COMPARISON OF EFFECTS OF BALANCED ANAESTHESIA AND NEUROLEPTANALGESIA ON POSTOPERATIVE CARDIOVASCULAR FUNCTION IN PATIENTS WITH CORONARY ARTERY DISEASE

Patients with chronic ischaemic heart disease and a historyof myocardial infarction or who present with exertional or spontaneousangina suffer a decrease in left ventricular pump function duringrecovery from anaesthesia and in the period immediately afteroperation. This decrease is reflected in an increase in pulmonarycapillary wedge pressure and in a decrease in stroke volumeand cardiac output. Two groups of 10 such patients, clinicallyand haemodynamically comparable in the preoperative period,were studied: 10 patients received balanced anaesthesia, and10 neuroleptanalgesia. The disturbance in left ventricular functionwas less pronounced with neuroleptanalgesia. A significant differencewas noted between the groups with regard to pulmonary capillarywedge pressure during recovery from anaesthesia (balanced anaesthesia15.8±4.4 mm Hg; neuroleptanalgesia 10.7±4.4 mmHg; P<0.02). There was a relationship between type of anaesthesiaand pulmonary capillary wedge pressure variations (P<0.01).     

两种阴道成形术式的临床应用比较

目的 对比两种阴道成形术的临床应用价值。方法 1996年1月～2005年3月，对37例应用羊膜移植阴道成形术和26例腹腔镜下改良Vecchitti阴道成形术进行对比，比较分析其治疗先天性无阴道的优缺点，并分别对两种术式应用的阴道模型进行了相应改进。结果 羊膜移植阴道成形术组37例均取得成功，术后随访35例，随访时间2个月～4年；发生羊膜感染3例，瘢痕挛缩2例，其中1例于术后13个月行瘢痕切开术获成功，另1例拒绝再次手术。腹腔镜下改良Vecchitti阴道成形术组手术26例均取得成功，术后均获随访，随访时间2个月～2．5年，无阴道感染及瘢痕挛缩。两种术式成形的阴道宽敞，黏膜呈粉红色，有皱壁、润滑、弹性好，外阴外观无改变，性生活满意。两种术式中的改进之处均取得了良好的临床应用效果。结论 腹腔镜下改良Vecchitti阴道成形术与羊膜移植阴道成形术比较具有明显优势，有推广价值。     

NEUROLEPTANALGESIA: A DOUBLE-BLIND COMPARISON OF PENTAZOCINE AND PHENOPERIDENE FOR NEURORADIOLOGICAL INVESTIGATIONS

In a double-blind, between-patient study involving fifty-fivepatients undergoing neuroradiological investigations, pentazocineand phenopendine have been compared in the technique of neuroleptanalgesia.Subjective assessment has shown both drugs to be equally satisfactory.Cardiovascular changes were more marked after phenoperidineand this drug also caused a greater and more persistent increasein arterial carbon dioxide tension. It is concluded that pentazocineis a suitable alternative for phenoperidine in combination withdroperidol in neuroleptanalgesia.     

ANAESTHESIA AND THE RETICULO-ENDOTHELIAL SYSTEM: COMPARISON OF HALOTHANE-NITROUS OXIDE AND NEUROLEPTANALGESIA

The effect of halothane anaesthesia and neuroleptanalgesia (NLA)on the phagocytic activity of the reticulo-endothelial system(RES) was investigated with the aid of the Lipofundin clearancetest. The results suggest that halothane in nitrous oxide depressesthe phagocytic activity of the RES. NLA did not exert a depressanteffect on the RES function. As it is essential for the bodyto be in a defensive condition to cope adequately with infectionand cancer metastases, care must be taken to ensure that ananaesthetic procedure does not cause additional impairment ofRES function. The results of the investigations suggest thatNLA may have advantages in this respect     

A COMPARISON OF MORPHINE AND PHENAZOCINE IN POSTOPERATIVE PAIN

Phenazocine, in doses of 1.4 mg/70 kg and 2.1 mg/70 kg, wascompared with 10.5 mg/70 kg morphine under "double blind" conditionsfor the relief of postoperative pain. All the patients had undergoneabdominal surgery and all the interviews were carried out byone assessor. No significant difference was found between thedegree or duration of pain relief produced by the three preparations.In over one third of the patients the pain did not return tothe pre-injection level. It was found that after upper abdominalsurgery there is more likely to be a need for an analgesic andthe injection will be required earlier than after lower abdominaloperations. The results are discussed in relation to those ofother studies.     

A SYSTEM FOR THE MEASUREMENT OF RESPIRATORY AND ACID-BASE PARAMETERS IN BLOOD

A system is described which, using electrodes for the determinationof pH, Pco₂, and Po₂, and a microhaematocrit centrifuge, allowsthe determination of the pH, Pco₂, Co₂, Po₂, Co₂, and haematocritof a sample of blood taken from an anaesthetized animal in atotal time of 30 minutes. The accuracy of each measurement isdescribed.     

A COMPARISON OF THE RESPIRATORY EFFECTS OF MEPTAZINAOL PENTAZOCINE AND MORPHINE

The respiratory effects of a new strong analgesic, meptazinol,were compared with a placebo and with equianalgesic doses ofmorphine and pentazocine in a double-blind crossover trial inseven healthy volunteers. No significant change in the ventilatoryresponse to rebreathing carbon dioxide was observed after meptazinol100 mg/70 kg or placebo. However, both morphine 10 mg/70 kgand pentazocine 60 mg/70 kg depressed the slope of the ventilatoryresponse ( — 30.0% and —31.6% respectively, P>0.02,averaged over the first 3.5-h period). End-tidal carbon dioxidetension (Pe‘co) while breathing room air increased significantlyfollowing all three drugs. However, the increase in Pe’qo,after meptazinol (0.22 kPa averaged over 3.5 h) was significantlyless than that following morphine (0.40 kPa, P>0.05) andpentazocine (0.59 kPa, P>0.01). While breathing room airwith a resistive inspiratory load of 8 kPa litre₁ s, Pe‘co,again increased significantly (P>0.05) following all threedrugs. The increase in Pe’co after meptazinol was thenthe same as that after morphine (0.51 kPa averaged over 3.5h). The increase following pentazocine (0.80 kPa) was significantlygreater than that after both morphine and meptazional(P>0.02).     

COMPARISON OF NEFOPAM AND PETHIDINE IN POSTOPERATIVE PAIN

A double-blind, between-patient, two-dose comparison was performedwith pethidine and nefopam in 100 subjects, the majority ofwhom were recovering from upper abdominal surgery. Either 15or 30 mg of nefopam or 50 or 100 mg of pethidine were givenby i.m. injection in a random order. All assessments were madeby the same observer on the first day after operation, at least4 h after the previous analgesic injection. Nefopam 15 mg wasequipotent with pethidine 50 mg, peak analgesia being achieved1 h after the i.m. injection. Pethidine 100 mg provided significantlybetter pain relief than nefopam 30 mg, the latter being notmore effective than nefopam 15 mg apart from the duration ofanalgesia which was longer. The incidence of nausea and vomitingwas similar after both drugs. Sweating and tachycardia wereobserved more frequently after nefopam, whereas sedative side-effectswere more common after pethidine.     

COMPARISON OF VISUAL AND MEASURED TRAIN-OF-FOUR RECOVERY AFTER VECURONIUM-INDUCED NEUROMUSCULAR BLOCKADE USING TWO ANAESTHETIC TECHNIQUES

This study evaluated train-of-four recovery after the administrationof vecuronium, comparing measured with visually observed responses.Responses to supramaximal stimuli of the ulnar nerves were measuredby a force transducer, and compared with visually observed movementsof the contralateral thumb. For the 10 patients anaesthetizedwith nitrous oxide and enflurane, the second, third and fourthtwitches visually reappeared at 84 (±10) %, 76 (±11)%, and 70 (±12) % measured blockade, respectively. Forthe other 10 patients, anaesthetized with a narcotic-barbituratetechnique, the second, third and fourth twitches reappearedat 81 (±8) %, 68 (±9) %, and 59 (±11) %.These results were not different for the two anaesthetic techniques.     

COMPARISON OF LENGTH OF STAY AFTER HERNIA REPAIR IN TWO VICTORIAN HOSPITALS

The objective of this study was to ascertain factors which determine the length of stay in relation to adult patients admitted for hernia surgery in two different hospitals. It was conducted prospectively on a total of 141 patients, 82 in a central hospital and 59 in a district hospital. There were no significant differences with regard to age, sex, type of hernia, pre-existing disease and postoperative complications. There was a significant difference between the average length of stay in the two hospitals (6.7 days in the central hospital and 3.9 days in the district hospital). There was a longer pre-operative stay in the central hospital through administrative problems, availability of operating time and admission for pre-operative investigations. In the postoperative period there was a significant difference between the day of operation and the time the surgeon stated that the patient could be discharged (i.e. the surgically advised discharge (SAD) date). This period was 4 days at the central hospital, as against 2 days at the district hospital. Once the SAD date was determined, there was no difference between the two hospitals with regard to placement. Consideration should be given to improving admission practices, including patient ‘work-up’ in the preadmission phase and to shortening the postoperative stay after hernia surgery.     

COMPARISON OF RESPIRATORY CHARACTERISTICS DURING ENFLURANE AND HALOTHANE ANAESTHESIA

The effects of enflurane on certain respiratory characteristicswere compared with those of halothane in 70 patients duringanaesthesia with spontaneous breathing using a specially designedcircuit. The rate of respiration with enflurane (mean 22 b.p.m.)was slower than with halothane (mean 31 b.p.m.; P<0.001)and the tidal volume greater (enflurane mean 240ml, halothane180ml; P<0.05). There was no statistically significant differencein the minute volume of ventilation or end-tidal carbon dioxideconcentration between the two agents. The effects of a narcoticpremedication were observed in 16 patients in the study. Themain effect was to produce slowing of respiratory rate (enfluranemean 16 b.p.m.; halothane 18 b.p.m.). The value of the respiratorypattern compared with the measurement of heart rate and arterialpressure as a clinical guide during anaesthesia is discussed.     

POSTOPERATIVE RESPIRATORY MORBIDITY: IDENTIFICATION AND RISK FACTORS

Two hundred consecutive patients admitted for general surgery were studied prospectively to evaluate the contribution of risk factors to postoperative respiratory morbidity (PORM). PORM was expressed both in terms of individual clinical features present on the second postoperative day (when the incidence was greatest), and as an aggregate score incorporating many clinical features. The importance of recognised risk factors, such as previous respiratory disease, cigarette smoking, upper abdominal procedures and the duration of surgery was confirmed, in that these factors were associated with some of the individual clinical features of PORM. The relative importance and independent contribution of these risk factors were assessed by their association with the aggregate score. A naso-gastric tube (NGT) present for 24 hours postoperatively was the factor more associated with PORM. The NGT identified patients at risk more clearly than, and independently of, the next most important factor, upper abdominal surgery. The duration of surgery did not contribute to PORM after the influence of NGT and site of surgery had been considered. Previous respiratory disease predisposed to PORM, and was best identified by, in order of importance, an observed productive cough, a reduced one second forced expiratory volume, and purulent sputum. After the influence of these factors had been considered, cigarette smoking and a history of a chronic productive cough did not contribute further to PORM.     

COMPARISON OF EFFECTS OF INTRAOPERATIVE AND POSTOPERATIVE METHADONE: ACUTE TOLERANCE TO THE POSTOPERATIVE DOSE?

The effects of methadone 10 mg administered in two differentclinical contexts, at induction of anaesthesia and followingoperation, were studied in two groups of patients undergoingelective total hip replacement. The intraoperative group receivedmethadone 10 mg i.v. at induction of anaesthesia as part ofa balanced anaesthetic technique. The postoperative group receivedmethadone 10 mg i.v. following operation, extradural bupivacainebeing used for the operative period. A demand analgesia systemdelivering methadone i.v. was used after operation in both groups.Arterial blood-gas tensions, cortisol and glucose concentrations,analgesic effects and plasma methadone concentrations were comparedin the two groups. The only major difference between the twogroups was in analgesic requirement. At the time of connectionto the demand system the two groups had the same plasma methadoneconcentrations. Subsequently, the postoperative group had asignificantly greater analgesic requirement which resulted insignificantly greater plasma methadone concentrations the followingmorning. Thus, the administration of methadone following operationappeared to exert less analgesic effect than the same dose givenduring operation. The reasons for this are discussed.     

60例肝移植术后高胆红素血症的诊治体会

目的探索原位肝移植术后高胆红素血症的原因及处理。方法回顾性总结60例同种异体原位肝移植术后高胆红素血症的原因、诊断;提出不同的治疗方法及不足之处。结果术前高胆红素血症、原发病复发为原位肝移植术后高胆红素血症的主要原因。(1)术前高胆红素血症者占90.00%,未作特别处理,术后第1天血总胆红素明显下降,3周内降至正常;(2)原位肝移植术后肝脏缺血再灌注损伤者占95.00%,给予重组人生长激素10u×14天,术后血总胆红素1周内均逐渐升高,2周年左右达高峰,3周左右下降,1个月内基本正常。(3)急性排斥反应者占15.00%,均采用甲基强的松龙冲击治疗同时提高FK506谷值浓度、增加骁悉,多数患者总胆红素在治疗后第2天开始下降,3个月左右下降至正常;(4)胆道并发症者占11.67%,大部分患者解除胆漏或胆道狭窄后血总胆红素3周左右降至正常;(5)血管并发症导致的高胆红素血症患者占11.67%,其中,4例治愈,3例死亡;(6)原发病复发导致高胆红素血症占18.33%,均为肝脏恶性肿瘤复发所致,所有7例患者均在术后4~11个月内死亡。结论高胆红素血症是原位肝移植术后常见的并发症,病因多样而复杂,需根据血总胆红素升高的时间、辅助检查及病理学所见及时作出正确论断,才能达治疗的目的,巩固肝移植的成果。     

PREVENTION OF LATE FENTANYL-INDUCED RESPIRATORY DEPRESSION AFTER THE INJECTION OF OPIATE ANTAGONISTS NALTREXONE AND S-20682: COMPARISON WITH NALOXONE

Compared with naloxone, two opiate antagonists (naltrexone andS-20682) were tested in the intact dog in order to reverse respiratorydepression, induced by fentanyl 50µgkg^–1 i.v. Respiratoryrate and arterial blood-gases were measured at 5, 30, 60, 120,180 and 240min after the additional i.v. injection of the antagonist(1 µgkg^–1). Only S-20682, but not naloxone or nalrxcxone,prevented late (240min) fentanyl-induced depression of respiratorydrive. A late respiratory depression coincided with an increasein amplitudes and a reduction of frequency in electrical corticalactivity (EEG). Naltrexone exhibited an antagonistic effectof duration twice (60 min) that of naloxone     

RESPIRATORY AND METABOLIC ACID-BASE CHANGES DURING CARDIOPULMONARY BYPASS IN MAN

Twenty-two patients undergoing open-heart surgery with cardiopulmonarybypass have been studied to define acid-base changes associatedwith anaesthesia, bypass, hypothermia and recovery. The maintenanceof normal pH during the operation, or the inclusion of a periodof normothermia before cooling, had no measurable effect onthe postoperative acid-base state or clinical course as comparedwith the usual routine of bypass in respiratory alkalosis andwith immediate cooling. Lactate and pyruvate increased slowlythroughout anaesthesia and bypass to combined levels not exceeding5 m.equiv/1. Rapid metabolic acid-base shifts of at least equalmagnitude, not due to lactic or pyruvic acids, were apparentlyassociated mainly with temperature changes. Acidosis has notbeen found severe enough to need routine administration of bicarbonateat any stage.     

A TEST OF TWO TYPES OF HALOTHANE VAPORIZER

Two different types of halothane vaporizer are compared. TheGoldman is simple, small and inefficient as a vaporizer. TheFluotec is relatively large, complicated, and highly efficient.It is suggested that there is a need for a modified versionof the simple type, capable of producing up to 5 per cent vapour.It is further suggested that it is not necessary, in clinicalpractice, to be able to vary the concentrations by very accuratelyknown small amounts. To be able to do so is an expensive andunnecessary luxury which is not attainable in practice and theoreticallycarries the risk of accidentally delivering a gross overdose.     

POSTOPERATIVE ANALGESIA AND LUNG FUNCTION: A COMPARISON OF MORPHINE WITH EXTRADURAL BLOCK

Twenty-one patients for vagotomy with gastroenterostomy or pyloroplastywere allocated randomly to postoperative analgesia with eithermorphine by injection or continuous extradural nerve block.In terms of clinical assessment and A–a Po² differencemeasured before and after operation, extradural nerve blockwas found to reduce the degree of postoperative lung dysfunction.It is concluded that the conventional use of narcotics for postoperativeanalgesia increases the risk of lung morbidity. University Department of Anaesthesia (Western Infirmary), 4Lilybank Gardens, Glasgow W.2, Scotland.