Effects of isoflurane, sevoflurane, and desflurane on platelet function: A prospective, randomized, single-blind, in vivo study

Background:

The primary physiologic function of platelets is to facilitate hemostasisby aggregation. Volatile anesthetics have been reported to decrease platelet aggregation in vivo and in vitro.

Objective:

The aim of this study was to investigate the hematologic effectsof the anesthetics isoflurane, sevoflurane, and desflurane on hemoglobin (Hb), hematocrit (Hct), platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and platelet aggregation after minor surgery.

Methods:

Patients aged 20 to 60 years who were scheduled to undergominor surgery and American Society of Anesthesiologists physical status P1 or P2 (healthy or mild systemic disease) were randomized to 1 of 3 groups: 1 minimum alveolar concentration (MAC) of isoflurane, sevoflurane, or desflurane. None of the patients received premedication. Anesthesia was induced using IV thiopental 5 to 6 mg/kg, fentanyl 1 to 2 μg/kg, and vecuronium 0.1 mg/kg, and maintained with 1 MAC of isoflurane, sevoflurane, or desflurane in 66% nitrous oxide and 33% oxygen. Vecuronium 0.03 mg/kg was given when necessary for muscle relaxation. All patients were monitored throughout surgery; isotonic saline was given at a rate of 5 mL/kg · h. Hematologic studies were performed preoperatively, 15 minutes after intubation, and 1 hour after the end of surgery. Platelet aggregation tests were performed in a laboratory using a platelet function analyzer (PFA), collagen/epinephrine PFA test cartridges, collagen/adenosine diphosphate PFA test cartridges, and PFA trigger solution.

Results:

This prospective, randomized, single-blind, in vivo study was conducted at Gevher Nesibe Teaching Hospital, Erciyes University, Kayseri, Turkey. Thirty patients (15 men, 15 women) were randomized to the 3 treatment groups (each, n = 10). Hb, Hct, platelet count, aPTT, PT, and INR were statistically similar between all 3 groups. The measured parameters were not significantly different between the isoflurane and desflurane groups at any time point. However, in the sevoflurane group, mean (5D) platelet aggregation was significantly delayed 15 minutes after intubation and 1 hour after surgery compared with the preoperative values (collagen/epinephrine, 81.70 [9.85] seconds vs 196.20 [27.84] seconds and 115.40 [25.80] seconds; both, P < 0.05).

Conclusions:

In this study of the effects of isoflurane, sevoflurane, and desflurane in patients undergoing minor surgery, clinically relevant antithrombotic effects were observed 15 minutes after intubation with all 3 drugs, although the effects in patients receiving sevoflurane were significantly greater compared with those in patients receiving isoflurane and desflurane. The antithrombotic effects of isoflurane and desflurane were not continued at 1 hour after surgery; however, the inhibitory effects of sevoflurane on platelet function were continued at 1 hour after surgery but were significantly decreased from levels found at 15 minutes after intubation.     

Support for Australian carers from community pharmacy: Insight into carer perspectives of a novel service

The feasibility of an individualised carer support service delivered in community pharmacies was assessed from the perspective of carer participants using a pre–post questionnaire and semistructured interviews. Eligible pharmacies were required to offer a medication management service relevant to carers and have a semiprivate space for conversations. Carers were required to self‐identify as an unpaid support person for someone with a chronic condition or disability. Between September 2016 and March 2017, staff from 11 community pharmacies in South‐East Queensland, Australia were trained, and provided with ongoing mentoring from a pharmacist and carer to support service implementation. Identification of carers and support to achieve a personal and care‐giving goal were key features of the service. Questionnaires included the EQ‐5D‐3L, the Bakas Caregiving Outcomes Scale, and questions relating to goal achievement, carer roles, and responsibilities. Seven follow‐up carer interviews were undertaken between March and May 2017 and analysed thematically. Pre–post questionnaires were available for 17 carers (one withdrew, two incomplete). Of the 29 goals set, 10 were achieved and 14 partially achieved. EQ‐5D‐3L scores were unchanged, while 7 of the 15 items comprising the Bakas score improved (p < 0.05). Carer service evaluation was generally favourable, and these two main interview themes were the impact of caring and pharmacy experience. The impact of caring, while variable, was significant. Pharmacy experiences were mostly positive and the opportunity for carers to further engage with pharmacy staff was appreciated. The service was feasible and initial reported benefits to carers may support further research potentially in terms of a larger controlled trial.     

The effects of percutaneous nephrolithotomy on renal function in geriatric patients in the early postoperative period

Since percutaneous nephrolithotomy (PNL) is a surgical intervention, it may show deteriorative effects on renal function in the early postoperative period. In this study, the deteriorative effects of PNL on renal function were investigated in the geriatric population, and it was compared to the non-geriatric population. A total of 711 patients [64 in the geriatric group (female/male ratio: 33/31, mean age: 70.4 ± 4.2 years), 647 in the non-geriatric group (female/male ratio: 267/380, mean age: 40.9 ± 12.7 years)] were included in the study. Demographic data, biochemical parameters, stone diameters, duration of the operation and estimated glomerular filtration rates (eGFR) were recorded both preoperatively and postoperatively. The eGFR ratio (post-/preoperative) was 1.13 ± 1.00 in the geriatric group, 0.98 ± 0.20 in the non-geriatric group (P < 0.001). Although the mean stone diameter was larger in the geriatric group than the non-geriatric group (10.08 ± 6.5 mm, 8.28 ± 5.54 mm, P = 0.037), the mean duration of the operation was shorter in the geriatric group than in the non-geriatric group (55.7 ± 13.6 min, 61.3 ± 20.9 min, P = 0.036). Hematocrit, hemoglobin, urea levels, and grade of hydronephrosis were not different between the groups. Renal function impairment is expected to be common in the geriatric patient population since they already have lower basal renal function. In the present study, the ratio of postoperative to preoperative eGFR was higher in the geriatric group. Hematocrit, hemoglobin, and urea levels and degree of hydronephrosis of these two groups did not show a great difference. The relatively short duration of the operation in the geriatric group and the diversity of perioperative and postoperative care of these two groups may explain the difference.     

Primary aldosteronism

Primary aldosteronism is caused by autonomous overproduction of aldosteron in the adrenocortical cells ofzona glomerulosa. It is the most frequent form of endocrine hypertension. The morphologic base of this disorder are tumorous, or hyperplastic changes of the adrenal gland. Syndrome is divided into more well-defined pathogenetic forms. Therapy that we use is conservative, or surgical. Success of treatment depends on the correct diagnosis of pathogenetic form and on the duration of hypertension.     

Transsellar transsphenoidal rhino-oral encephalocele

Transsphenoidal encephaloceles are rare and the transsellar variety is the least common. We present a 1-year-old male patient with transsellar transsphenoidal encephalocele which herniated into the oral cavity through the congenital split palate. The patient was operated on using a combined transcranial and transpalatal approach without mortality or permanent morbidity. Clinical findings, imaging reviews, surgical repair techniques and postoperative morbidity are discussed with the relevant literature. We conclude that repair of a transsphenoidal encephalocele should be coordinated between a team of neurosurgeons and otorhinolaryngologists. Our surgical outcome supports a transcranial approach for the treatment of these difficult lesions, with transpalatal dissection and exposure.