Brian Fredman

The effect of tourniquet application, tranexamic acid, and desmopressin on the procoagulant and fibrinolytic systems during total knee replacement

STUDY OBJECTIVE To assess the influence of tourniquet inflation-deflation as well as desmopressin and tranexamic acid (TA) administration on prothrombin fragment 1.2, fibrinogen, plasmin antiplasmin complex, and D-dimer concentrations during total knee replacement. DESIGN Randomized, placebo-controlled study. SETTING Large referral hospital. PATIENTS 30 ASA physical status I, II, and III patients undergoing total knee replacement. INTERVENTIONS Patients were randomized to one of three treatment groups. Patients received either tranexamic acid, desmopressin, or an equal volume of saline, intravenously. MEASUREMENTS AND MAIN RESULTS Cubital blood was drawn immediately before induction of anesthesia, 1 hour after tourniquet application, and 2 and 15 minutes after tourniquet deflation. Fibrinogen and D-dimer levels were measured using the Clauss Method and latex agglutination, respectively. Plasmin antiplasmin complex and prothrombin fragment 1.2 levels were measured by enzyme-linked immunosorbent assay (ELISA). All assays were performed in duplicate, and intra-assay variability was documented. No statistically significant difference in fibrinogen, D-dimer, plasmin antiplasmin complex, or prothrombin fragment 1.2 levels was demonstrated among the groups. Similarly, within each group there were no statistically significant differences in the variables studied. However, despite the lack of statistical significance, when compared with their levels during tourniquet application, an increase in D-dimer and plasmin antiplasmin complex levels was observed in all three groups at 2 and 15 minutes after tourniquet release. In contrast, no increase in prothrombin fragment 1.2 generation was noted. Significantly more allogeneic blood was transfused in the Control and Desmopressin Groups when compared with the tranexamic acid group (p< 0.02). CONCLUSIONS No evidence of tourniquet-induced fibrinolysis or thrombin generation was demonstrated in the systemic circulation. Desmopressin and tranexamic acid had no significant effect on the variables measured.

Bispectral index monitoring does not improve early recovery of geriatric outpatients undergoing brief surgical procedures

PurposeTo assess if titration of sevoflurane using the bispectral index (BIS) monitor improves the early and intermediate recovery in geriatric outpatients undergoing brief urologic procedures under general anesthesia without muscle relaxants.MethodsAfter a standardized induction with propofol and fentanyl, a laryngeal mask airway was inserted and sevoflurane was administered in combination with 60% nitrous oxide in oxygen for maintenance of anesthesia in spontaneously breathing outpatients. In the Control group (n = 25), sevoflurane and fentanyl were titrated according to standard clinical practice. In the BIS directed group (n = 25), sevoflurane was titrated to maintain a BIS value between 50 and 60, and supplemental fentanyl, 25 μgiv boluses were administered to treat tachypnea. The intraoperative anesthetic and analgesic requirements, as well as the times to eye opening, removal of the laryngeal mask airway device, response to simple commands, orientation to person and place, and postanesthesia care unit discharge eligibility (fast-track score of 14) were assessed at specific time intervals.ResultsThe minimum alveolar concentration-hour of sevoflurane (0.25 ± 0.15 and 0.31 ± 0.2) and end-tidal concentrations of sevoflurane at the end of surgery (0.3 ± 0.3 and 0.4 ± 0.20%) did not differ significantly between the Control and BIS-directed groups, respectively. Although the percentage of patients requiring supplemental boluses of fentanyl was reduced in the BIS directed group (16vs 48%,P <0.05), the intraoperative BIS values and recovery times were similar in the two groups.ConclusionIn this non-paralyzed elderly outpatient surgery population, the use of BIS monitoring for titrating the maintenance anesthetic (sevoflurane) failed to improve the early recovery process.RésuméObjectifÉvaluer si le titrage du sévoflurane à ľaide d’un moniteur d’index bispectral (BIS) améliore la récupération précoce et intermédiaire des patients ambulatoires âgés après une brève intervention urologique sous anesthésie générale sans myorelaxants.MéthodeAprès une induction normalisée avec du propofol et du fentanyl, un masque laryngé a été inséré et le sévoflurane administré en combinaison avec un mélange de protoxyde d’azote et d’oxygène à 60 % pour maintenir ľanesthésie chez des patients en ventilation spontanée. Dans le groupe témoin (n = 25), le sévoflurane et le fentanyl ont été dosés selon la pratique courante. Dans le groupe sous monitorage BIS (n = 25), le dosage visait à maintenir une valeur de BIS entre 50 et 60, et du fentanyl complémentaire, en bolus de 25 μg iv, a été administré pour traiter la tachypnée. ľanesthésique peropératoire et les besoins d’analgésiques, de même que le temps précédant ľouverture des yeux, le retrait du masque laryngé, la réponse à des commandes simples, la reconnaissance des gens et du lieu et la possibilité de quitter la salle de réveil (score séjour bref de 14) ont été notés à des intervalles spécifiques.RésultatsLa concentration-heure de sévoflurane (0,25 ± 0,15 et 0,31 ± 0,2) et les concentrations télé-expiratoires de fin d’opération (0,3 ± 0,3 et 0,4 ± 0,20 %) n’affichaient pas de différence significative entre les groupes témoin et de monitorage BIS respectifs. Le pourcentage de patients qui ont eu besoin de bolus complémentaires de fentanyl était plus bas avec le BIS (16 vs 48 %, P < 0,05), mais les valeurs peropératoires de BIS et le temps de récupération étaient similaires dans les deux groupes.ConclusionDans cette population de patients ambulatoires âgés, opérés sans myorelaxants, ľusage du monitorage BIS pour le titrage de ľanesthésique de maintien (sévoflurane) n’a pu améliorer la récupération précoce.

LONG-TERM INCIDENCE OF ACUTE MYOCARDIAL INFARCTION AFTER OPEN AND TRANSURETHRAL RESECTION OF THE PROSTATE FOR BENIGN PROSTATIC HYPERPLASIA

PURPOSE Acute myocardial infarction was found to be the main cause of increased long-term mortality in patients after transurethral compared to open prostatectomy in various retrospective studies. We performed a randomized prospective study to compare morbidity and incidence of acute myocardial infarction in patients after transurethral compared to open prostatectomy for benign prostatic hyperplasia. MATERIALS AND METHODS We studied 365 patients who were assigned to transurethral (236) or open (129) prostatectomy only according to the size of the prostate and who were followed for 7 to 8 years. The clinical status of the patients in both groups before and after the operation was compared, and the rate of myocardial infarction and long-term mortality was studied. RESULTS More patients with a history of cerebrovascular accident (5.4 versus 0.8%) and indwelling catheters (16.3 versus 7.6%) before the operation were in the open prostatectomy group. Among the 236 patients operated on transurethrally 31 were reoperated on (6 more than once) during followup compared to 4 of the 129 patients who underwent open prostatectomy. In 15 patients from the transurethral prostatectomy group myocardial infarction developed compared to 9 patients in the open prostatectomy group. This difference was not statistically significant. The rate of acute myocardial infarction after prostatectomy, no matter which approach was used, was greater than 6% and it appeared to be higher when compared to the rate of infarction in the general population of the same age group, which is approximately 2.5% in our county. There was no statistically significant difference in the overall mortality rate between the transurethral and open prostatectomy groups, which was 14.4 and 8.5% respectively. CONCLUSIONS Open prostatectomy is more effective in overcoming urinary obstruction than the transurethral approach. No significant differences in myocardial infarction or overall mortality rates were found between the 2 groups.

The opioid-sparing effect of diclofenac sodium in outpatient extracorporeal shock wave lithotripsy (ESWL)

STUDY OBJECTIVE To evaluate the opioid-sparing and analgesic effect of diclofenac sodium in ambulatory nonimmersion extracorporeal shock wave lithotripsy (ESWL). DESIGN Randomized, double-blind, placebo-controlled study. SETTING Large referral hospital. PATIENTS Twenty-seven ASA physical status I and II patients with upper renal tract nephrolithiasis. INTERVENTIONS ESWL was performed with a sedative-analgesic technique. Diclofenac sodium 75 mg or an equal volume of saline was given intramuscularly 45 minutes prior to the procedure. Fentanyl and midazolam were added to maintain adequate sedation and analgesia. MEASUREMENTS AND MAIN RESULTS Demographically, both groups were comparable. In the diclofenac sodium group, heart rate was slightly higher, treatment time was shorter, more shock waves were administered (p < 0.02), and less fentanyl was required (p < 0.02). Mean arterial pressure was lower and arterial oxygen saturation by pulse oximeter was higher in the diclofenac sodium group. There were no differences between the groups in voltage, stone size, fragmentation, dose of midazolam administered, or overall assessment by both the doctors and patients. CONCLUSIONS Patients administered diclofenac sodium received a greater number of shock waves, required less fentanyl, and showed a marginal improvement in hemodynamic stability and oxygenation during ambulatory nonimmersion ESWL.

The induction, maintenance, and recovery characteristics of spinal versus general anesthesia in elderly patients

STUDY OBJECTIVE To compare the induction and recovery profiles of three combinations of general anesthesia when used as an alternative to spinal anesthesia for elderly patients. DESIGN Randomized, prospective, open-label study. SETTING Large referral hospital. PATIENTS 100 [ASA physical status I, II, and III] patients over 60 years of age undergoing brief transurethral surgery. INTERVENTIONS In Groups Propofol-Propofol (P-P), Propofol-Isoflurane (P-I), and Propofol-Desflurane (P-D), anesthesia was induced with fentanyl (1 to 2 micrograms/kg i.v.) and propofol (1.0 to 2.0 mg/kg i.v.) and maintained with 70% nitrous oxide in oxygen and either a propofol infusion (75 to 150 micrograms/kg/min) or isoflurane (end-tidal 0.7% to 1.2%) or desflurane (end-tidal 1% to 4%), respectively. After induction, a laryngeal mask airway was placed and spontaneous ventilation was maintained. In Group Spinal (S), 1.5 ml 4% lidocaine (60 mg), in an equal volume of 10% dextrose, was administered intrathecally. MEASUREMENTS AND MAIN RESULTS Induction and recovery characteristics were compared. Induction with propofol was technically easier and significantly (medp < 0.0001) faster (4.6 +/- 1.7 min, 4.7 +/- 2.2 min, and 3.8 +/- 1.4 min for Groups P-P, P-I, and P-D, respectively) than induction of spinal anesthesia (9.3 +/- 3.4 min). During the induction period, mean arterial blood pressure and heart rate were significantly higher in Group S. Emergence, extubation, and orientation times were similar among the general anesthesia treatment groups. In Group S, patient-generated pain scores were lower (p < 0.05) and recovery room admission longer (p < 0.001). Time to return to baseline digit symbol substitution test (DSST) scores was marginally improved in Groups P-P and P-D when compared to Group P-I. Postoperative nausea, sleepiness, anxiety, and coordination were unaffected by the treatment modality. CONCLUSION General anesthesia with propofol and desflurane facilitates shorter induction and recovery times without adversely affecting patient comfort. Therefore, this technique may be preferable to spinal anesthesia for elderly patients undergoing short transurethral surgical procedures.

Surgical treatment of lumbar spinal stenosis in patients aged 65 years and older

Spinal stenosis syndrome affects mainly patients at their 5th-6th decades of life. The main goals of surgical treatment in the elderly are to allow the individual to walk longer distances, maintain the activities of daily living (ADL) and social life. Our aim was to evaluate the results of surgical treatment for lumbar spinal stenosis in elderly patients. All patients over 65 years of age who underwent surgery due to spinal stenosis syndrome between 1990 and 1998 were evaluated. There were 29 males and 17 females aged between 65 and 90 years. The clinical presentation included low back pain (89%), intermittent claudication (100%) and neurological involvement (87%). The radiological examination showed a frequent narrowing at the level L4-L5 in 93.5% of the patients. The results of the surgery in a mean follow-up of 22 months were good to excellent in 80% of the patients, fair in 11%, and poor in 9%. An improvement in the intensity of pain and in walking distances was noted in 89 and 85% of the patients, respectively. Improvement was achieved in the level of daily activity and in social lives in 57 and 61%, respectively. Major and minor complication rates were 6.5 and 19.5%, respectively. No mortality was noted in this series. Eighty-seven percent of the patients were satisfied with the results of the surgery. We conclude that Surgery for spinal stenosis is a successful and relatively safe procedure, also for patients aged over 65, and should be considered as a treatment option for these patients.

Delivery room analgesia: an analysis of maternal satisfaction

On the first post-partum day, 324 mothers completed a questionnaire designed to assess maternal perception of delivery room experience. Antenatal pain expectation, actual pain severity, analgesia received, as well as maternal satisfaction and choice of analgesia for future deliveries were recorded. Forty-five percent of primiparae and 36% of multiparae reported that they anticipated suffering extreme pain during delivery. The incidence of unbearable pain was similar among patients who received no analgesia or intravenous pethidine but significantly (P<0.0001) higher when compared to epidural analgesia. During the first stage of labour, continuous epidural analgesia was associated with severe or unbearable pain in 51% and 58% of primiparae and multiparae, respectively. The incidence of severe or unbearable pain during the second stage of labour was 43% and 46% for primiparae and multiparae, respectively. Patient satisfaction with epidural analgesia did not correlate with subjective pain scores. Among mothers who received continuous epidural analgesia 70% described their experience as good or excellent and 65.8% indicated that they would request similar pain relief in the future. Despite advances in obstetric analgesia, women anticipate and actually experience severe pain during childbirth. However, due to psychological and cultural factors, as well as possible post-partum euphoria, satisfaction with the delivery room experience is high.

Alternating patient position following the induction of obstetric epidural analgesia does not affect local anaesthetic spread

To assess the influence of gravity on epidural-induced sensory blockade during the first stage of labour, 60 parturients were recruited to a randomized, controlled, single-blinded study. In all cases an epidural catheter was placed with the patient in the left lateral position. Thereafter, patients were randomized to one of three groups. In group supine (S), the epidural injection was performed in the supine position with a 15-20 degrees right flank elevation and the patient remained supine. In group left (L) patients remained in the left lateral position for 10 min after injection. In group left and right (L+R) patients remained in the left lateral position for 5 min and then assumed the right lateral position for 5 min. Thereafter, in groups L and L+R patients lay supine with a 15-20 degrees right flank elevation. All patients received 50 microg fentanyl in 10 ml of 0.125% bupivacaine. Ten minutes after injection loss of pinprick and temperature sensation were assessed and pain scores measured. Height of sensory deficit 10 min after injection and after maximal blockade were unaffected by patient position. In all cases maximal blockade reached T8 or higher. Time to maximal block was 14.7 +/- 2.3 min, 14.1 +/- 1.6 min and 13.9 +/- 1.5 min for groups L, L+R and S respectively. After maximal blockade, pain scores were significantly (P<0.0001) decreased in all groups, with no differences between them. We conclude that position immediately following local anaesthetic drug administration has little effect on onset and distribution of epidural analgesia.

BUPIVACAINE INFILTRATION INTO THE NEUROVASCULAR BUNDLE OF THE PROSTATIC NERVE DOES NOT IMPROVE POSTOPERATIVE PAIN OR RECOVERY FOLLOWING TRANSVESICAL PROSTATECTOMY

PURPOSE We assessed the effect of intraoperative bupivacaine infiltration into the neurovascular bundle of the prostatic nerve on postoperative pain and patient outcome. MATERIALS AND METHODS The study included 40 American Society of Anesthesiologists physical status I to III patients undergoing transvesical prostatectomy. Following surgical resection of the prostate the neurovascular bundle of the prostatic nerve was infiltrated with either 10 ml. bupivacaine 0.5% or saline. Postoperative pain intensity was assessed using a patient generated 100 mm. visual analog scale and a patient controlled analgesia device. Additional analgesic requirements, time to ambulation, length of hospitalization and return to normal activity were also recorded. RESULTS There were no differences in visual analog scale for pain, patient controlled analgesia demands or actual morphine delivered. Similarly, saline versus bupivacaine infiltration did not influence ambulation time (21.3 +/- 2.7 versus 25.0 +/- 11.8 hours, respectively), length of hospitalization (7.06 +/- 0.8 versus 7.11 +/- 0.6 days, respectively), return to normal activity (14.4 +/- 8.8 versus 14.2 +/- 8.2 days, respectively) or patient satisfaction. On postoperative days 1 and 2 more patients in the saline treatment group requested additional oral analgesia compared to the bupivacaine treatment group. However, no statistical difference was demonstrated. CONCLUSIONS Following transvesical prostatectomy, prostatic nerve blockade has no beneficial effects on postoperative pain or patient outcome.

Effect of spinal versus general anesthesia on bladder compliance and intraabdominal pressure during transurethral procedures

STUDY OBJECTIVE To evaluate the influence of spinal versus general anesthesia on bladder compliance and intraabdominal pressure in elderly males undergoing elective transurethral resection of the prostate. DESIGN Prospective, randomized, open-label study. SETTING Teaching hospital. PATIENTS 21 ASA physical status I, II, and III patients at least 18 years of age, undergoing transurethral surgery. INTERVENTIONS According to a computer-generated randomization schedule, patients were allocated to one of two groups. In Group Spinal (S), 10 mg of hyperbaric tetracaine was administered intrathecally. In Group General Anesthesia (GA), patients received, fentanyl intravenous (i.v. 1 to 2 micrograms/kg and propofol i.v. 1.0 to 2.0 mg/kg for induction of anesthesia. Thereafter, a laryngeal mask airway was inserted and, with spontaneous ventilation, anesthesia was maintained by administering isoflurane (end-tidal 0.7% to 1.2%) and 70% nitrous oxide (N2O) in oxygen. Intraabdominal pressure and bladder compliance were recorded prior to the induction of anesthesia and immediately before the onset of the surgical procedure. MEASUREMENTS AND MAIN RESULTS The two groups were demographically comparable. In Group S, mean bladder compliance was significantly (p = 0.003) higher and mean intraabdominal pressure significantly lower (p = 0.007) when compared to baseline preanesthetic values. In Group GA, mean intraabdominal pressure significantly (p = 0.006) decreased when compared to baseline preanesthetic recordings. Following the induction of general anesthesia, a small change in bladder compliance was noted. However, statistical significance was not reached. Data were analyzed and compared using Students t-test (p < 0.05 was considered statistically significant). CONCLUSION Both spinal and general anesthesia induced a significant decrease in intraabdominal pressure. While both techniques were associated with an increase in bladder compliance, statistical significance was demonstrated only in the spinal anesthesia treatment group.