Subcutaneous adrenaline infiltration in paediatric burn surgery.

Paediatric burn surgery may be associated with significant blood loss and postoperative pain. To investigate methods of reducing these symptoms, we studied a prospective series of 29 children with small to medium sized burns. Presurgically both the burn wound and split skin graft donor sites were injected with a 1:500,000 adrenaline solution, to which bupivicaine had been added. No patient required blood transfusion and no patient developed systemic side effects from the injected solution. Four patients required parenteral analgesia, two in the immediate postoperative period and two at first dressing change. In all other patients pain was controlled with oral analgesia alone. Mean graft take in our series was 95%, indicating that this technique does not compromise burn depth assessment, nor impair graft survival.     

Plasma catecholamine concentrations—changes after infiltration with local anaesthetic solutions and adrenaline during bat-ear surgery

Plasma catecholamine concentrations were measured in 12 patients who had bilateral bat-ear surgery following infiltration of each ear with 2 ml 2% lignocaine with adrenaline 1:100,000. Venous blood samples were withdrawn before and at set intervals after infiltration. Plasma adrenaline concentration increased from 0.8 pmol/ml to a peak of 2.2 pmol/ml at 2 minutes after infiltration; this is an increase of 175%. There was no significant change in plasma noradrenaline concentration.     

Plasma catecholamine levels following topical application versus infiltration of adrenaline for nasal surgery.

Plasma catecholamine concentrations were measured after vasoconstrictor solutions were administered either by instillation (Moffett's method) or by submucosal infiltration in twenty patients undergoing elective nasal surgery. Following infiltration with 4.4 ml of 1:80,000 adrenaline and 2% lignocaine, plasma adrenaline concentrations increased by 44.3 times to a peak of 9.9 nmol.l-1 (1813 pg.ml-1) within one minute. In contrast the peak level of adrenaline in the patients receiving Moffett's solution containing 1 ml of 1:1,000 adrenaline was 1.27 nmol.l-1 (232 pg.ml-1) occurring 10 minutes after instillation of the solution. The difference in the adrenaline concentrations between the groups was statistically significant (P less than 0.01). The lack of sympathoneuronal response was confirmed by simultaneous measurements of plasma noradrenaline concentrations, which did not change significantly. The operative field was subjectively assessed to be better in the infiltrated patients and the mean operating time and measured blood loss were less in this same group of patients.     

The efficacy of bupivacaine with adrenaline in reducing pain and bleeding associated with breast reduction: a prospective trial.

In a randomised, double-blind, placebo-controlled trial, the effect of preoperative local anaesthesia vasoconstrictor infiltration on peri- and postoperative bleeding and postoperative pain was evaluated in 24 consecutive patients undergoing breast reduction. After the induction of general anaesthesia, one breast was infiltrated with a solution of bupivacaine with adrenaline and the other with the same amount of normal saline solution simultaneously. The perioperative blood loss was calculated by weighing swabs, and postoperative drainage was measured at 3, 24 and 48 h by using suction drains. Postoperative pain was assessed using visual analogue scales and verbal response scores at 3, 6, 10 and 24 h post-infiltration. There was a reduction in perioperative blood loss in the breast infiltrated with bupivacaine and adrenaline (P < 0.01). The mean blood loss in the drains from the infiltrated breasts was also less than that from the control sides at 3 and 24 h post-infiltration (P < 0.05). Pain was significantly less (P < 0.01) at 3 h on the local anaesthetic side. At 6, 10 and 24 h, pain tended to be less on the local anaesthetic side, but this did not reach statistical significance. No major complications were seen. Our results confirm a beneficial effect of bupivacaine with adrenaline on peri- and postoperative bleeding as well as in the early postoperative phase of pain.     

利多卡因混合不同剂量肾上腺素局部浸润麻醉对全麻下鼻内窥镜手术患者血液动力学的影响

目的 观察利多卡因混合不同剂量肾上腺素局部浸润麻醉对全麻下鼻内窥镜手术患者血液动力学的影响。方法 69例拟在全身麻醉下行鼻内窥镜手术的患者随机分为3组（n=23），采用含不同剂量肾上腺素的1％利多卡因进行鼻粘膜下多点浸润注射。Ⅰ组：含1：20万肾上腺素的1％利多卡因4ml（20μg）；11组：含1：10万肾上腺素的1％利多卡因4ml（40μg）；Ⅲ组：1％利多卡因4ml（不含肾上腺素）。采用阻抗心动图（ICG）测量并记录浸润麻醉开始前（基础值）、浸润麻醉开始后0．75、1．5、2．25、3、3．75、4．5、5．25、6min平均动脉压（MAP）、心率（HR）、心脏排血指数（CI）、外周血管阻力指数（SVRI）和加速度指数（ACI），同时评价术中出血状况。结果与基础值比较，Ⅰ组和Ⅱ组在浸润麻醉开始后1．5min时MAP下降，HR增快（P〈0．01）；从浸润麻醉开始后1．5minSVRI下降，CI、ACI上升，到浸润麻醉开始后6min时仍未恢复（P〈0．05或0．01）。与Ⅱ组比较，Ⅰ组在浸润麻醉开始后2．25、3、3．75minMAP下降，从2．25min起CI下降（P〈0．01或〈0．05）。与Ⅲ组比较，Ⅰ组、Ⅱ组出血较少（P〈0．01）；Ⅰ组和Ⅱ组之间差异无统计学意义。结论 全身麻醉下鼻内窥镜手术中局部浸润麻醉时，局麻药中肾上腺素的吸收会引起明显的血液动力学变化，推荐在鼻内窥镜手术中使用含有5μg/ml肾上腺素的利多卡因。     

A prospective randomised trial of tourniquet in varicose vein surgery

A prospective randomised trial of 50 patients was carried out to assess the autoclavable Lofquist cuff (Boazal, Sweden) as a tourniquet in varicose vein surgery and determine the effect on bleeding, bruising, cosmesis and patient pain and activity. Patients undergoing unilateral long saphenous vein ligation, stripping and avulsions were randomised to tourniquet or no tourniquet. Lofquist cuffs were applied after inflation to 120 mmHg to the upper thigh for the duration of the surgery. Varicose vein grade, duration of surgery, blood loss, extent of bruising at 7 days, pain and activity scores over the first week, and wound complications and cosmetic result at 6 weeks were recorded. Patients' age, sex, and varicose vein grade were similar in the two groups. Peroperative blood loss (median, range) was significantly reduced in the tourniquet group (0 ml, 0-20 ml) compared to the no tourniquet group (125 ml, 20-300; P < 0.01). Operative time and thigh bruising (median, range) were also reduced in the tourniquet group (30 min, 11-47 min; 72 cm2, 30-429 cm2), respectively, compared to the no tourniquet group (37 min, 18-50 min; 179 cm2, 24-669 cm2) both (P < 0.01). There was no difference in pain and activity scores in the two groups and cosmetic results were also similar. The use of the Lofquist cuff tourniquet during varicose vein surgery reduces peroperative blood loss, operative time and postoperative bruising without any obvious drawbacks.     

An inhalation bolus of sevoflurane versus an intravenous bolus of remifentanil for controlling hemodynamic responses to surgical stress during major surgery: a prospective randomized trial

We studied 120 patients scheduled for elective major thoracic or abdominal surgery, randomized into 2 groups: a Sevoflurane group (n = 63) and a Remifentanil group (n = 57). Heart rate (HR) and mean arterial pressure (MAP) are indicative of sympathetic response to surgical stress. A positive response was defined as a 15% increase in the HR and MAP above baseline measurements. When a positive response occurred, in the Sevoflurane group we administered a bolus dose of 8% sevoflurane (fresh gas flow 6 L/min) and in the Remifentanil group, an IV bolus dose of remifentanil 1 microg x kg(-1) x min(-1), which was maintained until MAP and HR returned to baseline measurements (effective bolus). If, after a bolus dose, a decrease in MAP and/or HR of >15% occurred with respect to baseline values, the response was considered to be excessive. The bolus dose was ineffective in 4.8% of the responses in the Sevoflurane group and in 17.8% of the responses in the Remifentanil group (P < 0.05). In the Sevoflurane group, an excessive effect occurred in 12% of responses, and in 26.7% in the Remifentanil group (P < 0.05). An inhalation bolus of sevoflurane seems to be more effective than an IV remifentanil bolus during maintenance, with more effective control of hemodynamic responses to surgical stress. IMPLICATIONS: We compared an inhalation bolus of sevoflurane with remifentanil for managing hemodynamic responses to major abdominal or thoracic surgery. This prospective, randomized trial demonstrated better results with sevoflurane.     

Gastric cancer surgery without drains: A prospective randomized trial

Prophylactic drain placement during major abdominal surgery has been widely practiced without clear scientific evidence to support it. We hypothesized that prophylactic drain placement is not necessary in gastric cancer surgery. A randomized prospective trial was conducted between February 1, 2001, and July 30, 2001. Patients were randomly assigned to either the drain group or the no-drain group. One hundred seventy patients completed the study by undergoing either subtotal or total gastrectomy with D2 lymph node dissection. Surgical outcome between the two groups was compared within the subtotal and total gastrectomy subgroups. Postoperative complication within 30 days was the primary end point of the study. No significant difference was noted in the incidence of postoperative complication between the drain group and the no-drain group. The results of this study suggest that prophylactic drain placement does not offer additional benefit for patients undergoing gastric cancer surgery with extended lymph node dissection.     

Immunosuppression for human saphenous vein allograft bypass surgery: A prospective randomized trial

Purpose: Vein allografts are an alternative bypass conduit for patients who lack adequate autogenous vein. Animal studies have demonstrated that patency can be augmented by low-dose immunosuppression with azathioprine.Methods: In a prospective trial, 40 patients (20 men, 20 women) were randomly assigned to receive (17) or to not receive (23) azathioprine (1 mg/kg/day) after cryopreserved vein allograft bypass grafting. Patients had pain or tissue loss that required bypass grafting to pedal or crural outflow and lacked adequate autogenous saphenous vein. Anti-HLA antibody screens were obtained before and after surgery. Biopsies of allografts were performed at implantation and at all subsequent opportunities. Postoperative physical and vascular laboratory examinations occurred every 3 months.Results: During the 31-month follow-up interval (mean, 15.7 months) there were 10 deaths (none immunosuppression-related). The primary graft patency rate at 12 months was 13%, and the limb salvage rate was 42%. No significant difference (p > 0.05) was noted between immunosuppressed and control groups for mortality rate, primary graft patency rate, or limb salvage rate. As a predictor of graft failure, positive preoperative anti-HLA antibody screen (8 patients) approached significance (p = 0.09). Of 22 explanted grafts, 13 (59%) had histologic evidence of rejection (six immunosuppressed, seven control). Seven patients who had negative results of preoperative anti-HLA antibody screens converted after surgery, and six patients had positive results of preoperative screens that became more strongly positive.Conclusion: Vein allograft failure is in part mediated by rejection, which is not eliminated by low-dose azathioprine. Both humoral (antibody) and cellular responses to vein allografts develop. The poor patency rates of vein allograft bypass grafts may be improved by more potent immunosuppression as well as improvement in allograft procurement, preservation, and matching. (J Vasc Surg 1997;26:32-42.)     

The effects of infiltration with adrenaline on blood loss during reduction mammaplasty.

Between March and November 1990 a prospective study of the effect of an infiltration of diluted adrenaline on bleeding during and after reduction mammaplasty was carried out in 12 consecutive patients. There was a significant reduction in blood loss to less than 50% of that from the non-infiltrated breasts. There was no signs of increased postoperative bleeding or reduced flap viability as a result of infiltration of adrenaline.     

鼻咽部手术后冷敷材料与间隔时间探讨

目的探讨鼻咽部手术后适宜的冷敷材料及间隔时间,增进患者舒适感。方法将236例鼻咽部手术后患者随机分为对照组79例,观察Ⅰ组74例,观察Ⅱ组83例。对照组术后行常规护理,不使用冰袋进行冷敷。观察Ⅰ组将小方巾包裹10%盐水冰袋5～6min,待小方巾冷却后取下三折敷于患者前额或颈部。冷敷的持续时间和间隔时间均为30min。5～10min更换小方巾1次。观察Ⅱ组方法同观察Ⅰ组,冷敷的持续时间和间隔时间分别为30min、1h。分别于手术回病房后30min、1h、2h、3h、4h、5h、6h观察三组患者出血情况。结果三组各时间点出血率比较,差异有统计学意义(均P0.01),对照组出血率显著高于观察Ⅰ、Ⅱ组(均P0.0125)。结论冷敷可明显改善鼻咽部手术后患者出血,采用冷却的小方巾冷敷患者感觉舒适,术后冷敷间隔时间30min或1小时均可。     

Evaluation of complications and long-term results after surgery for gynaecomastia

In an attempt to evaluate ten years of surgical treatment of gynaecomastia, we analysed the incidence of complications and the quality of the results in a group of patients classified according to Simon. Over the decade 1992-2002, 107 patients with gynaecomastia aged from 17 to 79 years were treated. The prevalent surgical approach was subcutaneous mastectomy. In 71 patients the surgical approach was via a periareolar inferior incision, superior in 15, inferior with bilateral extensions in 10; using a complete circumareolar approach (according to Padron) in 8 patients and a subcutaneous transareolar mastectomy in 3. No immediate complications were observed. Ten patients presented a modest postoperative haematoma. Only in one diabetic patient with chronic bronchitis and grade III gynaecomastia did partial dehiscence of the surgical wound occur. Most patients achieved good results. We judged the results excellent in 94 patients, good in 11, and unsatisfactory in 2. On the basis of our experience and in agreement with the literature data, we can affirm that the best results were obtained by subcutaneous mastectomy with a periareolar incision.