Effects of a continuous diltiazem infusion on renal function during cardiac surgery

Thirty-five male patients undergoing coronary artery surgery were studied to investigate renal function during a continuous infusion of the calcium channel blocker diltiazem. All patients had preoperative renal function within normal limits (serum creatinine below 0.133 mmol/L) and were randomly divided into three groups: Control (C), Diltiazem 1 (D1), and Diltiazem 2 (D2). Diltiazem was infused in D1 (1 μg/kg/min) and D2 (2 μg/kg/min) patients throughout surgery and during the following 36 hours. Glomerular function was investigated using the endogenous creatinine clearance while tubular function was assessed by means of water and sodium reabsorption tests, as well as urinary enzyme activity measurements. Hemodynamic monitoring was performed using a pulmonary artery catheter. The glomerular filtration rate of C and D1 patients showed a significant fall during cardiopulmonary bypass (CPB) with respect to the prebypass period and returned to the baseline values only in the postoperative period. A similar change was not observed in D2 patients. The analysis of variance demonstrated that the glomerular filtration rate was significantly higher in Group D2 versus Group C during and after CPB (P = 0.03 and P = 0.04, respectively). Furthermore, after CPB, urinary output was significantly improved in D2 patients, both versus C and D1 patients (P = 0.003), notwithstanding a lower mean arterial pressure in the D2 Group (P = 0.04 v C Group). Tubular function was not influenced by diltiazem infusion. It is concluded that a continuous diltiazem infusion, at a dose of 2 μg/kg/min during cardiac surgery, may be useful to prevent a decrease in glomerular function secondary to cardiopulmonary bypass.     

上腹部手术对小气道功能的影响

通过监测用力呼气中期流速（ＭＭＦ）和呼出２５％、５０％、７５％用力肺活量（ＦＶＣ）时瞬时呼气流速（ＦＥＦ）２５％、ＦＥＦ５０％和ＦＥＦ７５％等指标，对２５例不同麻醉方法下（全麻、硬膜外阻滞）行上腹部手术患者围术期小气道功能进行了连续观察。结果显示，术后４小时ＭＭＦ为术前的３２．７％，术后第７天为术前的６８．２％。表明上腹部手术后小气道功能严重减退。     

胸段硬膜外腔注射可乐定对上腹部手术术后膈肌功能的影响

目的　观察胸段硬膜外腔注射可乐定对上腹部手术 (UAS)术后膈肌功能的作用。方法　在连续硬膜外神经阻滞麻醉下行剖腹胆囊切除术病人 2 0例 ,均分为可乐定 (A)组与生理盐水(B)组。术后 2小时A组经硬膜外导管注入可乐定 4μg/kg ,B组注入生理盐水。记录注药前、注药后30分钟、2小时有无反常呼吸运动以及RR、VT。结果　A组注射可乐定 30分钟后膈肌功能改善 :反常呼吸运动消失 ,RR减慢 (由 2 0 0± 1 8降到 15 2± 1 7,P <0 0 0 1)、VT 增加 (由 2 19 8± 2 6 8ml/m2 增到 2 91 0± 2 5 5ml/m2 ,P <0 0 0 1) ,连续观察 2小时 ,膈肌功能仍优于注药前。B组注射生理盐水后上述指标无明显变化。结论　胸段硬膜外腔注射可乐定可改善UAS术后膈肌功能     

Effects of epidural anaesthesia on surgical stress-induced immunosuppression during upper abdominal surgery

BACKGROUND: Previously, we have demonstrated that surgical stress rapidlyinduced transient hyporesponsiveness of blood cells to endotoxinand that monocyte mCD14 and HLA-DR expression decreased soonafter the start of surgery under general anaesthesia. This studywas designed to investigate the effects of epidural anaesthesiaon surgical stress-induced immunosuppression in patients undergoingupper abdominal surgery. METHODS: After having obtained informed consent, patients were randomlyallocated to receive general anaesthesia (Group G) or generalanaesthesia with epidural anaesthesia (Group E). Perioperativechanges in neutrophil phagocytic activity, neutrophil respiratoryburst activity, monocyte mCD14 and HLA-DR expression, plasmaIL-10 concentration, and the LPS-induced TNF- production inwhole blood were measured. RESULTS: Surgical stress rapidly depressed neutrophil phagocytic activity,monocyte mCD14 and HLA-DR expression, and LPS-induced TNF- productionex vivo (P < 0.05 vs preoperation) in both Group G and GroupE. In contrast, the plasma IL-10 concentration increased significantly2 h after the start of surgery (P < 0.05) in both groups.There were no significant differences between the two groups.The neutrophil respiratory burst activity did not change duringthe operation in either group. CONCLUSION: This study showed that the innate immune system is suppressedfrom the early period of upper abdominal surgery. Subgroup analysissuggested that epidural anaesthesia to T4 dermatome as wellas general anaesthesia may not protect patients from this immunosuppression.These results in part explain the impairment of host-defensemechanisms seen in the perioperative period.     

Effect of diltiazem on kidney function during laparoscopic surgery

Background  Pneumoperitoneum is known to be associated with transient impairment in kidney function. This study was designed to investigate the effect of diltiazem on acute kidney injury during positive pneumoperitoneum in patients undergoing laparoscopic surgery. Methods  Thirty-two patients of American Society of Anesthesiologists (ASA) 1 and 2 physical status undergoing laparoscopic surgery were randomly divided into control (normal saline infusion) and diltiazem groups (diltiazem 2 μg/kg/min). Urinary flow, urinary sodium excretion, creatinine clearance (CrCl), and hemodynamic variables were determined during pneumoperitoneum and at postoperative 2 h. CrCl using Cockcroft–Gault equation was calculated before surgery (baseline), and at postoperative days 1 (POD1) and 2. Results  The hemodynamic parameters were similar in both groups. CrCl during pneumoperitoneum in the diltiazem group was significantly higher than that in the control group (90.8 ± 49.0 ml/min/1.73 m² vs. 54.2 ± 31.6 ml/min/1.73 m²) (P = 0.026). CrCl calculated with Cockcroft–Gault equation was similar in both groups at baseline, POD1, and POD2. Urinary flow was significantly increased in both groups at postoperative 2 h compared with that during pneumoperitoneum. Conclusion  Continuous infusion of diltiazem 2 μg/kg/min prevented the decrease in CrCl during pneumoperitoneum without hemodynamic derangement. Although the decrease in CrCl was transient in patients with normal kidney function in this study, diltiazem may be used to prevent further kidney injury in those with elevated CrCl during laparoscopic surgery.     

Lung mechanics during upper abdominal surgery

Functional residual capacity (FRC) and breath-by-breath compliance of the respiratory system (Crs) were studied after induction of anaesthesia, after insertion of retractors and after wound closure in patients undergoing upper abdominal surgery via a subcostal (n = 8) or a midline (n = 8) incision. After anaesthesia induction the mean FRC was 1.6 +/- 0.3 l. In the subcostal incision group FRC did not change between the studied stages, but Crs fell after retractor placement from 51 +/- 3 to 43 +/- 5 ml/cmH2O (p less than 0.01). In the midline incision group FRC rose by 21% (p less than 0.01) when the retractors were inserted, but regained outset level after wound closure. Crs in this group did not change significantly after retraction, but after closure of the wound it fell to 44 +/- 6 ml/cmH2O, i.e. less (p less than 0.05) than the outset value (52.6 ml/cmH2O). FRC thus did not decrease in either group, but Crs fell by about 15%. The authors conclude that the known difference in postoperative pulmonary complications between midline vs. subcostal incisions is not caused by the studied intraoperative events.     

不同剂量5-HT3受体拮抗剂托烷司琼对全麻术后恶心呕吐的影响的临床研究

目的观察不同剂量的5-HT3受体拮抗剂托烷司琼(Tropisetron)对术后恶心呕吐(PONV)的作用时效,以寻求一种比较理想的止吐药物及合适的剂量预防和减少PONV的发生.方法择期上腹部吸入全麻手术患者120例,随机双盲分成生理盐水对照组(A组),恩丹西酮8mg组(B组),托烷司琼2mg(C组)及5mg(D组),每组各30例.术毕观察给止吐药至第1次出现恶心呕吐的时间、各组发生恶心、呕吐的病人数、接受补救药物的病人数、恶心的严重程度、病人对止吐药的的满意度、头晕头痛、椎体外系症状等副作用.结果各组病人性别、体重、年龄、麻醉持续时间、术中生命体征等各组间比较差异无显著性(P>0.05).各组发生恶心、呕吐和接受补救药物病人数,初次出现恶心的时间,恶心严重程度评分的比较中,托烷司均优于恩丹西酮,P<0.05.结论①托烷司琼的镇吐效果优于恩丹西酮.②托烷司琼2mg不仅可以减少药物用量、增强抗吐时效,而且能减少副作用的发生,是一种经济、有效、安全且值得推广应用的止吐方法.     

Doxapram improves pulmonary function after upper abdominal surgery

The effects of doxapram on postoperative pulmonary function were studied in 40 ASA I and II patients randomly allocated to receive either doxapram 1.8 mg· kg^-1. h^-1 or placebo for 2 h immediately after elective cholecystectomy. The two groups displayed similar reductions of carbon dioxide production at 2 h and 6 h postoperatively, whereas oxygen consumption remained at preoperative levels for 24 h. Minute ventilation was similarly reduced in the two groups at 2 h and 6 h postoperatively, with corresponding increases in Paco₂. Pao₂ was similarly and significantly decreased in both groups postoperatively, whereas P(A-a)o₂ remained unchanged at 2 h and 6 h in doxapram-treated patients. FRC was reduced postoperatively in both groups, significantly more so in the control group at 6 h. Various indices of intrapulmonary gas distribution, including the functional (nitrogen) dead space, underwent similar changes in the two groups. By contrast, the physiological dead space was reduced in doxapram-treated patients at 2 h, 6 h and 24 h postoperatively, whereas no significant changes were seen in the control group. The ventilatory equivalent for CO₂ was significantly lower in the doxapram-treated group, implying higher ventilatory efficiency. Our findings indicate that infusion of doxapram postoperatively attenuates the impairment of pulmonary function postoperatively, chiefly via effects on V'_A/Q' ratios. No side effects of doxapram were observed.     

Acute ventilatory complications during laparoscopic upper abdominal surgery

Purpose

This article examines and summarizes the published reports dealing with subcutaneous emphysema, pneumothorax and carbon dioxide (CO₂) embolism during laparoscopic upper abdominal surgery. The purpose is to describe the expected clinical picture, the differential diagnosis and the management of these complications.

Source

The information was obtained from a Medline literature search and the annual meeting supplements of Anesthesiology, Anesth Analg, Br J Anaesth and Can J Anaesth.

Principal findings

An abrupt increase in PetCO₂ is the first sign of subcutaneous emphysema and of pneumothorax. Desaturation and increased airway pressure occur with pneumothorax, but not with subcutaneous emphysema alone. Desaturation and increased airway pressure also occur with bronchial intubation. The preliminary diagnosis is made by verifying the position of the tube, examination of the patient for swelling and crepitus and auscultation for air entry. Chest radiography and paracentesis confirm the diagnosis of pneumothorax, which frequently occurs with subcutaneous emphysema but is rarely of the tension type. Pulmonary embolism due to CO₂ during WAS has not been reported, but the available data suggest that small, haemodynamically inconsequential CO₂ embolism occurs without change in PetCO₂. Massive embolism is possible and will markedly decrease PetCO₂, arterial O₂ saturation (SpO₂) and blood pressure.

Conclusion

The immediate recognition of the three complications requires continuous monitoring of PetCO₂, arterial saturation, airway pressure, and an index of pulmonary compliance.     

Effects of aminophylline on diaphragmatic dysfunction after upper abdominal surgery

The effects of upper abdominal surgery on diaphragmatic function were studied in eight supine patients before and after administration of aminophylline. Changes in pleural (delta Ppl) and gastric pressure (delta Pga) swings were measured with balloon catheter systems. Transdiaphragmatic pressure change (delta Pdi) was calculated as the difference delta Pga-delta Ppl. The ratio delta Pga/delta Pdi, used as an index of the diaphragmatic contribution to the quiet breathing process, decreased significantly as early as 1 h after operation without any further change throughout the 6-h period studied. Administration of aminophylline (6 mg/kg), six hours postoperatively, produced a significant increase in this diaphragmatic index. These data indicate that the early reduced diaphragmatic activity, after upper abdominal surgery, partially may be reversed by administration of aminophylline. The mechanism of its action may involve central nervous stimulation and/or a direct inotropic effect on diaphragmatic muscle. Further studies are needed to evaluate if the correction of altered diaphragmatic motion by aminophylline improves postoperative lung function.     

疼痛对上腹部术后呼吸肌功能不全的影响

目的　观察疼痛在上腹部手术后呼吸肌功能不全中所起的作用。方法　ASAⅠ～Ⅱ级择期腹腔镜胆囊切除术患者 30例 ,随机分为病人自控镇痛 (PCA)组与对照组 ,每组 15例。用最大吸气压 (MIP)和最大呼气压 (MEP)来评估呼吸肌功能。两组于术前 ,术后 2 4、4 8h分别测定MIP、MEP ,并用视觉模拟疼痛评分法 (VAS)评估疼痛程度。结果　术后对照组的MIP与MEP比术前显著下降 (P <0 0 5 )。VAS评分两组均增加 ,与术前相比 ,对照组有显著差异 (P <0 0 5 )。两组相比 ,PCA组的VAS增加明显少于对照组 (P <0 0 5 )。MIP、MEP和疼痛在统计学上有显著相关 (P <0 0 1)。结论　疼痛是导致上腹部术后呼吸肌功能不全的一个重要因素 ,而PCA则能部分地改善术后呼吸肌功能不全     

术前呼吸功能锻炼对上腹部手术患者肺功能的影响

目的 观察术前呼吸功能锻炼对上腹部手术患者肺功能的影响.方法 选择行上腹部手术患者36例,随机分为呼吸功能锻炼组(实验组)与对照组,实验组术前连续3天进行束腹深胸式呼吸训练和有效的咳嗽排痰训练,观察两组患者术前、术后肺功能的变化情况.结果 呼吸锻炼组术后肺功能指标明显好于对照组(P＜0.05).结论 呼吸功能锻炼可改善病人的肺功能,提高患者对上腹部手术的耐受性,减少术后肺部并发症的发生.     

Influences of chest deformation by upper abdominal retractor on respiratory system impedance during abdominal surgery

The present study was carried out to clarify the effects of chest deformation by upper abdominal retractor on respiratory system impedance during abdominal surgery. We measured the impedances of respiratory system (RS), lung, and chest wall (CW) in nine anesthetized paralyzed subjects employing a pseudorandom noise forced volume oscillation technique. These measurements were performed before and after the lifting chest wall by upper abdominal retractor. The effects of chest deformation was significant on the impedances of RS, lung, while no discernible effect was found in CW impedance. Lifting chest wall decreased RS resistance which was totally accounted for by the decrease in lung resistance, whereas the lifting did not affect reactance in either RS or lung. The mathematical modeling showed the significant lifting effect on the resistance of the parenchyma. In conclusion, change in RS mechanics produced by chest deformation by upper abdominal retractor is dominated in lung but not in CW. Among the lung mechanical components, parenchyma is the primary site of the lifting effect.     

不同麻醉方法对上腹部手术病人免疫球蛋白的影响

目的　探讨上腹部手术中三种不同麻醉方法对血清免疫球蛋白IgG、IgA和IgM浓度的影响。方法　 30例择期上腹部手术随机分为静脉复合全麻组 (Ⅰ组 ) ,静脉、吸入复合全麻组 (Ⅱ组 )和静脉全麻复合硬膜外阻滞 (Ⅲ组 )。测定麻醉前 (T0 )、手术开始后 6 0分钟 (T1)、术后 2 4小时(T2 )、术后 4 8小时 (T3 )和术后 72小时 (T4)血清中IgG、IgA和IgM的浓度 ,同时连续监测SBP、DBP、MAP和HR的变化。结果　与麻醉前相比 ,Ⅰ、Ⅱ组IgG、IgA和IgM浓度显著升高 (P <0 0 1) ,而Ⅲ组IgG、IgA、IgM浓度显著降低 (P <0 0 1)。术后 2 4小时变化幅度最大 ,术后 2～ 3天接近麻醉前水平。Ⅲ组的IgG、IgA和IgM浓度变化幅度明显小于Ⅰ组 (P <0 0 1)。三组的IgG、IgA、IgM浓度与SBP、DBP、HR均无相关性。结论　静脉全麻复合硬膜外阻滞用于上腹部手术 ,对血清IgG、IgA、IgM浓度的影响最小 ,机体恢复较快     

The changes in arterial keton bodies during upper abdominal surgery

The relationship between the arterial keton body ratio (AKBR: acetoacetate/-hydroxybutyrate) and the plasma hormone activities were studied under a general anesthesia using enflurane group (group G) and a GO + Epidural group (group E) with continuous glucose loading (10g·hr^–1) during partial gastrectomy. In both groups, the AKBR increased significantly during the operation. The plasma insulin activity was significantly positively correlated with the AKBR and it was negatively correlated with log (-hydroxybutyrate) in both groups. We could not find any significant difference of the AKBR between group G and group E. Our results indicate that the plasma insulin activity affects the arterial keton body ratio and that the AKBR must be evaluated considering the plasma hormone activity, especially insulin activity during the operation.(Ogata M, Obata K, Matsumoto et al.: The changes in arterial keton bodies during upper abdominal surgery. J Anesth 4: 131–137, 1990)     

Epidural anesthesia during upper abdominal surgery provides better postoperative analgesia

Since repeated noxious stimuli may sensitize neuropathic pain receptors of the spinal cord, we tested the hypothesis that the appropriate blockade of surgical stimuli with epidural anesthesia during upper abdominal surgery would be beneficial for postoperative analgesia. Thirty-six adult patients undergoing either elective gastrectomy or open cholecystectomy were randomly allocated to receive either inhalational general anesthesia alone (group G) or epidural anesthesia along with light general anesthesia (group E) throughout the surgery. Postoperative pain management consisted of patient-controlled analgesia (PCA) with bupivacaine accompanied by the continuous infusion of buprenorphine. To assess postoperative pain, a visual analogue scale (VAS) was employed at 2, 24, and 48 h postoperatively. While there was no significant difference in the bupivacaine dose, more patients undergoing gastrectomy in group G required supplemental analgesics than those in group E, and the VAS scores in group E demonstrated significantly better postoperative analgesia compared to group G after both types of surgery. Thus, an appropriate epidural blockade during upper abdominal surgery likely provides better postoperative pain relief.     

Changes in pulmonary function during continuous epidural bupivacaine with or without morphine following upper abdominal surgery

To assess the effect of postoperative continuous thoracic epidural infusion of bupivacaine on pulmonary function, a prospective randomized study was conducted in patients undergoing upper abdominal surgery (UAS). Sixteen patients, divided into two treatment groups, received continuous epidural infusion of 0.25% bupivacaine at a rate of 2–5ml·hr^–1, or that of a combination of 0.125% or 0.25% bupivacaine and 0.0025% or 0.005% morphine at a rate of 2–4ml·hr^–1. One, 4, 10, 16, 24 and 40hr postoperatively, the following indices were measured: visual analogue scale score, modified Prince Henry pain scale score, arterial Pa_{O 2} and Pa_{CO 2}, functional residual capacity (FRC), and tidal volume (TV). There was no difference in pain scores between the two groups except for significantly less pain at 40hr in the combination group. Postoperative measurements of pulmonary function revealed a significant fall in Pa_{O 2}, FRC and TV, indicating a reduction of 15–25% as compared with the preoperative values, and no significant differences between the two groups. The authors conclude that postoperative continuous epidural infusion of bupivacaine combined with morphine is highly effective in alleviating pain and impoving pulmonary function in patients following USA.(Sakura S, Yanagidani T, Saito Y et al.: Changes in pulmonary function during continuous epidural bupivacaine with or without morphine following upper abdominal sugery. J Anesth 4: 319–326, 1990)