J. P. Mulier

Ideal versus corrected body weight for dosage of sugammadex in morbidly obese patients: Sugammadex dose in the morbid obese

To date, the dosing of sugammadex is based on real body weight without taking fat content into account. We compared the reversal of profound rocuronium‐induced neuromuscular blockade in morbidly obese patients using doses of sugammadex based on four different weight corrections. One hundred morbidly obese patients, scheduled for laparoscopic bariatric surgery under propofol‐sufentanil anaesthesia, were randomly assigned four groups: ideal body weight; ideal body weight + 20%; ideal body weight + 40%; and real body weight. Patients received sugammadex 2 mg.kg−1, when adductor pollicis monitoring showed two responses. The primary endpoint was full decurarisation. Secondary endpoints were the ability to get into bed independently on arrival to the post‐anaesthetic care unit and clinical signs of residual paralysis. There was no residual paralysis in any patient. Morbidly obese patients can safely be decurarised from rocuronium‐induced neuromuscular blockade T1‐T2 with sugammadex dosed at 2 mg.kg−1 ideal body weight + 40% (p < 0.0001).

Anesthesia for craniotomy: Total intravenous anesthesia with propofol and alfentanil compared to anesthesia with thiopental sodium, isoflurane, fentanyl, and nitrous oxide

STUDY OBJECTIVE To compare a total intravenous (IV) anesthetic technique based on propofol and alfentanil with a commonly used anesthetic technique for craniotomy. DESIGN Open-label, randomized, clinical study. SETTING Neurosurgical clinic at a university hospital. PATIENTS Forty patients, aged 18 to 55 years, scheduled for brain tumor surgery. INTERVENTIONS In 20 patients, anesthesia was induced with fentanyl and thiopental sodium and maintained with fentanyl, dehydrobenzperidol, isoflurane, nitrous oxide (N2O), and a thiopental sodium infusion. Twenty patients were anesthetized with a propofol loading infusion followed by a maintenance infusion at a fixed rate. In addition, alfentanil was administered as a loading bolus, followed by a variable-rate infusion, with additional doses as necessary to maintain hemodynamic stability. MEASUREMENTS AND MAIN RESULTS A decrease in blood pressure (BP) after induction with thiopental sodium was followed by a significant increase in BP and heart rate (HR) during intubation. BP and HR did not change during the propofol loading infusion. However, the administration of alfentanil was followed by a similar decrease in BP with a return to baseline values during the intubation period. Return of normal orientation (7 +/- 5 minutes vs 27 +/- 23 minutes) and concentration (12 +/- 12 minutes vs 35 +/- 37 minutes) was shorter and more predictable for the propofol-alfentanil-treated patients than for the thiopental sodium patients. Maintenance propofol concentration (nine patients) was between 3 +/- 0.69 micrograms/ml and 3.36 +/- 1.17 micrograms/ml, while the concentration at awakening was 1.09 microgram/ml. Alfentanil concentration at extubation (nine patients) was 79 +/- 34 ng/ml. CONCLUSION A total IV anesthetic technique with propofol and alfentanil is a valuable alternative to a more commonly used technique based on thiopental sodium, N2O, fentanyl, and isoflurane.

Interaction of antibiotics on pipecuronium-induced neuromuscular blockade

STUDY OBJECTIVE To measure the interaction of two antibiotics (clindamycin and colistin) on neuromuscular blockade induced by pipecuronium bromide (a new long-acting, steroidal, nondepolarizing neuromuscular blocking drug). DESIGN Prospective, randomized, placebo-controlled study. SETTING Inpatient gynecologic and gastroenterologic service at a university medical center. PATIENTS Three groups of 20 ASA physical status I and II patients with normal kidney and liver function, taking no medication, and undergoing elective surgery under general anesthesia. INTERVENTIONS Anesthesia was induced with propofol and alfentanil intravenously (IV) and maintained with a propofol infusion and 60% nitrous oxide in oxygen. Pipecuronium bromide 50 micrograms/kg was administered after reaching a stable baseline of single-twitch response. At 25% recovery of pipecuronium-induced neuromuscular blockade, patients received one of two antibiotics, clindamycin 300 mg or colistin 1 million IU, or a placebo. MEASUREMENTS AND MAIN RESULTS The recovery index (RI, defined as time from 25% to 75% recovery of neuromuscular blockade) was measured using the single-twitch response of the adductor pollicis muscle with supramaximal stimulation of the ulnar nerve at the wrist. RI after administration of an antibiotic (given at 25% recovery) was measured and compared with RI of the control group using Students unpaired t-test. Statistical analyses of the results showed a significant prolongation of the recovery time (from 25% to 75% recovery) of 40 minutes for colistin. CONCLUSIONS When this type of antibiotic is used during anesthesia with pipercuronium as a muscle relaxant, one must be aware of a significant prolongation of an already long-acting neuromuscular blockade and (although not observed in this study) possible problems in antagonism.

Comparison of eltanolone and propofol on a pressure-volume analysis of the heart.

We designed a randomized study to compare the effect of eltanolone and propofol on cardiac contractility.Patients were anesthetized, tracheally intubated and ventilation controlled. Propofol, 1.25 or 2.5 mg/kg, or eltanolone, 0.5 or 1 mg/kg, or a lipid emulsion only was administered in an intravenous (IV) bolus dose. Pressure-volume analysis was used based on radial artery pressure and transesophageal left ventricular cross-sectional area. Both propofol and eltanolone have negative inotropic properties in humans. We conclude that equianesthetic doses of these drugs produce similar changes in myocardial contractility. (Anesth Analg 1996;83:233-7)

Comparison of the cardiovascular effects of cisatracurium and vecuronium in patients with coronary artery disease

PurposeCisatracurium besylate (Nimbex® Injection, Glaxo Wellcome Inc., Research Triangle Park, NC) is an intermediate-acting bis-benzylisoquinolinium neuromuscular blocking drug that is one of the stereoisomers of atracurium. At doses ≤. 8 × ED95, it caused no clinically important cardiovascular side effects or histamine release in healthy patients. The purpose of the present study was to investigate the haemodynamic effects of high doses of cisatracurium in patients with coronary artery disease.MethodsOne hundred patients undergoing myocardial revascularization participated in a pilot study (seven patients) and a double-blinded, randomized, controlled trial comparing the haemodynamic effects of cisatracurium with vecuronium at three centres. The patients were anaesthetized using oxygen 100%, with etomidate, fentanyl and a benzodiazepine, and tracheal intubation was facilitated using succinylcholine. After baseline haemodynamic measurements, the study drug was administered over 5–10 sec according to group assignment: Group A (pilot) cisatracurium, 0.20 mg·kg−1 (4 × ED95), (n = 7); Group B-cisatracurium, 0.30 mg·kg−1 (6 × ED95), (n = 31); Group C-vecuronium, 0.30 mg·kg−1 (6 × ED95), (n = 31); Group D cisatracurium, 0.40 mg·kg−1 (8 × ED95), (n = 21); Group E-vecuronium, 0.30 mg·kg−1 (6 × ED95), (n = 10). The haemodynamic measurements were repeated at 2, 5, and 10 min after cisatracurium or vecuronium.ResultsTwo patients in Group D had > 20% decreases in MAR but only one required therapy for hypotension. The haemodynamic changes from pre-to post-injection in the cisatracurium patients were minimal and similar to patients receiving vecuronium.ConclusionsIn patients with coronary artery disease, rapid cisatracurium (4-8×ED95) boluses and vecuronium (6×ED95) result in minor, clinically insignificant haemodynamic side effects.RésuméObjectif Le bésylate de cisatracurium (Nimbex® Injection, Glaxo Wellcome Inc., Research Triangle Park, NC) est un myorelaxant di-benzylisoquinolinium à action intermédiaire qui est un des stéréo-isomères de l’atracurium. En doses de ≤ 8 × ED 95 , il ne cause pas d’effets secondaires cardiovasculaires importants ou de libération d’histamine chez les patients en santé. L’objectif de la présente étude était d’examiner les effets hémodynamiques de fortes doses de cisatracurium chez des patients souffrant d’insuffisance coronarienne.MéthodesCent patients devant subir une revascularisation myocardique ont participé à une étude pilote (sept pa tients), et à un essai contrôlé en double insu et randomisé, où ont été comparés les effets hémodynamiques du cisatracurium et du vécuronium dans trois centres. Les patients ont reçu une anesthésie avec de l’oxygène 100 %, avec étomidate, fentanyl et une benzodiazépine; on a utilisé de la succinylcholine pour faciliter l’intubation endotrachéale. Après les mesures hémodynamiques de départ, le médicament à l’étude a été administré pendant 5 à 10 secondes selon l’attribution du groupe: Groupe A (pilote) cisatracurium, 0,20 mg·kg−1 (4 × ED95), (n = 7); Groupe B-cisatracurium, 0,30 mg·kg−1 (6 × ED95), (n = 31); Groupe C-vécuronium, 0,30 mg·kg−1 (6 x ED95), (n = 31); Groupe D cisatracurium, 0,40 mg·kg−1 (8 × ED95), (n = 21); Groupe E-vécuronium, 0,30 mg·kg−1 (6 × ED95), (n = 10). Les mesures hémodynamiques ont été reprises 2, 5 et 10 min après l’administration de cisatracurium ou de vécuronium.RésultatsDeux patients du Groupe D ont présenté une baisse > 20% de la TAM, mais aucune thérapie pour l’hypotension n’a été nécessaire. Les changements hémodynamiques survenus entre la préinjection et la postinjection ont été minimes et semblables chez les patients ayant reçu le cisatracurium ou le vécuronium.ConclusionChez les patients souffrant d’insuffisance coronarienne, l’administration rapide de bolus de cisatracurium (4-8 × ED95) et de vécuronium (6 × ED65) n’a produit que des effets secondaires hémodynamiques mineurs, peu significatifs sur le plan dinique.

A one-step conversion from gastric banding to laparoscopic Roux-en-Y gastric bypass is as safe as a two-step conversion: A comparative analysis of 885 patients

Abstract Aims: To achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (LAGB) can be converted to a laparoscopic Roux-en-Y gastric bypass (RYGB). There is limited data on the feasibility and safety of routinely performing a single-step conversion. We assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution. Methods: Between October 2004 and December 2015, a total of 885 patients who underwent LAGB removal with RYGB were identified from a prospectively collected database. In all cases, a single-stage conversion procedure was planned. The feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed. Results: A single-step approach was successfully achieved in 738 (83.4%) of the 885 patients. During the study period, there was a significant increase in performing the conversion from LAGB to RYGB single-staged. No mortality or anastomotic leakage was observed in both groups. Only 45 patients (5.1%) had a 30-d complication: most commonly hemorrhage (N = 20/45), with no significant difference between the groups. Conclusion: Converting a LAGB to RYGB can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. With increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. Only a migrated band remains a formal contraindication for a one-step approach.

Factors determining the smooth flow and the non-operative time in a one-induction room to one-operating room setting.

Rationale, aims and objectives What factors determine the use of an anaesthesia preparation room and shorten non-operative time? Methods A logistic regression is applied to 18 751 surgery records from AZ Sint-Jan Brugge AV, Belgium, where each operating room has its own anaesthesia preparation room. Surgeries, in which the patients induction has already started when the preceding patients surgery has ended, belong to a first group where the preparation room is used as an induction room. Surgeries not fulfilling this property belong to a second group. A logistic regression model tries to predict the probability that a surgery will be classified into a specific group. Non-operative time is calculated as the time between end of the previous surgery and incision of the next surgery. A log-linear regression of this non-operative time is performed. Results It was found that switches in surgeons, being a non-elective surgery as well as the previous surgery being non-elective, increase the probability of being classified into the second group. Only a few surgery types, anaesthesiologists and operating rooms can be found exclusively in one of the two groups. Analysis of variance demonstrates that the first group has significantly lower non-operative times. Switches in surgeons, anaesthesiologists and longer scheduled durations of the previous surgery increases the non-operative time. A switch in both surgeon and anaesthesiologist strengthens this negative effect. Only a few operating rooms and surgery types influence the non-operative time. Conclusion The use of the anaesthesia preparation room shortens the non-operative time and is determined by several human and structural factors.

What are the Challenges of Laparoscopy in Morbid Obese Patients

Laparoscopic surgery requires the insufflation of carbon dioxide in the peritoneal cavity under pressure to create sufficient surgical workspace. The physiologic effects of pneumoperitoneum include systemic absorption of CO2 and physiologic alteration in respiratory and cardiovascular homeostasis due to the increased intraabdominal pressure. Few studies have examined the effects of CO2 pneumoperitoneum in the morbidly obese. There is frequently insufficient workspace. High insufflation pressures can help but further challenge the respiratory and hemodynamic function. We first looked at how to measure the surgical workspace. We searched for what the laparoscopic surgeons need for workspace. Are there objective measures that the surgical workspace is more limited in obese patients? We ended with questioning the methods available to improve the surgical workspace and to reduce the respiratory and hemodynamic problems in morbidly obese patients.

CARDIODYNAMIC EFFECTS OF PROPOFOL IN COMPARISON TO THIOPENTAL: ASSESSMENT WITH A TRANSESOPHAGEAL ECHOCARDIOGRAPHIC APPROACH

In 40 patients, the cardiovascular effects of low- and high-dose propofol anesthesia (single bolus of 2.5 mg/kg in group A, 2.5 mg/kg in group C) were examined and compared with those of low- and high-dose thiopental (4 mg/kg in group B, 6.5 mg/kg in group D) (n = 10 patients per group). After induction of anesthesia with etomidate, all patients were ventilated with 70% nitrous oxide in oxygen. Peripheral arterial systolic blood pressure (SAP) and transesophageal echocardiographic short-axis measurements were used to calculate the end-systolic pressure-volume relationship (E) as an index of global myocardial contractility. In all groups SAP decreased significantly below baseline levels for the duration of the measurements (15 min after drug administration), except for the lower dose of thiopental, where SAP returned to baseline values within 10 min. Propofol at a dose of 1.5 mg/kg significantly decreased cardiac output (CO) (from 5.1 t 0.25 [mean ± SEM] to 4.2 ± 0.23 L/min), stroke volume (SV) (from 64 ± 3 to 56 ± 3.6 mL), and the slope of E (from 71 ± 3.5 to 65 ± 4.2 mm Hg/mL) until 4 min after drug administration.The higher dose of propofol significantly decreased CO (from 5.1 ± 0.29 to 4.1 ± 0.26 L/min), SV (from 64 ± 3 to 52 ± 4.6 mL), and the slope of E (from 71 ± 3.6 to 62 ± 3.7 mm Hg/mL) until 20 min after drug administration. End-systolic volume increased significantly (from 60 ± 7.6 to 68 ± 5.5 mL) until the sixth minute, followed by a decrease in end-diastolic volume at 10 min (from 124 ± 6.5 to 118 ± 4.3 mL).Thiopental at a dose of 4 mg/kg reduced end-diastolic volume significantly at 10 min (118 ± 7.2 versus 128 ± 7.8 mL) and resulted in a significantly higher CO (4.6 ± 0.29 versus 4.2 ± 0.23 L/min) and the slope of E (69 ± 3.9 versus 65 ± 4.2 mm Hg/mL) when compared with low-dose propofol at 4 min. Thiopental at a dose of 6.5 mg/kg significantly reduced the index of afterload (SAP/SV) (from 63 ± 5 to 56 ± 4.6 mm Hg/mL) and the slope of E (from 69 ± 4.2 to 63 ± 3.6 mm Hg/mL), whereas heart rate increased (from 76 ± 5.2 to 84 ± 6.8 beats/min) until the fourth minute after drug administration. When compared with high-dose propofol, end-systolic volume was significantly lower and SAP, SV, CO, and slope of E were significantly higher during thiopental at equipotent doses.It is concluded that propofol reduces SAP mainly through its negative inotropic properties. Furthermore, the cardio-depressant effects of propofol are more pronounced and more prolonged than those of equipotent doses of thiopental when given as a single bolus.

Is it possible to measure the abdominal pressure-volume relation with three points?: A-127

A-127 Is it possible to measure the abdominal pressure-volume relation with three points? J.P. Mulier1, S. Van Cauwenberge2, B. Dillemans2 1Department of Anaesthesiology, 2Department of Surgery, AZ Sint-JanAV Brugge, Belgium Background and Goal of Study: The abdominal pressure-volume relation (APVR) can be calculated by measuring many pressure-volume points during insufflation. This relation was proven to be linear giving an m and b factor. The APVR might be measured repeatedly during laparoscopy but this takes a lot of work and time. Measuring three points of the relation should be sufficient and fast to find the APVR. Goal of this study was to test this hypothesis. Materials and Methods: 10 patients, ASA class I or II, between 21 and 75 years old, without any abdominal intervention and scheduled for a laparoscopic surgery were included in this study with approval from the hospital ethical committee. Anaesthesia was induced with Propofol 200 mg, Sufentanil 20 g, Nimbex 0.2 mg/kg and Sevoflurane 1.5 Mac in a 50% O2/N2O. Patients were asked to empty the bladder before surgery. The stomach was emptied by suction through a gastric tube. All the CO2 was allowed to escape after insertion of the trocar. The insufflator Olympus UHI-3 was initialised and a stepwise insufflation at a flow of 1 l/min was given. Measurements were taken every 100 ml till the abdominal pressure reached 15 mmHg. All the CO2 was then allowed to escape. The insufflator was reinitialised and a high flow insufflation till 7, 11 and 15 mmHg was given. At each pressure set the actual pressure and volume was measured when the flow stopped. The multipoints and the three points measurements were each fitted by a line giving an m, m and b, b . The m’s and b’s were compared by a paired t-test. Results and Discussions: No statistical significant difference was found between both groups. Conclusion(s): The APVR can be measured by three points initial and during the procedure. This allows measurements in all patients and a rapid evaluation during the procedure.