Volume kinetics of glucose 2.5% solution during laparoscopic cholecystectomy

Background. Analyses of the distribution and elimination ofglucose 2.5% solutions can be used to suggest combinations ofinfusion rates and infusion times which yield a predeterminedplasma glucose level and degree of plasma dilution during surgery. Methods. Twelve patients aged between 27 and 51 (mean 40) underwentlaparoscopic cholecystectomy. An i.v. infusion of 1.4 litresof glucose 2.5% over 60 min was started when surgery began.A volume kinetic model was fitted to measurements of the plasmaglucose concentration and the degree of haemodilution. Nomogramswere constructed based on the kinetic results. Results. The volume of distribution for the glucose and infusedfluid and the plasma insulin levels were similar to the onesrecorded in previous volunteer studies, but 50–70% lowervalues were obtained for the clearance of glucose (mean 0.21litres min^–1), endogenous glucose production (1.1 mmolmin^–1) and the elimination rate constant for the infusedfluid (median 37 ml min^–1). Urinary excretion was markedlydepressed and amounted to 9% of the infused fluid volume 4 hafter starting surgery. To prevent hyperglycaemia, nomogramssuggested that the infusion should be directed towards a ‘target’glucose concentration and then slowed down in a controlled way.At steady state, the infused fluid maintains a 3.5% plasma dilutionfor each mmol that plasma glucose remains above baseline. Conclusion. Metabolic changes warrant careful balancing of infusionrates of glucose 2.5% during laparoscopic cholecystectomy, whichis facilitated by a nomogram. Volume expansion from the infusedfluid volume should be recognized. Br J Anaesth 2004; 92: 485–92     

Validation of volume kinetic analysis of glucose 2.5% solution given by intravenous infusion

Background. The distribution and elimination of glucose solutionscan be analysed by means of a volume kinetic model, but theability of the model to predict plasma dilution (‘modellinearity’) has not been evaluated. Methods. Six male volunteers received four separate infusionsof glucose 2.5%: 10 ml kg^–1 and 15 ml kg^–1 over30 min, and 15 ml kg^–1 and 25 ml kg^–1 over 60 min.The kinetic model was fitted to measurements of plasma glucoseconcentration and haemodilution. Results. The mean volume of distribution for the glucose was9.2 (SEM 0.4) litres while the infused fluid expanded a centralbody fluid space (V₁) of 3.1 (0.3) litres. Increasing the amountof infused fluid, but not the infusion rate, resulted in a proportionalincrease in the area under the curve for plasma glucose andplasma dilution, the only confounder being glycosuria. The biasof computer simulation was slightly increased by rebound hypoglycaemia,which could occur with the highest infusion rates, but the accuracywas almost identical regardless of whether the kinetic parametersfrom all 24 experiments or from any of the subgroups were used. Conclusion. The volume kinetic model for glucose 2.5% is linearand can therefore be used for computer simulation as long asmarked glycosuria does not occur. Br J Anaesth 2003; 90: 600–7     

Morbidity after total abdominal hysterectomy

Total abdominal hysterectomy (TAH), the commonest major gynaecological operation performed at the Groote Schuur and Somerset Hospitals, is associated with considerable financial and social problems for the family. A retrospective series of 300 consecutive patients who had undergone TAH is presented. This series was analyzed for factors influencing the prevalence of wound haematoma, sepsis and dehiscence, pain and decreased mobility, the main parameters of postoperative morbidity. The four factors found to be important in minimizing postoperative complications of TAH were: (i) the experience of the surgeon; (ii) the use of the Pfannenstiel rather than the subumbilical midline incision; (iii) closure of the skin with Dermalon rather than with black silk; and (iv) drainage of the wound.     

Volume kinetics of Ringer solution after surgery for hip fracture

PURPOSE: To study the time course of volume changes during and after infusion of Ringer's solution in elderly patients after a standardised trauma. METHODS: The kinetics of 12.5 ml.kg-1 Ringer's solution infused over 30 min were studied in ten patients one day after surgery for hip fracture (mean age, 70 yr) and in an age- and sex-matched control group. Hemodilution, as measured every five minutes for 90 min, was used to calculate the size of the fluid space expanded by the fluid (V) and the elimination rate constant (kr). The baseline fluid balance status in the patients and the controls was compared by bioelectrical impedance analysis. RESULTS: The size of V was 4.1 +/- 0.51 (mean +/- SEM) in the patients and 3.4 +/- 0.21 in the controls (P:NS) while the corresponding results for kr were 85 +/- 12 and 166 +/- 27 ml.min-1, respectively (P < 0.04). Bioelectrical impedance analysis showed that the extracellular fluid space and the total body water volumes did not differ between the two groups. Computer simulations based on the data obtained for V and kr indicate that trauma increases the dilution of the plasma volume and the retention of fluid in response to slow and moderate infusion rates, while these indices of short-term changes in fluid balance remain the same in the two groups during very rapid infusion of Ringer's solution. CONCLUSION: A slower elimination rate increased dilution of plasma and retention of fluid when Ringer's solution was infused in elderly trauma patients.     

Dextromethorphan and pain after total abdominal hysterectomy

Dextromethorphan is an N-methyl-D-aspartate (NMDA) receptor antagonist which has been shown to inhibit the development of cutaneous secondary hyperalgesia after tissue trauma. We studied 60 ASA I-II patients undergoing total abdominal hysterectomy in a randomized, double-blind, placebo-controlled study. Patients received either dextromethorphan 27 mg capsules, two doses before operation and three doses in the first 24 h after operation, or placebo. Visual analogue pain scores (VAS) at 24 and 48 h were assessed at rest, on coughing and on sitting up, and were not significantly different between groups. Morphine consumption from a patient-controlled analgesia (PCA) device was also not significantly different between groups. Evidence of secondary hyperalgesia was assessed with von Frey hairs 10 cm above the Pfannenstiel incision. Both groups of patients exhibited evidence of secondary hyperalgesia after 24 and 48 h but there were no significant differences between groups. There was also no difference between groups in VAS scores at 1 month.      

择期腹部手术后胰岛素抵抗相关因素研究

目的 研究腹部择期手术后发生胰岛素抵抗(IR)的相关因素,探讨IR的作用部位.方法 选择首都医科大学宣武医院2006年3月至2006年6月间腹部择期手术病人14例,其中男性5例.女性9例.分别检测病人术前1d(术前)、术中、术后第1天(术后)血浆肿瘤坏死因子α(TNF-α)、白介素6(IL-6)、血糖(BG)、血胰岛素(INS),利用稳态模式评估法(HOMA)计算胰岛素抵抗指数(HOMA-IR)、胰岛素分泌指数(HOMA-β)和胰岛素敏感指教(ISI).用逆转录聚合酶链反应(RT-PCR)方法,检测肌肉组织中胰岛素受体(INSR)、葡萄糖载体4(CLUT4)的基因表达.结果 术中和术后的BG、INS、IL-6和TNF-α分别呈进行性增加,其差异具有统计学意义(均为P<0.001).术后HOMA-IR明显高于术前,差异具有统计学意义(P<0.001);术后HOMA-β高于术前,但差异无统计学意义(P=0.103).手术结束时腹直肌的GLUT4 mRNA表达较手术开始有显著下降(P<0.001),而INSR mRNA表达却无明显差异(P=0.165).ISI与手术时间(r=-0.736、P<0.001)、术中出血(r=-0.594、P=0.032)、术后TNF-α水平(r=-0.641、P=0.018)呈负相关.结论 腹部择期手术病人存在IR.IR的主要作用部位在受体后.缩短手术时间、降低手术创伤强度、减少出血对减轻IR具有重要意义.     

The impact of impaired insulin release and insulin resistance on glucose intolerance after renal transplantation

The current knowledge of the pathogenesis of post-transplant glucose intolerance is sparse. This study was undertaken to assess the relative importance of insulin secretion (ISec) and insulin sensitivity (IS) in the pathogenesis of post-transplant diabetes mellitus (PTDM), impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) after renal transplantation. An oral glucose tolerance test (OGTT) was performed in 167 non-diabetic recipients 10 wk after renal transplantation. Fasting, 1-h and 2-h insulin and glucose levels were used to estimate the insulin secretory response and IS. One year after transplantation 89 patients were re-examined with an OGTT including measurements of fasting and 2 h glucose. Ten weeks after transplantation the PTDM-patients had significantly lower ISec and IS than patients with IGT/IFG, who again had lower ISec and IS than those with normal glucose tolerance (NGT). One year later, a similar difference in baseline ISec was observed between the three groups, whereas baseline IS did not differ significantly. Patients who improved their glucose tolerance during the first year, were mainly characterized by a significantly greater baseline ISec, and they received a significantly higher median prednisolone dose at baseline with a subsequent larger dose reduction during the first year, than the patients who had their glucose tolerance unchanged or worsened. In conclusion, both impaired ISec and IS characterize patients with PTDM and IGT/IFG in the early course after renal transplantation. The presence of defects in insulin release, rather than insulin action, indicates a poor prognosis regarding later normalization of glucose tolerance.     

PCA ketamine and morphine after abdominal hysterectomy.

Following a standardized general anaesthetic for total abdominal hysterectomy, patients received either patient controlled analgesia (PCA) with morphine 1 mg/ml (group M, n = 33) or morphine 1 mg/ml plus ketamine 2 mg/ml (group K, n = 37) for 48 hours in a randomized, double-blind fashion. In 43 women the area of allodynia around the scar was mapped as a measure of the degree of central sensitization. A significant reduction in the area of allodynia was found in those receiving ketamine with morphine (42 cm2 [interquartile range (IQR) 57] compared with 57 cm2 [IQR 82] z = -2.0, P = 0.04) in those receiving morphine alone. There were no significant differences between the two groups with respect to age, or weight, or between the subgroups within which the area of allodynia was measured with respect to length of incision. No significant differences were found between the groups with respect to pain scores, total or hourly drug consumption, patient satisfaction, nausea scores or antiemetic use. Patients in group K were more likely to require PCA for a shorter period than those in group M (median 40 hours, IQR 26 versus 48 hours IQR 7). Ten patients in group K were withdrawn because of side-effects (dysphoria n = 4, nausea n = 2, pruritus n = 4) compared with one in group M (nausea n = 1) (P = 0.006). The potential usefulness of ketamine after hysterectomy was offset by a high incidence of adverse effects and a lack of opioid-sparing effects, such that combined intravenous ketamine and morphine PCA as used in this study cannot be recommended for routine care.     

Effect of continuous epidural 0.2% ropivacaine vs 0.2% bupivacaine on postoperative pain, motor block and gastrointestinal function after abdominal hysterectomy

We have investigated the effect of 24-h postoperative continuous epidural infusion of 0.2% ropivacaine or 0.2% bupivacaine 8 ml h-1 on pain, request for supplementary analgesics, motor block and gastrointestinal function, in a double-blind, randomized study in 60 patients undergoing open hysterectomy. There were no significant differences between groups in pain, number of patients requesting supplementary analgesics, motor block, ability to walk or time to first flatus or stool. In the subgroup of patients who received supplementary analgesics, patients in the ropivacaine group received significantly more ketorolac than patients in the bupivacaine group. Time to discharge from hospital was similar with ropivacaine and bupivacaine.      

Sorbitol 2.5% mannitol 0.54% irrigation solution for hysteroscopic endometrial ablation surgery

Purpose

To determine if systemic absorption of sorbitol 2.5%/mannitol 0.54% imgation solution (165 mosm·L^?1) during hysteroscopic endometrial ablation with diathermy is associated with hyponatraemia and hypoosmolality.

Methods

In 35 day surgery patients in a university hospital we measured baseline preoperative variables: serum sodium and creatinine concentrations and osmolality, haematocnt, haemoglobin, urine osmolality and sodium concentration, and weight. Fractional excretion of sodium (FE_Na) was calculated. The same observations were obtained postoperatively before discharge (one hour post resection). Volumes of intraoperative fluid imgation intravasation and penoperative intravenous fluid absorption (lactated Ringer’s solution) were estimated clinically (vdumetric).     

Analgesic effect of epidural neostigmine after abdominal hysterectomy

STUDY OBJECTIVE: To evaluate the effects of epidurally administered neostigmine on pain after abdominal hysterectomy. DESIGN: Prospective, randomized, double-blind study. SETTING: Teaching hospital. PATIENTS: 45 ASA physical status I adult patients scheduled for abdominal hysterectomy. INTERVENTIONS: All patients received identical general and epidural anesthesia. At the end of the surgery, they received epidural bupivacaine (10 mg) with either saline (control group, n = 15), 5 micro g/kg (5-micro g group, n = 15), or 10 micro g/kg neostigmine (10-micro g group, n = 15). Postoperatively, 50 mg diclofenac suppository was given for pain relief on patient demand. MEASUREMENTS AND MAIN RESULTS: The time to first diclofenac administration and the number of times diclofenac was required during the first 24 postoperative hours were recorded. Pain was assessed using a 10-cm visual analog pain scale (VAS) at rest at the first diclofenac request, and at 15 and 24 hours after surgery. The time to first diclofenac administration was significantly longer (p < 0.05) in the 10-micro g group (223 +/- 15 min) than in the control (78 +/- 17 min) or 5-micro g groups (88 +/- 18 min). However, epidural neostigmine at both doses did not reduce the number of postoperative diclofenac administrations. There were no differences in VAS among the three groups. CONCLUSIONS: Epidural neostigmine of 10 micro g/kg in bupivacaine provides a longer duration of analgesia than does bupivacaine alone or with 5 micro g/kg of neostigmine after abdominal hysterectomy.     

Wound infiltration with local anaesthetic after abdominal hysterectomy

The study was performed to investigate if wound infiltration with 20 ml of 0.5% bupivacaine after abdominal hysterectomy improved analgesia and reduced morphine requirements from a patient-controlled analgesia system during the first 6 h after operation. Forty patients undergoing abdominal hysterectomy were allocated randomly to one of two groups. The study was performed in a double-blind controlled manner. Morphine requirements in the first 6 h after operation were similar in both the control (30.3 mg) and bupivacaine (29.0 mg) groups. Cumulative hourly morphine requirements did not differ significantly between the two groups. Pain scores assessed by visual analogue were similar in both groups.      

Volume kinetics of Ringer's solution in female volunteers

The kinetics of crystalloid solutions in humans have not been adequately described previously. Therefore, we measured blood haemoglobin concentration during and for 120 min after i.v. infusion of 25 ml kg-1 of Ringer's acetate solution over 15, 30, 45 and 80 min, and 12.5 ml kg-1 over 30 min in six adult female volunteers. The dilution- time profiles were analysed according to a new kinetic model adapted for fluid spaces. Volume expansion produced by Ringer's solution approached steady state in an exponentially decaying manner when plasma volume had increased by approximately 550 ml. The size of the fluid space expanded by Ringer's solution was only 4.8 litre (95% confidence interval 3.8-5.8 litre) except for the fastest infusion, where it averaged 9.0 litre. The rate of fluid elimination could be predicted as the product of plasma dilution and a constant averaging 95 (95% confidence interval 68-122) ml min-1.      

Comparison of peritoneal equilibration test with 2.27% and 3.86% glucose dialysis solution

BACKGROUND: The standard Peritoneal Equilibration Test (PET) uses a 2.27% glucose dialysis solution in peritoneal dialysis (PD). A more hypertonic solution (3.86%) has recently been proposed to obtain further information about ultrafiltration (UF). AIM: To compare results in terms of peritoneal solute transport (4h-dialysate-to-plasma ratio, 4h-D/P) between 2.27% and 3.86% PET. DESIGN: 23 patients on PD were randomized to form two groups, A and B. A 2.27% dextrose 2-L exchange was used in group A, followed on the same day by a 3.86% dextrose 2-L exchange, both with a 4-hour dwell (2.27% and 3.86% PET); in group B, the same treatment was administered in reverse. 4h-D/P of urea, creatinine and sodium at time 0, 60, 120 and 240 minutes and net UF were calculated for each PET and compared. RESULTS: No significant statistical differences were found for the usual peritoneal transport indexes, 4h-D/P of urea and creatinine, between 2.27% and 3.86% PET, which produced almost identical results. The creatinine 4h-D/P were 0.67+/-0.09 vs. 0.66+/-0.10 (p= NS) and the urea 4h-D/P 0.91+/-0.04 vs. 0.90+/-0.04 (p= NS). The sodium D/P was lower at all times during the 3.86% PET: D/P60= 0.92+/-0.05 vs. 0.88+/-0.03, D/P120= 0.91+/-0.02 vs. 0.87+/-0.03, D/P240= 0.92+/-0.02 vs. 0.88+/-0.04 (p< 0.0001). The net UF was 478 +/- 175 vs. 936 +/- 233 mL respectively (p< 0.0001). CONCLUSION: Our study suggests that a 3.86% PD solution could be used for PET instead of the 2.27% solution in order to assess peritoneal solute transport, as well as UF, while obtaining almost identical results as the 2.27% solution.     

Comparison of peritoneal equilibrium test with icodextrin and 2.5% glucose dialysis solutions

BACKGROUND: Icodextrin provides a different ultrafiltration mechanism than glucose-based dialysate. METHODS: To evaluate the difference in the peritoneal equilibrium test (PET) with regard to using icodextrin (Ico-PET) and glucose dialysate we designed a prospective study using Ico-PET and 2 cross-over conventional 2.5% glucose-based dialysate PETs (Gluco 1-PET and Gluco 2-PET) administered 3 months before and after the Ico-PET in 58 chronic peritoneal dialysis patients. RESULTS: More patients demonstrated higher transport types with the Ico-PET than the Gluco 1-PET and Gluco 2-PET (p<0.001). After a dwell time of 4 hours, the Ico-PET did not show an ultrafiltration benefit compared with the Gluco-PET (272.8 +/- 137.1 mL vs. 348.3 +/- 215.2 mL, p<0.001). The Ico-PET not only showed significantly higher values in the 0-hour, 2-hour and 4-hour dialysate to plasma creatinine concentration ratio (D/P Cr) than those of the Gluco 1-PET (p=0.029 and p<0.001, respectively), but also showed higher values in the 0-hour and 4-hour D/P Cr than those of the Gluco 2-PET (both p<0.001). The total ultrafiltration volume was positively correlated with the 4-hour D/P Cr with the Ico-PET (r=0.41, p=0.001), but the correlation was negative with the Gluco 1-PET (r=-0.33, p=0.012) and Gluco 2-PET (r=-0.51, p<0.001). The ratio of the glucose concentration in the outflow dialysate compared with baseline level (D/Do glucose), was also significantly higher with the Ico-PET than with the Gluco 1-PET and Gluco 2-PET after both 2 and 4 hours (both p<0.001). CONCLUSIONS: The Ico-PET showed a completely different result from the conventional Gluco-PET. The Ico-PET provi-des a superior solute transport and inferior ultrafiltration rates, and the prevalence of high transporters was also increased with the Ico-PET.     

Effect of meloxicam on postoperative pain after abdominal hysterectomy

We studied 36 patients, allocated randomly to receive meloxicam 15 mg rectally (n = 18) or placebo suppository (n = 18) before total abdominal hysterectomy in a double-blind study. Visual analogue scores for pain at rest (P < 0.005), on movement (P < 0.05) and on coughing (P < 0.05) were significantly decreased in the meloxicam group during the first 24 h after surgery. Mean 24-h PCA morphine requirements were 33.2 (SD 16.9) mg and 38.2 (20.8) mg in the meloxicam and placebo groups, respectively (ns). There was no difference in the incidence of nausea, vomiting or sedation between groups.      

The analgesic effects of gabapentin after total abdominal hysterectomy

We investigated, in a randomized, placebo-controlled, double-blind study, the efficacy and safety of gabapentin on pain after abdominal hysterectomy and on tramadol consumption in patients. The 50 patients were randomized to receive either oral placebo or gabapentin 1200 mg 1 h before surgery. Anesthesia was induced with propofol and maintained with sevoflurane in 50% N(2)O/O(2) with a fresh gas flow of 2 L/min (50% N(2)O in O(2)) and fentanyl (2 microg/kg). All patients received patient-controlled analgesia with tramadol with a 50 mg initial loading dose, 20 mg incremental dose, 10-min lockout interval, and 4-h limit of 300 mg. The incremental dose was increased to 30 mg if analgesia was inadequate after 1 h. Patients were studied at 4, 8, 12, 16, 20, and 24 h for visual analog (VAS) pain scores, heart rate, peripheral oxygen saturation, mean arterial blood pressure, respiratory rate, sedation, and tramadol consumption. The VAS scores in the sitting and supine position at 1, 4, 8, 12, 16, and 20 h were significantly lower in the gabapentin group when compared with the placebo group up to 20 h after surgery. The tramadol consumption at 12, 16, 20, and 24 h and total tramadol consumption were significantly less in the gabapentin group when compared with placebo group. Sedation scores were similar at all the measured times. There were no differences between groups in adverse effects. Preoperative oral gabapentin decreased pain scores and postoperative tramadol consumption in patients after abdominal hysterectomy. IMPLICATIONS: This randomized, controlled trial examined the effects of preoperative oral gabapentin 1200 mg on postoperative pain and tramadol consumptions. We conclude that preoperative oral gabapentin is effective in reducing postoperative pain scores and tramadol consumption in patients after abdominal hysterectomy.