地氟醚复合吗啡快通道麻醉在腹腔镜胆囊切除术的应用

目的 研究地氟醚复合吗啡快通道麻醉在腹腔镜胆囊切除术（LC） 的应用.方法 选择ASAⅠ-Ⅱ级LC 患者90 例,随机分为3 组：P 组（丙泊酚＋ 瑞芬太尼）、S 组（七氟醚＋瑞芬太尼）和D 组（地氟醚＋ 吗啡）,术前和诱导用药相同,麻醉维持：P 组静脉输注丙泊酚、瑞芬太尼和顺式阿曲库铵;S 组吸入七氟醚及静脉输注瑞芬太尼,不追加顺式阿曲库铵;D 组吸入地氟醚及静脉注射吗啡,不追加顺式阿曲库铵.术中观察血流动力学波动情况和呼吸恢复、拔管、离室时间、术中知晓发生率以及苏醒期躁动评分.结果 与P 组比较,D 组和S 组的血压和心率波动例数减少（P 〈 0.05）;与P 组和S 组比较,D 组呼吸恢复、拔管、离室的时间缩短（P 〈 0.05）,苏醒期躁动的评分较高（P 〈 0.05）.3 组患者均未出现术中知晓.结论 地氟醚复合吗啡快通道麻醉应用于腹腔镜胆囊切除术对血流动力学波动影响小,术后苏醒速度快、质量高.     

Total Intravenous Anesthesia with Midazolam, Remifentanil, Propofol and Cisatracurium in Morbid Obesity

Background: According to physical impairments of massive obesity, cardiac, respiratory and gastrointestinal physiology must be considered as much as pharmacokinetic behavior. Anesthetic management of morbidly obese patients has to be carefully planned, in order to minimize the increased risks of aspirative pneumonitis, hemodynamic instability and delay in recovery.The ideal anesthesia should provide a smooth and quick induction, allowing rapid airway control, prominent hemodynamic stability, and rapid emergence from anesthesia.To approach these ideal conditions,aTotal Intravenous Anesthesia (TIVA) with midazolam, remifentanil, propofol and cisatracurium was designed and analyzed. Methods: 10 consenting morbidly obese patients scheduled for elective Laparoscopic Adjustable Gastric Banding participated in the study.TIVA with midazolam, remifentanil, propofol and cisatracurium was used in all cases.Time to loss of consciousness, tracheal intubation, perianesthetic physiological parameters and complications, incidence of awareness with recall, recovery times, postoperative analgesia and costs of drugs were evaluated. Results:The analyzed data showed adequate time and physiological conditions for induction and tracheal intubation, stable maintenance with easy handling of deepness, low incidence of perianesthetic complications, excellent recovery performance and institutional efficiency. Conclusions: TIVA with midazolam, remifentanil, propofol and cisatracurium was found to be effective, secure, predictable and economic for the anesthetic management of morbidly obese patients.     

Combined general and epidural anesthesia with ropivacaine for renal transplantation

AIM: To evaluate the effectiveness and safety of epidural ropivacaine anesthesia in association with light general anesthesia during renal transplantation and compare epidural and endovenous analgesia techniques for postoperative pain control. METHODS: Experimental design: prospective randomized study. SETTING: Organ Transplantation Center, Department of Surgery, "Tor Vergata" University of Rome, St. Eugenio Hospital, Rome. PATIENTS: 25 patients affected by chronic renal failure were enrolled in this study. Thirteen constituted the combined epidural-general anesthesia group (EPI-GEN), mean age 40.15+/-9.81 years; while the others constituted the general anesthesia group (GEN), mean age 46.75+/-7.45 years. Operation: cadaveric renal transplantation. Group EPI-GEN: epidural anesthesia performed with 12-15 ml of a ropivacaine 0.75% and fentanyl 5 microg/ml solution followed by light intravenous or inhalatory general anesthesia and postoperative epidural analgesia with ropivacaine 0.2% and fentanyl 2 mg/ml. Group GEN: inhalatory or intravenous general anesthesia and intravenous tramadol postoperative analgesia. Measurements: hemo-dynamics, renal function, arterial blood gases analysis, acid-base balance and postoperative pain data was collected and examined. RESULTS: Postoperative epidural analgesia resulted significantly more effective than intravenous tramadol. PaO(2)/FiO(2) ratio was significantly higher in group EPI-GEN patients both on awakening and throughout postoperative observation. Hemodynamics and renal function did not appear to differ significantly. CONCLUSION: Combined epidural-general anesthesia is as valid a technique as any for renal transplantation; however postoperative epidural ropivacaine analgesia resulted more effective than intravenous tramadol. Respiratory function appeared less affected, facilitating a fast and uncomplicated postoperative recovery.     

An evaluation of intrathecal bupivacaine combined with intrathecal or intravenous clonidine in children undergoing orthopedic surgery: a randomized double-blinded study

Background: Propofol is a popular agent for providing intraoperative sedation in pediatric population during lumbar puncture and spinal anesthesia. Adjuvant‐like clonidine is used increasingly in pediatric anesthesia to provide postoperative analgesia with a local anesthetic agent. The aim of this study was to assess the effects of intrathecal and intravenous clonidine on postoperative analgesia/sedation and intraoperative requirements of propofol after intrathecal bupivacaine for orthopedic surgery in children. Methods: Fifty‐nine ASA I and II children aged 6–8 year undergoing orthopedic surgery were randomized to receive intrathecal 0.5% bupivacaine 0.2–0.4 mg·kg^?1 and intravenous 2 ml saline (Group B), intrathecal 0.5% bupivacaine 0.2–0.4 mg·kg^?1 plus 1 μg·kg^?1 clonidine and intravenous 2 ml saline (Group BCit), and 0.5% bupivacaine 0.2–0.4 mg·kg^?1 and intravenous 1 μg·kg^?1 clonidine in 2 ml of saline (Group BCiv). Intraoperative sedation was maintained with 20–50 μg·kg^?1·min^?1 of propofol infusion. The requirements of propofol, time to first rescue analgesia, and postoperative pain or sedation scores were assessed. The duration of motor and sensory blocks and perioperative adverse events were determined. Results: Clonidine significantly prolonged the time to first rescue analgesia and reduced the requirements of propofol sedation whether administered intravenously or intrathecally. The mean Children and Infants Postoperative Pain Scale scores of children were significantly lower in groups BCit and BCiv than in group B. Postoperative sedation scores were higher in groups BCit and BCiv than in group B. Intrathecal clonidine significantly prolonged the time to regression of the sensory block and recovery of motor block. There were no significant differences among the three groups regarding the incidence of perioperative adverse events. Conclusion: Intrathecal or intravenous clonidine similarly provided better postoperative analgesia and sedation and reduced the requirements of propofol. Only intrathecal clonidine prolonged the duration of sensory and motor blocks.     

妇科腹腔镜手术全凭静脉麻醉与异氟醚吸入麻醉的对比研究

目的观察瑞芬太尼靶控输注复合异丙酚全凭静脉麻醉与异氟醚吸入麻醉在妇科腹腔镜手术中的应用效果。方法随意选择2008年1～12月择期妇科腹腔镜手术60例,ASA分级Ⅰ～Ⅱ级,分为2组：靶控输注瑞芬太尼复合异丙酚全凭静脉麻醉组（T组,n=30）,采用咪唑安定0.05 mg/kg,瑞芬太尼1μg/kg,异丙酚2～2.5 mg/kg及维库溴铵0.1 mg/kg快速诱导后,经口明视气管插管,维持采用瑞芬太尼靶浓度4～8 ng/ml,异丙酚4～8 mg.kg-1.h-1;异氟醚组（I组,n=30）,采用芬太尼2μg/kg,异丙酚2～2.5 mg/kg,维库溴铵0.1 mg/kg诱导,经口明视插管后,维持采用1∶1的氧气和异氟醚（维持呼气末浓度0.8～1.2 MAC）吸入麻醉。术中监测收缩压（SBP）、舒张压（DBP）、心率（HR）等指标。结果在插管后1 min（T3）,I组病人DBP、HR与基础值（T1）比较明显升高（P〈0.05）,T组病人DBP、HR则基本恢复到T1水平,2组比较差异有显著性（t=-4.277,P=0.000;t=-3.286,P=0.002）。清醒拔管时（T6）与T1比较,I组SBP、DBP、HR明显升高（P〈0.05）,而T组SBP、DBP、HR则无明显变化（P〉0.05）,2组比较差异有显著性（t=-5.461,P=0.000;t=-2.287,P=0.000;t=-4.382,P=0.000）。T组病人诱导时间、苏醒时间、拔管时间均显著短于I组（t=-6.386,P=0.000;t=-4.876,P=0.000;t=-6.632,P=0.000）。结论瑞芬太尼靶控输注复合异丙酚全凭静脉麻醉在妇科腹腔镜手术中既满足了手术要求又提高了麻醉药的可控性。     

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 propofol on the incidence of postoperative vomiting after strabismus surgery in pediatric outpatients

Vomiting is a common problem after strabismus surgery in pediatric outpatients. We compared the effects of propofol with and without N2O and droperidol to the effects of a conventional regimen consisting of halothane-N2O-droperidol on the recovery characteristics and the incidence of postoperative emesis after strabismus surgery in 120 ASA physical status 1 or 2 children. After induction of anesthesia with halothane-N2O, patients were randomly assigned to one of four groups. Group A (control) received halothane, 66% N2O, and droperidol 75 micrograms.kg-1; group B, propofol 2 mg.kg-1 bolus followed by infusion of 160 microgram.kg-1.min-1; group C, propofol (as in group B) and 66% N2O; and group D, propofol (as in group B), 66% N2O (as in group C), and droperidol 75 micrograms.kg-1. Patients in group B had more episodes of intraoperative oculocardiac reflex responses than patients in group A, but had shorter times to extubation, oral intake, ambulation, and discharge, as well as a lower incidence of postoperative emesis (P less than 0.05). The addition of N2O to the propofol anesthetic regimen (group C) was associated with an increased incidence of emesis (P less than 0.05), whereas the addition of droperidol to the propofol-N2O regimen (group D) did not affect the incidence of emesis compared to the other three groups. We conclude that maintenance of anesthesia with a total intravenous regimen using propofol results in a more rapid recovery and less postoperative emesis than with a halothane-N2O-droperidol regimen.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of dexmedetomidine in morbidly obese patients undergoing laparoscopic gastric bypass

BACKGROUND: Obese patients may be sensitive to the respiratory depressant effect of opioid analgesics. Alternative methods for analgesia may be beneficial for management of bariatric surgery. We evaluated the effect of dexmedetomidine on anesthetic requirements during surgery, hemodynamic, recovery profile and morphine use in the postoperative period. METHODS: Eighty adult patients scheduled for elective laparoscopic Roux-en-Y gastric bypass surgery were randomly assigned to one of two study groups; Group D (40 patients) received dexmedetomidine (0.8-microg/kg bolus, 0,4 microg kg(-1) h) and Group P (40 patients) received normal saline (placebo) in the same volume and rate. Intraoperative and postoperative mean blood pressure and heart rate were recorded. The total amount of intraoperative fentanyl and propofol required to maintain anesthesia were measured. Recovery profile, pain score and total amount of morphine used via patient controlled analgesia (PCA) were assessed. RESULTS: During surgery, dexmedetomidine decreased the total amount of intraoperative fentanyl and propofol required for maintenance of anesthesia compared to placebo. Patients who received dexmedetomidine showed significant decrease of intraoperative and postoperative mean blood pressure, heart rate. In the postoperative period, dexmedetomidine decreased pain scores and PCA morphine use significantly and showed better recovery profile as compared to the placebo Group. There was no difference in the incidence of postoperative nausea and vomiting (PONV) between both groups. CONCLUSION: The intraoperative infusion of dexmedetomidine decreased the total amount of propofol and fentanyl required to maintain anesthesia, offered better control of intraoperative and postoperative hemodynamics, decreased postoperative pain level, decreased the total amount of morphine used and showed better recovery profile compared with placebo.     

舒芬太尼与瑞芬太尼各自复合丙泊酚静脉麻醉在腹腔镜胆囊切除术的效果比较

目的:比较腹腔镜胆囊切除术(LC)中采用舒芬太尼与瑞芬太尼各自复合丙泊酚静脉麻醉复合丙泊酚静脉麻醉的应用效果。方法:纳入2017年3月―2018年3月行LC的患者90例,随机均分为两组,分别行舒芬太尼复合丙泊酚麻醉(舒芬太尼组)与瑞芬太尼复合丙泊酚麻醉(瑞芬太尼组),比较两组麻醉各时间段的血流动力学指标与血清应激指标、自主呼吸恢复时间、睁眼时间和拔管时间、术后视觉模拟(VAS)评分、术前与术后的简易精神状态量表(MMSE)评分以及麻醉复苏期不良反应情况。结果:与瑞芬太尼组比较,舒芬太尼组在麻醉诱导气管插管即刻、CO_2气腹后5min、拔管即刻的心率与平均动脉压、血清皮质醇与和去甲肾上腺素水平均明显降低(均P0.05);自主呼吸恢复时间、睁眼时间和拔管时间均明显延长(均P0.05);术后2、6、12h的VAS评分均明显降低(均P0.05);术后1d的MMSE评分明显升高(P0.05);总不良反应发生率明显降低(P0.05)。结论:相比瑞芬太尼复合丙泊酚麻醉,舒芬太尼复合丙泊酚静脉麻醉用于LC更有利于维持患者血流动力学稳定,应激反应更小,患者术后痛觉感受更轻,认知功能恢复更快,不良反应少。     

Total intravenous anesthesia with remifentanil, propofol and cisatracurium in end-stage renal failure

PURPOSE: To compare recovery parameters of total intravenous anesthesia (TIVA) with remifentanil and propofol, hemodynamic responses to perioperative events, and pharmacodynamic parameters of cisatracurium in 22 end-stage renal failure and 22 normal renal function patients. METHODS: Anesthesia was induced with 2-3 mg x kg(-1) propofol and 1 microg x kg(-1) remifentanil and maintained with 75 microg x kg(-1) x min(-1) propofol and propofol initial infusion of 0.2 microg x kg(-1) x min(-1) propofol. Arterial pressure and heart rate were maintained by remifentanil infusion rate adjustments. The first twitch (T1) was maintained at 25% by an infusion of cisatracurium. RESULTS: There was no difference in the time to maintenance of adequate respiration, date of birth recollection, first analgesic administration, between the renal failure (4.8+/-2.5, 7.8+/-3.2, 12.3+/-5.3 min respectively) and the control group (5.2+/-2.8, 8.1+/-3.1, 12.7+/-5.5 min): nor were there any differences in the time to 25% T1 recovery, T1 recovery from 25% to 75%, or cisatracurium infusion rate between the renal failure group (32.1 +/-10.8 min, 18.2+/-5.5 min, 0.89+/-0.29 microg x kg(-1) min(-1) respectively) and the control group (35.9 (7.9 min, 18.4+/-3.8 min, 0.95+/-0.22 microg x kg(-1) x min(-1)). CONCLUSION: End-stage renal failure does not prolong recovery from TIVA with remifentanil and propofol, or the recovery from cisatracurium neuromuscular block.     

Duration and recovery profile of cisatracurium after succinylcholine during propofol or isoflurane anesthesia

Study Objective: To determine the duration and recovery profile of maintenance doses of cisatracurium besylate following succinylcholine, and during propofol or isoflurane anesthesia.

Design: Randomized, open-label study.

Setting: Operating suite of a university-affiliated medical center.

Patients: Forty ASA physical status I and II adult patients having elective surgery with general anesthesia lasting longer than 90 minutes.

Interventions: Following a standardized induction sequence, a baseline electromyogram (EMG) was obtained. An intubating dose of intravenous (IV) succinylcholine 1.0 mg/kg was administered. Ventilation was maintained with a face mask until the first twitch (T₁) of the evoked train-of-four (TOF) reached 10% of control when tracheal intubation was performed. Spontaneous recovery from neuromuscular blockade was allowed to occur until the first twitch returned to 25% of control. Patients then were randomized to receive cisatracurium as follows. Group 1: 0.025 mg/kg [0.5 × 95% effective dose (ED₉₅)]; Group 2: 0.05 mg/kg (ED₉₅); Group 3: 0.05 mg/kg (ED₉₅); and Group 4: 0.1 mg/kg (2×ED₉₅). Anesthesia for Groups 1 and 2 were maintained with isoflurane 1% to 2%, 66% nitrous oxide (N₂O) in oxygen (O₂), and in Groups 3 and 4, anesthesia was maintained with propofol 80 to 160 μg/kg/min, 66% N₂O in O₂. The TOF-evoked EMG was recorded at 10-second intervals. The time for the evoked EMG to spontaneously return to 25%, 50%, and 75% of the original baseline was recorded.

Measurements and Main Results: There were 10 patients in each of the four groups. The duration of action of cisatracurium 0.05 mg/kg (ED₉₅) after an intubating dose of succinylcholine is 24.5 ± 10 minutes and 21.3 ± 9 minutes during anesthesia maintained with isoflurane and propofol, respectively. Doubling the dose of cisatracurium resulted in approximately twice the duration of action (40.2 ± 7 min) during propofol anesthesia. Following a dose of cisatracurium 0.025 mg/kg (0.5×ED₉₅), the T₁ of the EMG-evoked response did not decrease below 25% in 7 of 10 patients.

Conclusion: Following succinylcholine, the duration of action of a single dose of cisatracurium 0.05 mg/kg is 20 to 25 minutes during anesthesia maintained with propofol or isoflurane. The duration and recovery profile of cisatracurium is dose dependent during propofol and isoflurane anesthetics. Cisatracurium 0.025 mg/kg is an inadequate maintenance dose following recovery from succinylcholine and it fails to provide adequate surgical relaxation.     

瑞芬太尼联合丙泊酚全凭静脉麻醉在乳腺整形手术中的应用

目的探讨乳腺美容整形手术中应用瑞芬太尼（remifentanil）＋丙泊酚（propofol）联合输注全凭静脉麻醉（total intrarenous anesthesia,TIVA）方法对诱导麻醉、维持麻醉及术后苏醒过程的影响。方法ASAⅠ～Ⅱ级择期美容整形手术40例,随机分成两组（每组20例）：瑞芬太尼＋丙泊酚组及芬太尼（feutanyl）＋丙泊酚组,观察两组麻醉诱导、气管插管及术中的血压、心率变化。术毕停药后患者自主呼吸恢复时间、呼之睁眼时间、拔管时间,术后恶心、呕吐发生情况和术中知晓的发生率。结果术中瑞芬太尼＋丙泊酚组血循环稳定,血压、心率的变化与芬太尼＋丙泊酚组比较,差异有统计学意义（P〈0．05）;术毕呼之睁眼时间、拔管时间两组比较,差异有统计学意义（P〈0．05）;两组术后恶心、呕吐的发生情况无明显差异。结论瑞芬太尼＋丙泊酚联合输注TIVA用于乳腺美容整形,手术中血流动力学稳定,术后苏醒迅速。     

Analgesic transition after remifentanil-based anesthesia in neurosurgery. A comparison of sufentanil and tramadol

AIM: Transition from the end of remifentanil infusion and postoperative analgesia must be planned carefully owing to remifentanil's (R) rapid offset. Intraoperative morphine has been used for the transition to postoperative analgesia following remifentanil-based anesthesia. Sufentanil (S) is a very potent opioid with high micro-receptor affinity, a much wider therapeutic index and a lower fractional receptor occupancy. These pharmacological and dynamics features make sufentanil an interesting alternative to morphine for immediate postoperative analgesia. METHODS: Experimental design: perspective, randomized, single blinded and comparative study. Institution: neurosurgical operating theatre at University. Patients: 96 patients, aging from 25 to 67 years, ASA class I-III, undergoing neurosurgical operations, were studied. Interventions and Measurements: the anesthetic management was: premedication: atropine 0.01 microg kg(-1) + remifentanil 0.20 microg kg(-1) min(-1); induction: propofol 2.0 microg kg(-1) + cisatracurium 0.15 microg kg(-1); maintenance: sevoflurane 0.8% + remifentanil (titrated infusion) cisatracurium. All patients received ketorolac 30 mg i.v. 1 hour before the end of surgery and ketorolac (60-90 mg) + tramadol (200-300 mg) by elastomeric pump; patients were divided into 2 groups: group T receiving tramadol 100 mg and group S receiving a bolus dose of sufentanil 0.10 microg kg(-1), 30 and 15 minutes before the end of surgery respectively. Recovery time, postoperative analgesia evaluated by VAS, cardiocirculatory parameters and side effects like nausea, vomiting, shivering, muscle rigidity, sedation and respiratory depression were recorded. RESULTS: VAS was significantly lower in Group S. Recovery time was shorter in Group T than in Group S (8.8 +/- 3.6 vs 11.6 +/- 4.6 min), no statistically significant differences between groups as regards nausea, vomiting and shivering. Short-lasting respiratory depression was detected in 3 cases in Group S. CONCLUSION: At the emergence much better control of the transition phase in patients treated with sufentanil: smooth recovery with better tolerability of the endotracheal tube; efficacious analgesia along with cardiocirculatory stability.     

瑞芬太尼复合芬太尼全凭静脉麻醉用于腹腔镜胆囊切除术的临床研究

目的对比研究瑞芬太尼复合芬太尼全凭静脉麻醉与单纯使用瑞芬太尼或芬太尼静脉复合麻醉用于腹腔镜胆囊切除术（LC）的效果。方法60例择期LC患者，随机分为三组：单纯瑞芬太尼组（R）、瑞芬太尼＋芬太尼组（RF）和单纯芬太尼组（F）（n=20）。观察记录全麻诱导、维持及苏醒期平均动脉压（MAP）、心率（HR）、SpO2，停药至患者自主呼吸恢复时间、意识恢复时间、拔除气管导管时间，病人拔管后即刻、1、3、7、12h的疼痛程度评分（VRS）、意识状态评分（OAAS）及苏醒期并发症。结果与RF、F组及组内诱导前比，R组诱导插管时MAP较低，HR较快，术毕MAP较高，HR增快，术中维持过程无明显差异。RF、F两组间及组内在诱导与维持过程MAP及HR无明显差异，拔管及离开手术室时RF组MAP升高、HR增快。R、RF两组术后各观察指标时间差异无显著性，F组明显延长。三组术后并发症无统计学差异。R组术后VRS明显高于RF、F组（P〈0．01）；组内与拔管后即刻相比，R组术后VRS评分均明显升高，RF、F组无明显变化。F组在拔管后即刻，术后1、3h的OAAS均明显低于R、RF组（P〈0．01）。结论与单纯使用瑞芬太尼或芬太尼麻醉相比较，在麻醉诱导期复合使用瑞芬太尼和芬太尼，后期再以瑞芬太尼维持麻醉，其麻醉效应更加平稳，苏醒质量不受明显影响，术后不良反应更轻，并可减少患者术后对于镇痛的要求。     

Severe traumatic brain injury: management and prognosis

AIM: The aim of the study is to assess the efficacy of early treatment in severe traumatic brain injury by evaluating patients' survival and functional recovery. METHODS: We subdivided 184 patients into 2 groups (Group A: patients admitted to hospital within the first hour of injury; Group B: patients admitted after the first hour of injury). In order to maintain the mean arterial pressure (MAP) >90 with cerebral perfusion pressure (CPP) >70 mmHg, we used plasma expanders; in 76 patients with MAP >90 mmHg, we administered dopamine, and in 5 cases noradrenaline. In 157 patients we used mechanical ventilation (MV). For orotracheal intubation and sedation/analgesia, we administered: propofol (a bolus of 2 mg/kg+1 mg/kg/h)+midazolam (0.03 mg/kg/h) + cisatracurium besilate (0.2 mg/kg) in 113 patients, or thiopentone sodium (a bolus of 4 mg/kg + 1-2 mg/kg/h)+cisatracurium besilate (0.2 mg/kg) in 44 patients with endocranial hypertension without bleeding and convulsions. After muscle relaxation we administered remifentanyl (0.075 microg/kg/min). Surgical decompression was performed in 57 cases. Data were analysed with Student's t-test. RESULTS: The number of deaths was significantly lower in Group A (P<0.05): 9 patients from Group A and 21 patients from Group B died within 24 h (P<0.05), while 15 patients from Group A and 16 patients from Group B died after the first 24 h period. After the recovery of critical life functions, 53 patients from Group A and 34 patients from Group B were transferred to a medical ward (P<0.0001), while 15 patients from Group A and 21 patients from Group B were transferred to a rehabilitation facility (P<0.05). CONCLUSIONS: Prevention, early treatment of complications and maintenance of homeostasis lead to a better prognosis in terms of survival, functional recovery and to a reduction in economic and social costs.     

The use of a ketamine-propofol combination during monitored anesthesia care

Supplemental analgesics are commonly used to enhance analgesia and improve patient comfort during procedures performed under local anesthesia and sedation. Because the use of ketamine as an analgesic adjunct to propofol sedation has not been well established, we evaluated its impact on analgesia, sedation, and recovery after ambulatory surgery. One hundred female outpatients undergoing breast biopsy procedures under local anesthesia participated in this randomized, double-blinded, placebo-controlled study. After premedication with midazolam, 2 mg IV, patients received an infusion of a solution containing propofol (9.4 mg/mL) in combination with either placebo (saline) (Group 1) or ketamine, 0.94 mg/mL (Group 2), 1.88 mg/mL (Group 3), or 2.83 mg/mL (Group 4). The sedative infusion rate was varied to maintain a deep level of sedation (Observer Assessment of Alertness/Sedation score 4) and normal respiratory and hemodynamic functions. Sufentanil, 2.5 microg IV, "rescue" boluses were used as needed to treat patients' responses (if any) to local anesthetic infiltration or surgical stimulation. Ketamine produced a dose-dependent reduction in the "rescue" opioid requirements. However, there was an increase in postoperative nausea and vomiting, psychomimetic side effects, and delay in discharge times with the largest ketamine dosage (Group 4). The adjunctive use of ketamine during propofol sedation provides significant analgesia and minimizes the need for supplemental opioids. The combination of propofol (9.4 mg/mL)/ketamine (0.94-1.88 mg/mL) provides effective sedation/analgesia during monitored anesthesia care. IMPLICATIONS: Ketamine, when used in subhypnotic dosages, may be an useful adjuvant to propofol sedation.     

Addition of cisatracurium to lidocaine for intravenous regional anesthesia

STUDY OBJECTIVE: To determine the onset and regression time of motor and sensory block, and the quality of anesthesia and postoperative analgesia by the addition of cisatracurium to local anesthetic solution in small doses in intravenous regional anesthesia. DESIGN: Prospective, randomized, double-blind study. SETTING: University hospital. PATIENTS: 40 ASA physical status I and II patients undergoing elective hand surgery. INTERVENTIONS: Intravenous regional anesthesia was achieved using 3 mg/kg lidocaine diluted with saline to a total volume of 40 mL in the control group or 0.01 mg/kg of cisatracurium plus 3 mg/kg lidocaine diluted with saline to a total volume of 40 mL in the cisatracurium group. MEASUREMENTS: The onset and the regression time for sensory and motor block were recorded. Quality of anesthesia, intraoperative, and postoperative analgesic requirements were noted. Mean arterial pressure and heart rate were recorded every 5 minutes. MAIN RESULTS: The onset time of sensory and motor block in the cisatracurium group was shorter than in the control group, and the difference was statistically significant. The quality of anesthesia was better in the cisatracurium group than in the control group, and the difference was statistically significant. There was no difference between the two groups with respect to sensory block regression time. Motor block regression time was statistically longer in the cisatracurium group than in the control group. Analgesic requirement was greater in the control group than in the cisatracurium group. CONCLUSION: The addition of cisatracurium to lidocaine in intravenous regional anesthesia shortened the sensory and motor block onset times, improved the quality of anesthesia, and decreased analgesic requirements without causing clinical side effects.     

Postoperative analgesia in cardiac surgery: spinal versus intravenous morphine

OBJECTIVE: To compare the effects of spinal and intravenous administration of morphine to supplement anesthesia with remifentanil in terms of analgesia during early postoperative recovery and considering time until extubation. MATERIAL AND METHODS: This prospective, randomized, blinded trial enrolled 59 patients scheduled for cardiac surgery. The patients were assigned to receive either a spinal infusion of morphine (15 microg x Kg(-1)) or an intravenous infusion (0.3 mg x Kg(-1)). Anesthesia was maintained with 0.15 to 0.50 microg x Kg(-1) x min(-1) of remifentanil and 2 to 4 mg x Kg(-1) x h(-1) of propofol in perfusion. After the period of extracorporeal circulation, all patients were given an intravenous infusion of 30 mg of ketorolac. Later intravenous ketorolac was ministered at a dose of 30 mg per 8 hours; intravenous morphine (bolus dose of 3 mg) was also administered until pain was relieved. RESULTS: The same quality of postoperative analgesia and anesthetic recovery was achieved with both spinal and intravenous administration. The incidence of side effects was also similar. Likewise, the extubation times were similar in the 2 groups (spinal infusion group: 294.5 [SD, 150.5] minutes; intravenous group: 325.0 [139.9] minutes; P>0.05). Less postoperative intravenous morphine was administered in the first 24 hours to patients in the spinal morphine group (P<0.05) and fewer patients in that group required intravenous morphine boluses (P<0.05). CONCLUSIONS: Our study suggests that spinal morphine does not offer advantages over intravenous morphine with regard to postoperative analgesia, hemodynamic stability and respiratory parameters, time until extubation, or adverse effects.     

Combined regional-general anesthesia: evaluation of remifentanil based general anesthesia and postoperative epidural analgesia

OBJECTIVES: To evaluate whether remifentanil based general anesthesia combined with epidural analgesia for postoperative pain, has any advantages with respect to consumption of drugs, blood loss, quality of pain control, hemodynamic profile, in major abdominal surgery, as compared to other combined techniques. METHODS: A retrospective study based on chart reviews of patients who have undergone colectomy, radical cystectomy and radical prostatectomy over one year period in our Institution, operated under combined regional-general anesthesia. Twenty-six patients were analyzed and were divided into three groups according to the type of anesthesia received. Group A: combined general-epidural for per-operative and postoperative pain (10 patients). Group B: combined spinal-general anesthesia (8 patients) post-operative analgesia consisted of parenteral mepiridine and paracetamol. Group C: remifentanil based general anesthesia followed by epidural for postoperative analgesia (8 patients). RESULTS: The demographic data, age and M/F distribution were comparable in the three groups. The remifentanil group showed less utilization of muscle relaxant (Cisatracurium) with respect to other groups (p < 0.001). The amount of intraoperative blood loss was not significantly different among the three groups. The efficacy of the postoperative epidural analgesia was demonstrated by the minimal utilization of analgesics (p < 0.05 and 0.01) in group A and C as compared to group B. In the group of remifentanil, the blood pressure was more stable and maintained at a systolic of 80-100 mmHg as compared to initial hypotension mainly in group C. CONCLUSION: The use of remifentanil based general anesthesia offers the advantage of non-accumulation of drugs and hemodynamic stability. Post-operative analgesia can be provided by epidural route which proved to be satisfactory in the remifentanil group. The effect on blood loss was not conclusive in this study.     

Anesthesia with propofol, remifentanil and cisatracurium in renal transplantation

A 41-year-old woman with end-stage renal insufficiency in peritoneal dialysis for 3 years received a kidney transplant under anesthesia with remifentanil, propofol, and cisatracurium. She had a history of hypertension and was being treated with enalapril, metoprolol and erythropoietin. After anesthetic induction, blood pressure fell significantly and surgery was performed in a context of hemodynamic stability. The postoperative course was good, with a functional graft and adequate diuresis from the start. Anesthetics with minimal residual effects and as little renal toxicity as possible are ideal for use in kidney transplantation. The drugs used in this case had pharmacokinetic and pharmacodynamic properties that make them particularly appropriate for such patients.