain on propofol injection (r = -0.05, P = 0.58). CONCLUSIONS: The high-anxiety group needs more sedative requirement of propofol for conscious sedation than the low-anxiety group. Thus, we suggest that propofol dose for such sedation must take into account the individual patient's anxiety level when propofol is administered by an anesthesiologist for oocyte retrieval.     

丙泊酚静脉麻醉对行取卵术患者自然杀伤细胞数量及妊娠结局的影响

目的:评价丙泊酚静脉麻醉对行取卵术患者自然杀伤（natural killer, NK）细胞的数量及妊娠结局的影响。方法:选择择期接受体外受精-胚胎移植（in vitro fertilization and embryo transfer, IVF-ET）的患者110例,年龄20~40岁,ASA分级Ⅰ、Ⅱ级,采用随机数字...     

小剂量右美托咪定复合丙泊酚滴定麻醉用于经阴道取卵术的效果观察

目的 观察经阴道取卵术中使用右美托咪定复合丙泊酚滴定麻醉对患者安全性、舒适性的影响。方法 选择2019年5月至2019年10月在佛山市妇幼保健院生殖中心行择期经阴道取卵术的患者100例,根据随机数字表法分为D组（右美托咪定复合丙泊酚组）和C组（丙泊酚组）,每组各50例,两组均采用滴定给药方式,以MOSS/A镇静评分0分作为滴定终点。比较两组患者不同时间点的平均动脉压（MAP）、心率（HR）、脉搏氧饱和度（SpO₂）,记录丙泊酚用量、患者满意度及各种不良反应。结果 D组丙泊酚用量少于C组（P<0.05）,D组呼吸抑制、术中体动、术后腹痛等发生率显著低于C组（P<0.05）。两组患者丙泊酚注射痛、舒适度评分无统计学意义（P>0.05）,两组心动过缓、低血压发生率无统计学意义（P>0.05）。结论 与单纯使用丙泊酚相比较,右美托咪定复合丙泊酚可减少丙泊酚用量,降低呼吸抑制、术中体动及术后腹痛发生率,可更加安全地运用于无痛取卵术。     

Feasibility and outcome of emergency ureteroscopic removal of lower ureteral stone under intravenous sedation: A prospective study

ObjectiveTo compare the efficacy of emergency ureteroscopy (URS) with that of elective URS in the treatment of distal ureteral calculi.Patients and methodsThis prospective study included 132 patients diagnosed with a distal unilateral ureteral stone ≤5 mm and treated with either emergency or elective URS between August 2013 and July 2014. The indication for emergency URS was intractable renal pain not responding to narcotic analgesia. Children, pregnant women and patients with bilateral disease were excluded. The patients were categorized into two groups: Group I included 42 patients who underwent emergency URS under intravenous sedation, while Group II included 90 patients who underwent elective URS. The patients’ demographic data, the stone criteria, perioperative complications, procedure outcome and degree of patient satisfaction were recorded and statistically analyzed.ResultsThe mean stone size was 4.2 ± 0.5 mm in Group I and 4.1 ± 0.6 mm in Group II. The success rate was 90.5% and 97.8% in Groups I and II, respectively with a statistically insignificant difference. Complete stone retrieval without fragmentation was achieved in 83.3% in Group I and in 82.2% in Group II. The stone migrated proximally in 4 patients in Group I and in only 2 patients of Group II; these patients received ureteral stents. Mucosal injury was observed in 3 and 4 patients of Groups I and II, respectively. Thirty-seven patients of Group I (88%) reported that they were satisfied with the procedure and its outcome compared to 78 patients of Group II (87%).ConclusionEmergency URS under intravenous sedation is feasible, safe and equally effective when compared to elective URS for small lower ureteral stones.     

经阴道与腹腔镜子宫肌瘤切除术的对比研究

目的：比较经阴道子宫肌瘤切除术（transvaginal myomectomy,TVM）和腹腔镜子宫肌瘤切除术（laparoscopic myomectomy,LM）的特点,以指导临床术式的选择。方法：比较LM86例（腹腔镜组）和TVM65例（阴式组）的手术时间、术中出血量、术后体温恢复正常时间、术后排气和住院时间。结果：阴式组手术时间（55.3±9.7）min,腹腔镜组（98.2±24.3）min,差异无统计学意义（P〉0.05）;术中出血量阴式组（50.6±18.7）ml,腹腔镜组（92.4±30.7）ml（P〈0.05）;术后体温恢复正常时间阴式组（65.5±18.1）h,腹腔镜组（62.8±17.4）h（P〉0.05）,术后排气时间阴式组（18.9±6.8）h,腹腔镜组（25.1±7.1）h;术后住院时间阴式组（5.9±1.4）d,腹腔镜组（6.5±1.3）d（P〉0.05）。结论：两种术式均具有创伤小、术中出血少、术后恢复快及住院时间短等优点。但两种术式特点和适应证不同,不能完全互相替代。     

Meniscus suture techniques: a comparative biomechanical cadaver study

The primary stability of four common meniscus suture techniques was tested on human cadaver menisci. The test series was carried out under standard conditions (25 degrees C, 100% air humidity) using the Instron 1122 Tensometer. The tearing stress of different sutures was reproducible in different specimens dependent only on the suture technique. Knot-end techniques gave inferior results (tearing stress, 24 +/- 9 N) compared with arthroscopic techniques using a loop placed on the meniscus surface (tearing stress, 89 +/- 4 N). When an open meniscus repair is performed, a vertical stitching technique (tearing stress, 105 +/- 4 N) should be the preferred method. Horizontal sutures are weaker (tearing stress, 44 +/- 18 N).     

Pelvic osteotomy techniques and comparative effects on biomechanics of the hip: a kinematic study

Dysplasia of the hip is characterized by malpositioning of the proximal femur in a shallow acetabulum, providing deficient femoral head coverage. This abnormal relationship leads to altered biomechanics of the hip joint, as predicted by measurement of kinematic parameters such as increased load over reduced acetabular weight-bearing area, leading to increased joint contact stresses, which subsequently results in secondary osteoarthrosis, pain, and disability. To prevent these sequelae, particularly in children and younger adults, various osteotomies have been performed with varying degrees of success. The goal of this study was to devise a simple and reproducible laboratory method to perform a kinematic analysis of the individual and comparative effects of 5 commonly performed pelvic osteotomy techniques: Chiari pelvic osteotomy, Salter innominate bone wedge osteotomy, Steel triple pelvic osteotomy, T?nnis triple pelvic osteotomy, and Ganz periacetabular pelvic osteotomy. The aim was to determine which of the osteotomy techniques caused greater correction in most of the kinematic parameters used to estimate changes in the biomechanics of the hip joint. Our hypothesis was that pelvic osteotomies such as Chiari and Salter produced favorable changes and were relatively easily reproducible, but that more biomechanical correction in all planes would be achieved by the relatively more complex triple innominate bone and Ganz osteotomy.     

Effect of different preoperative patient characteristics on coronary surgery outcome: a comparative study between a developing and a developed country

Abstract   Objectives: To evaluate the impact of the preoperative patient characteristics on the results of coronary surgery in a developing country compared with a developed country. Patients and Methods: Preoperative risk factors for coronary artery disease (CAD) and intraoperative and immediate postoperative variables for coronary surgery were compared. Sixty patients were operated at Ain Shams University in Cairo (Egypt) between March and September 1999, compared with 60 patients operated at Hannover medical school (Germany) between March and September 2001. By using univariate analysis and multivariate logistic regression, model predictors for hospital mortality were determined. Results: Groups were comparable regarding a majority of risk factors except age, diabetes, chronic obstructive pulmonary disease (COPD), and hypertension. Seventy percent of the Egyptian patients presented in New York Heart Association (NYHA) class III, whereas 50% of the German patients were in NYHA class II. Fifty percent of the German patients showed left ventricular ejection fraction (LVEF) >60%, whereas 52% of the Egyptian patients had LVEF between 40% and 59%. Diabetes (56.6%) and COPD (43.3%) are the major predictors of hospital mortality among the Egyptian patients as proved by high odds ratio (4.6 and 3.4, respectively). Egyptian patients required prolonged mechanical ventilation and extended intensive care unit and hospital stay. Hospital mortality was 6.7% in the Egyptian versus 1.7% in the German group. Conclusion: Diabetes mellitus, COPD, and prolonged mechanical ventilation are the major predictors of hospital mortality in Egypt. This study tries to underline problems of coronary artery bypass graft surgery in different populations.     

A comparison of four intravenous sedation techniques and Bispectral Index monitoring in sinonasal surgery

This study was performed to investigate the quality of different intravenous sedation techniques, and the correlation between the Bispectral Index (BIS) values and the Observer's Assessment of Alertness/Sedation (OAA/S) scores. Eighty patients undergoing sinonasal surgery were randomly assigned to one of four groups. Group MF received midazolam and fentanyl, group PF received propofol and fentanyl, group MR received midazolam and remifentanil, and group PR received propofol and remifentanil. Heart rate and mean arterial pressure values were not different among the groups. SpO2 decreased only after intravenous medication in groups MF and MR (P < 0.017). Emesis was less common with propofol. A positive relationship existed between the BIS values and OAA/S scores during the operation in all groups and the strongest correlation was observed in group PR (r = 0.565 and P < 0.001). In conclusion, these four intravenous sedation techniques did not change mean arterial pressure, heart rate or SpO2 clinically and produced a similar level of light sedation. The BIS was useful for monitoring of sedation during sinonasal surgery under local anaesthesia with intravenous sedation.     

Early outcome of facial reconstructive surgery abroad: a comparative study

Every year, many medical missions are undertaken in the developing world but there is almost a universal lack of outcome data on the quality of these missions. The present study compares early clinical outcome and complication rate in two consecutive missions (facial reconstruction) undertaken to Ethiopia in 2007 and 2008. The object was to establish if measures adopted following feedback from the first mission led to improvement of the results. A significant improvement was observed in early clinical outcome and there were less severe complications in the 2008 compared to the 2007 mission. On both occasions, significantly more complications were experienced after complex compared to simple procedures. Despite improved outcome in 2008, 50% of the complex cases had an unfavourable clinical result. The data suggest that early outcome studies are a useful method of critically evaluating the quality of surgical mission. The unsatisfactory outcome of complex procedures underlines the need for feedback on the quality of these missions.     

Effect of nitrous oxide on propofol requirement during target-controlled infusion for oocyte retrieval

BACKGROUND: Oocyte (egg) retrieval for in-vitro fertilization is a relatively short procedure, usually performed as an outpatient. Propofol is a suitable anesthetic agent. Target-controlled infusion is a recently developed system that aids rapid recovery from propofol anesthesia. This study sought to determine the target concentration of propofol required to prevent movement in 50% (Cp50) and 95% (Cp95) of women during oocyte retrieval, and investigated whether supplemental nitrous oxide (N2O) modified the Cp50 and Cp95. METHODS: Forty-seven women scheduled for oocyte retrieval were randomly selected to receive either O2-air mixture (control group; n = 23) or 50% O2-N2O mixture (Nitrous oxide group; n = 24). Propofol was infused using a target-controlled infusion system with the concentration determined by up-down sequential allocation using 0.5 microg/mL step size. Transvaginal oocyte retrieval was performed after reaching target blood concentration. Patient responses to oocyte retrieval were noted as either no movement or movement. RESULTS: Using target-controlled infusion the Cp50 was 4.1 microg/mL in the control group and 3.3 microg/mL in the nitrous oxide group. Calculated Cp95 values were 4.0 microg/mL and 5.1 microg/mL with and without 50% nitrous oxide respectively. CONCLUSIONS: The Cp50 value for target-controlled infusion propofol during oocyte retrieval was significantly reduced by a factor of 1.24 (95% CI 1.07-1.44) with the use of 50% nitrous oxide.