A comparison of fentanyl and buprenorphine in total intravenous anesthesia using propofol during spinal surgery

A retrospective study was performed to compare the hemodynamic effect and postoperative pain relief of fentanyl (Group F, n = 11) and buprenorphine (Group B, n = 11) in total intravenous anesthesia (TIVA) using propofol during spinal surgery. All patients were premedicated with midazolam (3-5 mg) i.m. Anesthesia was maintained with propofol infusion, and increments of fentanyl or single dose of buprenorphine with 40% oxygen in air. Total doses of fentanyl and buprenorphine were 7.6 +/- 1.0 micrograms.kg-1 and 2.0 +/- 0.4 micrograms.kg-1, respectively. Maintenance doses of propofol (Group F: 5.5 +/- 0.8 mg.kg-1.h-1, Group B: 5.9 +/- 1.1 mg.kg-1.h-1) and vecuronium were not significantly different. Mean arterial pressures from 2 hours after incision to the end of surgery were elevated significantly in Group F than in Group B. Recovery time (Group F 12.5 +/- 6.1 min vs Group B 11.8 +/- 6.1 min) and extubation time (Group F 19.5 +/- 10.3 min vs Group B 15.0 +/- 7.0 min) were not different. At the end of anesthesia, seven patients in Group F and one patient in Group B (P < 0.01) complained of severe pain. All patients in Group F, and only two in Group B (P < 0.02) received analgesics within 20 hours. Neither nausea nor respiratory depression was found in both groups. This study suggests that buprenorphine would provide a more stable hemodynamic state and better postoperative pain relief than fentanyl in TIVA using propofol.     

Postoperative effects of low-dose intrathecal morphine in coronary artery bypass surgery

BACKGROUND: Intrathecal morphine has been used in hopes of providing long-lasting postoperative analgesia in patients after cardiac surgery. The aim of this study was to evaluate the effects of 7 micro/kg intrathecal morphine administration in coronary bypass surgery in the postoperative period. METHODS: We conducted a prospective, randomized, blinded, and controlled study. Twenty-three patients, who underwent primary elective coronary bypass surgery, were randomly allocated to receive morphine 7 micro/kg intrathecally, before the induction of general anesthesia (Group M, n = 12) or no intrathecal injection (Group C, n = 11). Pain scores, determined by visual analogue scale (VAS), were recorded immediately after extubation upon admission to the intensive care unit (ICU), at the 2nd, 4th, 6th, and 18th hour after extubation. Pethidine was administered if the patient's VAS > or = 4 and consumption was recorded. Extubation time and ICU length of stay were also recorded. RESULTS: VAS scores were lower in the Group M at each measured time than the control group (p = 0.016, 0.023, 0.004, 0.0001, and 0.001, respectively). According to the VAS scores, pethidine requirement was lower in the Group M than the control (p = 0.001). Extubation time (3.58 +/- 1.57 vs. 4.86 +/- 1.38 hours, p = 0.045) and ICU length of stay (16.25 +/- 2.70 vs. 19.30 +/- 2.45 hours, p = 0.014) were also significantly shorter in the Group M than the control group. No significant complications were seen in this group of patients. CONCLUSIONS: Intrathecal morphine provided effective analgesia, earlier tracheal extubation and less ICU length stay after on-pump coronary bypass surgery. The influence on ICU length of stay requires further evaluations.     

Influence of a vital capacity maneuver on pulmonary gas exchange after cardiopulmonary bypass.

OBJECTIVE: To investigate the effect of a single, vital capacity breath (vital capacity maneuver [VCM]), administered at the end of cardiopulmonary bypass (CPB), on pulmonary gas exchange in patients undergoing coronary artery bypass graft surgery. DESIGN: Prospective, randomized, double-blind study. SETTING: University-affiliated hospital. PARTICIPANTS: Forty patients scheduled for elective coronary artery bypass graft surgery and early tracheal extubation. INTERVENTIONS: Patients were randomized to 1 of 2 groups. VCM patients received a VCM at the conclusion of CPB. Control patients received no VCM. MEASUREMENTS AND MAIN RESULTS: Intrapulmonary shunt (Q(S)/Q(T)), arterial oxygenation (PaO2), and alveolar-arterial oxygen gradients (P(A-a)O2) were measured after induction of anesthesia, CPB, intensive care unit (ICU) arrival, and extubation. The duration of postoperative intubation was recorded for each group. Q(S)/Q(T) increased significantly 30 minutes after CPB in the control group (15.7 +/- 1.8% to 27.4 +/- 2.6%; p = 0.01). In the VCM group, a small decrease in Q(S)/Q(T) occurred (16.1 +/- 2.0% to 14.9 +/- 2.0%). After ICU arrival and extubation, no significant difference in Q(S)/Q(T) existed between the 2 groups. With the exception of a higher P(A-a)O2 in the control group at induction of anesthesia, no differences in PaO2 or P(A-a)O2 were present between the 2 groups at any measurement interval. Patients who received a VCM were extubated earlier than the control group (6.5 +/- 2.1 hours v 9.4 +/- 4.2 hours; p = 0.01). CONCLUSION: The use of a VCM prevented an increase in Q(S)/Q(T) from occurring in the operating room. Although a VCM did not influence pulmonary gas exchange in the ICU, its application in the operating room appears to exert a beneficial effect on tracheal extubation times after cardiac surgery.     

Methylprednisolone does not benefit patients undergoing coronary artery bypass grafting and early tracheal extubation

OBJECTIVE: We sought to determine whether methylprednisolone, when administered to patients undergoing cardiac surgery, is able to ward off the detrimental hemodynamic and pulmonary alterations associated with cardiopulmonary bypass. METHODS: After institutional review board approval and informed consent was obtained, 90 patients scheduled for elective cardiac surgery were randomized to 1 of 3 groups. Group 30MP patients received 30 mg/kg intravenous methylprednisolone during sternotomy and 30 mg/kg during initiation of cardiopulmonary bypass, group 15MP patients received 15 mg/kg methylprednisolone at the same 2 times, and group NS patients received similar volumes of isotonic sodium chloride solution at the same 2 times. Perioperative care was standardized, and all caregivers were blinded to treatment group. Various hemodynamic and pulmonary measurements were obtained perioperatively, as well as fluid balance, weight, peak postoperative blood glucose level, and tracheal extubation time. RESULTS: Demographic and clinical characteristics of patients and intraoperative data were similar among the 3 groups. Patients receiving methylprednisolone (either dose) exhibited significantly increased cardiac index (P =.0006), significantly decreased systemic vascular resistance (P =.0005), and significantly increased shunt flow (P =.0020) during the immediate postoperative period. All 3 groups exhibited significant increases in alveolar-arterial oxygen gradient (P <.0001), significant decreases in dynamic lung compliance (P <.0001), and significant decreases in static lung compliance (P <.0001) during the immediate postoperative period, with no differences between groups. Perioperative fluid balance and weights were similar between groups. A statistically significant difference in peak postoperative blood glucose level existed (P =.016) among group NS (234 +/- 96 mg/dL), group 15MP (292 +/- 93 mg/dL), and group 30MP (311 +/- 90 mg/dL). In patients extubated within 12 hours of intensive care unit arrival, a statistically significant difference in extubation times existed (P =.025) between group NS (5.7 +/- 2.3 hours), group 15MP (5.9 +/- 2.2 hours), and group 30MP (7.5 +/- 2.7 hours). CONCLUSIONS: Methylprednisolone, as used in this investigation, offers no clinical benefits to patients undergoing elective coronary artery bypass grafting with cardiopulmonary bypass and may in fact be detrimental by initiating postoperative hyperglycemia and possibly hindering early postoperative tracheal extubation for undetermined reasons.     

Is an increase in lactate concentration associated with cardiac dysfunction after the Fontan procedure?

PURPOSE: To investigate how blood lactate concentration changes in the early postoperative course after the Fontan procedure, and whether such a change is associated with postoperative hemodynamics. MATERIALS AND METHODS: Eight pediatric patients who underwent the Fontan procedure for congenital heart disease were included. Enrollment criteria were body weight >10 kg and staged Fontan procedure following the bidirectional Glenn procedure. Blood lactate concentration and central venous oxygen saturation (SvO2) were measured at five points: before skin incision, upon intensive care unit (ICU) admission, 15 minutes before, 15 minutes after, and 2 hours after extubation. Cardiac index (CI) was continuously monitored using the pulse contour technique. RESULTS: Lactate concentration increased in the ICU, peaking from 15 minutes before (2.7+/-1.3 mmol/L) to 15 minutes after (3.0+/-1.3 mmol/L) extubation. Values returned to normal parameters (1.0+/-0.1 mmol/L) within 48 hours. The CI values were also higher immediately after extubation (4.0+/-0.6 L/min/m2) than at ICU admission (3.3+/-0.6 L/min/m2) and before extubation (3.6+/-0.6 L/min/m2) (p=0.012). No significant change in central SvO2 or blood pressure (BP) was evident during the study period. CONCLUSION: In the early postoperative period after the Fontan procedure, blood lactate concentration increased temporarily around the time of extubation but the increase was not associated with hemodynamic deterioration.     

Supraventricular tachyarrythmia prophylaxis after coronary artery surgery in chronic obstructive pulmonary disease patients (early amiodarone prophylaxis trial).

OBJECTIVES: Supraventricular tachyarrhythmias (SVT) is common after coronary artery bypass grafting in chronic obstructive pulmonary disease (COPD). Preoperative FEV(1) is the major predetermining factor of mortality, morbidity and SVT. METHODS: Patients were divided into two groups according to their preoperative FEV(1) values. FEV(1) is <75% of predicted value in group 1 (no. 200), and >/=75% of predicted value in group 2 (no. 100). Group 1 is divided into two subgroups. SVT prophylaxis was not done in A subgroup (no. 100) whereas arrhythmia prophylaxis was done with amiodarone in all B subgroups (no. 100) in the early postoperative period. RESULTS: Atrial fibrillation developed in 28 patients in group 1A, whereas it developed in 12 in group 1B (P=0.005). Atrial flutter developed in 10 patients in group 1A but in 3 patients in group 1B (P=0.045). Multifocal atrial tachycardia developed in 13 patients in group 1A and in 4 in group 1B (P=0.022). Multivariate analysis identified ejection fraction (P<0.002, odds ratio (OR) 0.93), inotropy requirement (P<0.001, OR 3.98) amiodarone (P<0.001, OR 0.18), and FEV(1)<75% of predicted value (P<0.048, OR 1.84) as predictor of SVT. There were statistically significant differences between A and B subgroups of group 1 for hospital (P<0.001) and intensive care unit (ICU) stay (P<0.001). There was also statistically significant difference between groups 1A and 2 comparison for ICU (P<0.001; 6.4+/-3.4 versus 1.4+/-0.6 days) and hospital stay (P<0.001; 17.6+/-8.2 versus 6.9+/-0.6 days). CONCLUSIONS: Early prophylactic amiodarone not only significantly reduces SVT but also reduces SVT-related hospital and ICU stay. We strongly recommend prophylactic early use of amiodarone in COPD patients.     

Effects of intrapleural analgesia on pulmonary function and postoperative pain in patients with chronic obstructive pulmonary disease undergoing coronary artery bypass graft surgery

OBJECTIVE: Pain after coronary artery bypass graft (CABG) surgery remains a significant problem and may cause serious complications because of restricted breathing and limited early mobilization. The aim of this study was to assess the effects of intrapleural analgesia on the relief of postoperative pain in patients undergoing CABG surgery. DESIGN: Postoperative pain, pulmonary function tests, and outcomes were compared with a placebo group after CABG surgery in a double-blind randomized clinical trial. Settings: Cardiovascular surgery clinic. PARTICIPANTS: One hundred twenty-five patients with decreased lung function were studied. INTERVENTIONS: Group A (62 patients) received 20 mL of 0.5% bupivacaine bilaterally in the intrapleural spaces every 6 hours for 4 days, and group B (63 placebo patients) received sterile saline solution. MEASUREMENTS AND MAIN RESULTS: Group A had a significantly shorter extubation time than the placebo group (8 +/- 1 h v 10 +/- 4 hours, p < 0.001). Blood gas analysis showed higher PaO2 and lower PaCO2 levels in group A. The patients receiving bupivicaine had significantly higher FEV1, FCV, VC, MVV, PEF, and FEF 25-75% values postoperatively when compared with the placebo group. Postoperative analgesic requirements and visual analog pain scales were significantly lower in group A. The intensive care unit stay in group A was shorter (1.2 +/- 0.7 v 1.4 +/- 0.6 days, p = 0.04); however, the hospital stay did not differ between groups. CONCLUSIONS: Improvement in lung function parameters correlating with decreased postoperative pain with intrapleural bupivacaine was observed. Intrapleural analgesia provided a good level of analgesia, improved respiratory performance, and allowed rapid mobilization, which led to a reduction of postoperative respiratory complications.     

Early postoperative complications of pediatric liver transplantation: experience at one center

To evaluate the postoperative complications within the first month among 20 pediatric liver transplant recipients between April 1990 and March 2003 we retrospectively studied their medical charts to gather demographic data; primary diagnosis; operative duration; perioperative transfusions; time to extubation; length of intensive care unit (ICU) stay; mortality; perioperative laboratory values; and postoperative complications including respiratory, infections, renal, neurological, cardiovascular, and gastrointestinal tract (GIT) complications. Ten male and ten female patients of mean age 8 +/- 4 years had a mean operative duration, time to extubation, and length of stay in the ICU of 12.1 +/- 2.3 hours, 11.1 +/- 15.0 hours, and 7.2 +/- 5.5 days, respectively. The most frequent postoperative complication was respiratory (n = 14, 70%), followed by infections (n = 13, 65%), renal (n = 8, 40%), neurological (n = 7, 35%), cardiovascular (n = 4, 20%), and GIT (n = 4, 20%) infections. The overall mortality rate was 25% (n = 5). Compared with patients who survived, those who died displayed significantly lower perioperative platelet counts (P <.05), as well as a significantly higher incidence of postoperative neurological disorders (P =.031), and cardiovascular complications (P =.032).     

Intraoperative and early postoperative results after laparoscopic implantation of aortofemoral bifurcation prostheses

PURPOSE: The evaluation of multiple intra- and early postoperative parameters in patients undergoing laparoscopic aortobifemoral bypass grafting. METHODS: The charts of 22 patients who underwent laparoscopic aortobifemoral grafting between February 2nd, 1996 and April 30th, 1999 were retrospectively reviewed. RESULTS: All patients were men. The mean age was 54 +/- 7.2 years with the mean body weight being 76.3 +/- 10.9 kg and the Body-Mass-Index (BMI) 23 +/- 2.8. Claudication was present in 20 patients; one patient had rest pain and one patient suffered from tissue loss. The mean Ankle-Brachial-Index (ABI) was 0.57 +/- 0.1. In four cases conversion to open technique became necessary. The mean operation time was 316 +/- 73 min and the mean aortic cross-clamp time was 73 +/- 20 min. The mean intraoperative blood-loss reached 689 +/- 461 ml. The mean duration of postoperative ventilator support was 6.0 +/- 5.8 hours and the patients left the ICU after 2.2 +/- 3.2 days. Oral intake was allowed after a mean of 2.6 +/- 2.9 days and the central venous lines were removed after 3.8 +/- 3.9 days. The administration of analgetic drugs was required for 2.9 +/- 3.9 days. The mean length of stay in the hospital was 9.6 +/- 5.5 days. CONCLUSIONS: Laparoscopic aortobifemoral bypass grafting is feasible in a selected group of patients. Despite relatively long operation times and the use of a pneumoperitoneum, we did not encounter significant cardiopulmonary adverse effects.     

Female gender associates with increased duration of intubation and length of stay after coronary artery surgery. CABG Clinical Benchmarking Database Participants

BACKGROUND: Females have worse outcome than do males after coronary artery bypass grafting; however, gender effects on length of stay (LOS) outcomes, such as duration of intubation or intensive care unit (ICU) LOS, have not been evaluated previously. The authors hypothesized that adjustment for pertinent preoperative covariates would eliminate any significant effect of gender on duration of intubation, LOS in the ICU after extubation, total ICU LOS, postoperative (exclusive of ICU) LOS, or total postoperative LOS. METHODS: Patients undergoing elective or urgent primary coronary artery bypass grafting surgery at 51 academic health centers in 1995 and 1997 were studied. Unique multivariable statistical models were developed for duration of intubation, ICU LOS after extubation, total ICU LOS, and postoperative (exclusive of ICU and total) LOS to test for independent associations with gender. Preoperative but not intraoperative or postoperative variables were included in the model. P> or =0.01 was considered significant. RESULTS: All LOSs were of significantly longer duration in females than in males in both the 1995 (n = 1,064) and 1997 (n = 910) data collections. After covariate adjustment, female sex remained associated with significantly longer duration ICU LOS and total postoperative LOS in both the 1995 (female:male ratios 1.30:1 and 1.13:1, respectively) and the 1997 (female:male ratios 1.19:1 and 1.12:1, respectively) data sets. After covariate adjustment, duration of intubation and ICU LOS after extubation were of significantly longer duration in women than men in 1995 (female:male ratios 1.22:1 and 1.39:1, respectively), but the differences were not significant in 1997. CONCLUSIONS: Even in the context of accelerated recovery programs, these analyses show that female sex has powerful associations with increased LOS intervals for coronary artery bypass grafting surgery, even after adjustment for preoperative covariates. These effects could result from differences in the ways in which men and women respond to coronary artery disease, anesthesia, and coronary artery bypass grafting surgery, or to bias on the part of healthcare workers.     

Double supply to left anterior descending artery by additional saphenous vein graft in internal thoracic artery malperfusion syndrome

OBJECTIVE: Internal thoracic artery (ITA) grafting to the left anterior descending artery (LAD) may have catastrophic consequences and can be fatal due to "ITA malperfusion syndrome." We have investigated the efficacy of a second graft in this syndrome. METHODS: A total of 35 patients, 29 males (82.9%) and 6 females (17.1%), with a mean age of 53.0 +/- 8.7, (range: 38 to 70) undergoing coronary artery bypass grafting required a second supply to LAD due to ITA malperfusion syndrome. This was performed using a saphenous vein graft. The mean number of distal anastomosis was 2.7 +/- 0.45 per patient (range: 1 to 5). The decision for an additional grafting procedure was made in the first operation for 18 patients (51.4%) (Group I). For the remaining 17 patients (48.6%) (Group II), the additional grafting procedures were performed during a reoperation after the development of ischemic complications in the intensive care unit (ICU). RESULTS: The early mortality rate was 8.6% (3 of 35). Two patients had perioperative myocardial infarction (MI) (5.7%). The second vein graft proved to dramatically reduce the incidence of postoperative MI. Malignant refractory arrhythmias were recorded in 17 patients (48.6%). Twelve patients (34.3%) required inotropic support and seven patients (20%), all in Group II, required intra-aortic balloon pump (IABP) support. The average duration of IABP was 5 days +/- 1.8 days (range: 3 to 7). The necessity of IABP support was found to be statistically higher in the second group compared to the first one. CONCLUSIONS: Double supply to LAD using an additional saphenous vein graft is the treatment of choice for ITA malperfusion syndrome. The time interval between the first and the second grafts appears to be crucial for postoperative patient outcome.     

Interpleural analgesia improves pulmonary function after cholecystectomy

The purpose of this study was to examine the effects of interpleural bupivacaine on analgesia and ventilatory capacity after cholecystectomy. Forty-two patients undergoing elective cholecystectomy were randomly assigned to two groups: one to receive interpleural administration of bupivacaine-adrenaline mixture (Group 1 = 22 patients) and the other standard administration of intramuscular meperidine (Group 2 = 20 patients) for postoperative pain relief. The intensity of pain was evaluated by a visual analogue scale (VAS) preoperatively as well as at 2, 8, 24 and 48 hr postoperatively. At the same time, FVC and FEV1.0 measurements were obtained for all patients. The group given interpleural bupivacaine had better pain relief with mean VAS of 0.6 +/- 0.9 (mean +/- SD) 1.1 +/- 1.4, 0.6 +/- 0.9 and 0.8 +/- 1.2 compared with 5.2 +/- 2.2, 5.8 +/- 2.7, 5.5 +/- 2.2 and 4.5 +/- 1.8 for patients receiving meperidine (P less than 0.001). The patients in Group 1 also had larger FVC and FEV than those in Group 2: FVC 22 +/- 14.5 per cent vs 32 +/- 15.2 per cent (P less than 0.005), FEV1.0 25 +/- 15.5 vs 38 +/- 14.8 per cent (P less than 0.001) (mean +/- SD). We conclude that the interpleural analgesia can achieve better pain relief with greater ventilatory capacity than a standard analgesic regimen in the first two days after cholecystectomy.     

Surgical myocardial revascularization (CABG) in patients with pulmonary disease: beating heart versus cardiopulmonary bypass

BACKGROUND: Adverse effects on the respiratory system can be severe in many instances after coronarv artery bypass grafting (CABG) with cardiopulmonary bypass (CPBP). Recently, operative techniques without CPBP have gained widespread consent, thanks to the newly developed retractors that allow satisfactory immobilisation of the surgical field. METHODS: Thirty-seven patients operated upon in our Institution between April 1997 and April 1998 showed an obstructive and/or restrictive pulmonary disease. Twenty-one patients were operated on without CBPB (group A), while 16 patients were operated using CPBP (group B, control). The allocation in each group had been randomised. RESULTS: The length of the operation in group A was less than in group B (196+/-35 minutes vs 235+/-60 minutes), (p=0.014). A significant difference was found in postoperative bleeding: 562+/-381 ml vs 776+/-378 (p=0.046), in postoperative red cell count, hemoglobin level and Hct. Permanence on the ventilator was 19.1+/-13 hours in group B and 13.1+/-6.1 hours in group A (p=0.03). The length of stay in ICU was significantly different: 33.8+/-16.2 hours for group A vs 53.6+/-29.3 hours for group B (p=0.01). No respiratory failure occurred in group A; two patients experienced slow weaning from ventilation assistance and one died from that complication in group B. CONCLUSIONS: Myocardial revascularization without CPBP allows a better postoperative clinical course in patients with advanced pulmonary disease.     

Different CABG methods in patients with chronic obstructive pulmonary disease

BACKGROUND: Pulmonary dysfunction is still a major problem in coronary artery bypass grafting (CABG). The purpose of this randomized study was to determine the effect of different CABG techniques on pulmonary function. METHODS: Fifty eight patients with severe obstructive pulmonary disease had elective isolated coronary surgery. The surgical methods for the patients with chronic obstructive pulmonary disease (COPD) were standard CABG in 18 patients (group 1), beating heart surgery in 19 patients (group 2), and minimally invasive direct coronary artery bypass grafting (MIDCABG) in 21 patients (group 3). RESULTS: The earliest extubation time was from group 3 (p < 0.001). The average stay in the intensive care unit was significantly longer in group 1 (2.6 +/- 1.5 days) than in groups 2 (1.4 +/- 0.8 days) and 3 (1.1 +/- 0.8 days) (p < 0.05). The most prevalent respiratory morbidity was atelectasis that developed in 6 patients from group 1, in 2 patients from group 2, and in 3 patients from group 3. Forced expiratory volumes in 1 second (FEV1) obtained in the second postoperative month were significantly lower than preoperative values only in group 1 (p < 0.05). Forced vital capacity (FVC) values were significantly lower than the preoperative values in all three groups (p < 0.05). CONCLUSIONS: Off-pump bypass surgical procedures are more advantageous than on-pump methods for patients with COPD. These patients can be operated on using the beating heart technique or by using MIDCABG to prevent side effects of CPB on pulmonary function and effects of sternotomy.     

Use of aprotinin during pediatric heart surgery]

OBJECTIVE: To study the efficacy of high doses of aprotinin during cardiopulmonary bypass (CPBP) in pediatric patients with a tendency to intra- and postoperative bleeding: children undergoing repeated operations and those with cyanotic cardiopathy. PATIENTS AND METHODS: A simple retrospective, random sample of 71 pediatric patients with cyanogenic cardiopathy was studied. Group I (n = 36) received a test dose of 50,000 KIU in 2 min. The initial dose was 1,700,000 KIU (170 ml/m2 of body surface) i.v., at an infusion rate of 150 ml/h. CPBP circuit prime dose was 1,700,000 (170 ml/m2 of body surface), with replacement at a volume equivalent to the circuit prime. The maintenance dose was 400,000 KIU (40 ml/m2/h) i.v. Infusion was suspended 2 hours after a patient's arrival at the intensive care unit (ICU). We recorded red blood cell loss and blood product requirements in the first 24 hours in the ICU, duration of surgery, intra- and postoperative diuresis, and complications. RESULTS: Group I required 13.96 +/- 12.09 ml/kg/h of packed red cells whereas Group II required 22 +/- 16.22 ml/kg/h (p < 0.05). The volume lost was less in Group I than in Group II (0.77 +/- 0.48 ml/kg/h vs. 2.12 +/- 3.9 ml/kg/h; p < 0.05). The means for intra- and postoperative diuresis in the first 24 hours were not significantly different. CONCLUSIONS: Aprotinin significantly reduces red blood cell loss and homologous blood transfusion requirements. No complications attributable to aprotinin were observed.     

Combination of intrathecal morphine and remifentanil infusion for fast-track anesthesia in off-pump coronary artery bypass surgery

OBJECTIVE: The purpose of this study was to assess the combination of intrathecal morphine and remifentanil infusion with isoflurane in off-pump coronary artery surgery, with a focus on postoperative analgesia and fast-tracking. DESIGN: Prospective, randomized, controlled, blinded clinical study. SETTING: University hospital. PARTICIPANTS: Forty-six patients who underwent elective off-pump coronary artery bypass grafting. INTERVENTIONS: Patients were randomly assigned to receive remifentanil infusion alone (control group, n = 23) or remifentanil infusion plus 10 microg/kg of intrathecal morphine (ITM group, n = 23). Induction and maintenance anesthesia were the same in both groups. Maintenance therapy was remifentanil infusion (0.25-1 microg/kg/min) and 0.5% to 1.5% isoflurane, with adjustments according to hemodynamics. After extubation, intravenous patient-controlled analgesia with morphine (1-mg bolus and 5-minute lockout) was administered, and Wilson sedation scores, visual analog pain scores (scale, 0-100 mm) at rest and during coughing, and cumulative morphine consumption were assessed at 1, 2, 4, 8, 12, 24, and 48 hours. Examiners were unaware of patients' group identities. Anesthetic recovery parameters and opioid-related, spinal anesthesia-related, and cardiac complications were recorded. MEASUREMENTS AND MAIN RESULTS: There were no differences between the groups' intraoperative hemodynamic or anesthetic recovery findings. Pain scores and morphine consumption were significantly lower in the ITM group at all time points after extubation (p = 0.0001-0.05). Group frequencies of opioid-related and cardiac complications were similar. No patient had central neuroaxial hematoma or post-spinal tap headache. CONCLUSION: In the setting of isoflurane anesthesia for off-pump coronary artery bypass grafting, ITM combined with remifentanil infusion provides better postoperative analgesia than does remifentanil infusion alone, and does not improve or negatively affect fast-tracking.     

Myocardial ischaemia after coronary artery bypass grafting: early vs late extubation

The technique of early extubation after coronary artery bypass grafting is increasing in popularity, but its safety and effect on myocardial ischaemia remain to be established. In a randomized, prospective study, patients undergoing routine elective coronary artery bypass grafting were managed with either early or late tracheal extubation. The incidence and severity of electrocardiographic myocardial ischaemia were compared. Data were analysed from 85 patients (43 early extubation; 42 late extubation). Median time to extubation was 110 min in the early extubation patients and 757 min in the late extubation patients. After correction for randomization bias, there were no significant differences between groups in ischaemic burden, maximal ST- segment deviation, incidence of ischaemia and area under the ST deviation-time curve (integral of ST deviation and time). Similarly, there were no differences between groups in postoperative creatine kinase MB-isoenzyme concentrations and duration of stay in the ICU or hospital. Therefore, this study provides evidence for the safety of early extubation after routine coronary artery bypass grafting.      

Morbidity outcome in patients with hypertrophic obstructive cardiomyopathy undergoing cardiac septal myectomy: early-extubation anesthesia versus high-dose opioid anesthesia technique

OBJECTIVE: Anesthetic management of patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing septal myectomy is challenging. The morbidity outcome of early-extubation anesthesia (EEA), or fast tracking, versus high-dose opioid (HDO) anesthesia was studied. DESIGN: Retrospective study. SETTING: University teaching hospital. PARTICIPANTS: One hundred seventy-five cardiac septal myectomy patients (EEA, n = 53; HDO, n = 122). INTERVENTIONS: EEA technique consisted of low-dose fentanyl, 10 to 15 microg/kg; propofol infusion; midazolam; and inhalation agent. HDO technique consisted of fentanyl, 50 to 100 microg/kg, and benzodiazepines, with or without an inhalation agent. Demographic data, preoperative symptoms, and data on anesthesia management and postoperative complications were recorded. MEASUREMENTS AND MAIN RESULTS: There were no differences between the groups (EEA v HDO, respectively) regarding age, sex, preoperative symptoms (dyspnea, 89% v 79%; palpitations, 28% v 26%; angina, 47% v 61%; syncope, 47% v 41%), redo surgery, or combined surgery. Mean +/- standard deviation time to tracheal extubation was 7.2 +/- 5.3 hours in EEA versus 19.4 +/- 10.5 hours in HDO patients (p < 0.0001). Intensive care unit (ICU) stay was significantly shorter in EEA versus HDO patients (2.2 v 3.0 days; p < 0.005), with the trend toward earlier hospital discharge (9.7 v 11.3 days; p = 0.09). There was a high requirement for temporary pacing in both groups immediately postoperatively (EEA, 60% v HDO, 48%; p > 0.08). Permanent pacemaker insertion postoperatively was required in 7 of 53 patients (13%) in the EEA group and 11 of 122 patients (9%) in the HDO group (p > 0.25). Atrial arrhythmias occurred postoperatively in 25% of EEA patients versus 34% of HDO patients (p > 0.08). CONCLUSION: EEA facilitates earlier tracheal extubation by 12 hours in patients with HOCM undergoing septal myectomy, significantly shortening ICU stay by 1 day without increasing perioperative cardiac morbidity or mortality.     

Should We Give Prophylactic “Renal‐Dose” Dopamine After Coronary Artery Bypass Surgery?

OBJECTIVE: A prospective double-blind randomized study undertaken to assess the effect of postoperative prophylactic "renal-dose" dopamine on post-coronary artery bypass grafting surgery's clinical outcome. METHODS: Eighty-five consecutive patients undergoing CABG operation were randomized to receive either 3-5 microg/kg/min dopamine (group D, n = 41) or saline as placebo (group P, n = 45) for 48 postoperative hours. Clinical outcome parameters were collected for four postoperative days. RESULTS: Preoperative and operative parameters were similar in both groups. Four patients from group P and none from group D reached an end-point of the study (oliguria, renal dysfunction) and received dopamine. Two patients from group P and none from group D needed an additional inotropic support. Mean arterial pressure values were similar during the first 24 hours after operation, but left atrial pressure values tended to be higher in group P (10 +/- 4 vs 7 +/- 3 mmH2O, p = 0.18). The mean pH was higher in group D at 8 hours after operation (7.38 +/- 0.2 vs 7.36 +/- 0.3, p = NS), due to higher bicarbonate levels (23 +/- 2 mmol/l vs 21 +/- 2, p = 0.49). The incidence of lung congestion in chest X-rays and CT scans was significantly higher in group P (50% vs 29%, p = 0.073 at 48 hours postoperatively). Room air blood O2 saturation and maximal expiratory volume tended to be higher in group D (at 72 hours after operation- 92 +/- 4 vs 90%+/- 5, p = 0.29 and 646 +/- 276 vs 485 ml +/- 206, p = 0.16, respectively). There was no statistical difference in urine output but the amount of furosemide given to patients in group P was significantly higher (during the first 8 hours 2.5 +/- 0.5 vs. 0.3 mg +/- 1.6, p = 0.07). Plasma creatinine levels were significantly lower in group D (at 24 hours 0.93 +/- 0.02 vs 1.05 mg/dL +/- 0.02, p = 0.02). Mobilization after surgery was faster in group D. CONCLUSIONS: Prophylactic dopamine administration after coronary artery bypass grafting surgery improves patient hemodynamic and renal status, reduces the need for additional medical support (inotropes and furosemide) and thus, provides stable postoperative course.     

Assessment of postoperative pain using face scale judged by nurses: comparison between hepatectomy and esophagectomy]

The agreement between scores for observer-reported face scale (FS) and the self-reported visual analog scale (VAS) in postoperative pain assessment has not been compared for different types of surgery and for different times in the postoperative course. Five grade FS (1-5) judged by a nurse was compared with VAS (0-100 mm) reported by patients who had undergone hepatectomy (group H, n = 60) or esophageal cancer surgery by a thoracoabdominal procedure (group E, n = 50). Postoperative analgesia was mainly achieved by epidural morphine administration combined with lidocaine or bupivacaine in both groups. Pain measurement was performed at admission to the ICU, 1, 2, 6, and 10 hours later, and the following morning in group H, and 0.5, 1, 2, 6, 10, and 14 hours after tracheal extubation in group E. VAS scores (means +/- SD) were respectively 46 +/- 29 and 31 +/- 25 at ICU admission and one hour later in group H, and 41 +/- 36 and 36 +/- 33 thirty minutes and one hour after tracheal extubation in group E. FS values (means +/- SD) were respectively 2.6 +/- 1.2 and 2.1 +/- 1.1 at ICU admission and one hour later in group H, and 2.4 +/- 1.3 and 2.2 +/- 1.2 thirty minutes and one hour after tracheal extubation in group E. VAS and FS decreased in both groups over time postoperatively. A fair degree of agreement was found between VAS and FS scores in group H at ICU admission and one hour later (weighted kappa values = 0.29 and 0.28, respectively); on the other hand, good agreement between these two scores was found in group E thirty minutes and one hour after tracheal extubation (weighted kappa values = 0.67 and 0.62, respectively). Weighted kappa values decreased thereafter in group E, but did not change in group H over the postoperative course. We conclude that postoperative pain assessment based on facial expression is more useful early after extubation for patients who have undergone esophagectomy than for those who have undergone hepatectomy.