Philippe Randour

Propofol-alfentanil versus fentanyl-midazolam in coronary artery surgery.

OBJECTIVE To compare intraoperative hemodynamics profiles and recovery characteristics of propofol-alfentanil with fentanyl-midazolam anesthesia in elective coronary artery surgery. DESIGN Prospective, randomized study. SETTING University hospital. PARTICIPANTS Fifty patients with impaired or good left ventricular function. INTERVENTIONS In group 1, (n = 25) anesthesia was induced with an infusion of propofol, 3 to 4 mg/kg/h, alfentanil, 500 micrograms, and pancuronium 0.1 mg/kg, and maintained with propofol, 3 to 6 mg/kg/h (variable rate), and alfentanil infusions, 30 micrograms/kg/h (fixed rate). Additional boluses of alfentanil, 1 mg, were administered before noxious stimuli; group 2 (n = 25) received a loading dose of fentanyl, 25 micrograms/kg, midazolam, 1.5 to 3 mg, and pancuronium, 0.1 mg/kg for induction, followed by an infusion of fentanyl, 7 micrograms/kg/h, for maintenance. Additional boluses of midazolam (1.5 to 3 mg) and fentanyl (250 micrograms) were administered before noxious stimuli. MEASUREMENTS AND MAIN RESULTS. Cardiovascular parameters at eight intraoperative time points as well as time to extubation, morphine consumption, and pain scores were recorded. Induction of anesthesia was associated in both groups with a small but significant decrease in mean arterial pressure (1: 15 mmHg (15%); 2: 8 mmHg (8%) with significant decreases in cardiac index (1: 8%; 2: 8%) and left ventricular stroke work index (1: 24%; 2: 21%). Throughout surgery, hemodynamic profiles were comparable between groups except after intubation when the MAP was significantly lower in group 1 (75 +/- 12 mmHg) than in group 2 (89 +/- 17 mmHg). Group 1 required less inotropic support. Extubation was performed faster in group 1 (7.6 h) than in group 2 (18.0 h). Morphine requirements and pain scores were comparable between groups. CONCLUSIONS Propofol-alfentanil anesthesia provides good intraoperative hemodynamics and allows early extubation after coronary artery surgery.

Hemodynamic benefit of optimizing atrioventricular delay after cardiopulmonary bypass.

BACKGROUND Shortening of atrioventricular delay (AVD) by sequential cardiac pacing has been proposed to improve hemodynamics in patients with end-stage heart failure. In addition, optimization of prolonged AVD may be associated with a decrease of presystolic mitral insufficiency. The aim of this study was to explore the incidence of prolonged AVD during the early postcardiopulmonary bypass (CPB) period and to evaluate the hemodynamic benefit of its shortening by using sequential cardiac pacing. METHODS Fifty consecutive patients scheduled for coronary artery bypass grafting were prospectively screened. AVD was measured immediately after separation from CPB. Patients presenting with AVD greater than or equal to 200 ms entered the study. Sequential cardiac pacing was introduced with programmed AVD starting at 80 ms and randomly increased by steps of 20 ms until resumption of native anterograde atrioventricular node conduction. Cardiac index (CI) was derived from transesophageal echocardiographic data during each step of this procedure. RESULTS Nineteen patients were included. Median native AVD was 220 ms. Median optimal AVD was 140 ms. Mean native CI (CI-nat) was 2.59 +/- 0.42 L/min/m2. Mean optimal CI (CI-opt) was 3.12 +/- 0.45 L/min/m2. CI-opt/CI-nat was 1.20 +/- 0.07. CI-opt/CI-nat was significantly inversely correlated with preoperative left ventricular ejection fraction (r = -0.83). CONCLUSIONS Prolonged AVD is a common occurrence after CPB. Its artificial shortening by sequential cardiac pacing is always associated with a significant increase of CI. The magnitude of this hemodynamic improvement is inversely correlated with preoperative left ventricular ejection fraction.

Neuralgia following lumbar sympathectomy.

Between March and October 1986, 33 consecutive patients underwent unilateral lumbar sympathectomy in the Thoracic and Cardiovascular Surgical Unit of the Catholic University in Louvain, Belgium. Ten patients experienced postsympathectomy neuralgia. After a single epidural injection of fentanyl, 50 micrograms, and methylprednisolone 80 mg, pain disappeared completely in six patients. Neuralgia recurred in four patients requiring repeat epidural injection with relief of residual symptoms. Epidural infiltration is a reliable treatment for neuralgia after lumbar sympathectomy.

Intravenous infusion of propofol for induction and maintenance of anaesthesia during endoscopic carbon dioxide laser ENT procedures with high frequency jet ventilation.

Fourteen patients of ASA grades 1 3 were anaesthetised with continuous infusions of propofol and alfentanil for endoscopic carbon dioxide laser ENT microsurgery. Their lungs were ventilated with an oxygen‐air mixture using a high frequency jet ventilator. Propofol was given at an initial rate of 120 μg/kg/minute for 10 minutes after a bolus dose of 2.6 mg/kg, and then at 80 fig μg/kg/minute. Alfentanil was given at a rate of 0.5 μg/kg/minute. Arterial pressure decreased significantly after the bolus dose. It increased significantly for a few minutes after laryngoscopy and returned to baseline values during maintenance of anaesthesia. Heart rate increased significantly during induction and until laryngoscopy was performed but it decreased below its initial value after 5 minutes of maintenance. Platelet count and the degree of aggregation did not change during infusion of propofol.

Regional increment in myocardial reflectivity after aortic valve replacement: early detection of air and assessment of treatment by transesophageal echocardiography.

IR EMBOLISM during cardiac surgery is a common occurrence and may be responsible for neurologlc and cardiac complications. This case report illustrates how transesophageal echocardiography (TEE) showed the regional increment in myocardial reflectlvity secondary to coronary air embolism and how TEE momtoring aided in detecting the efficacy of maneuvers to remove the air. CASE REPORT A 56-year-old man was scheduled for an aortic valve replacement. He had a history of severe aortic valvular stenosis with a mean transaortlc gradient of 56 mmHg and an aortic valve area of 0.63 cm 2. Coronary angiogram was normal with a left ventricular ejection fraction of 60%. After induction of anesthesia, a multiplane TEE probe, operating at 5 mHz, connected to an echocardiographlc system (Hewlett Packard SONOS 1000; Andover, MA), was inserted in a routine manner. After cross-clamping of the ascending aorta, anterograde cold hyperkalemic cardioplegia was administered, followed by intermittent retrograde cold hyperkalemic cardioplegia. Cardiopulmonary bypass (CPB) was performed under mild systemic hypothermia (34.8°C). The aortic valve was replaced by a mechanical prosthetic valve (St Jude 23 ram). Before unclamping of the aorta, passive filling of the left ventricle (LV), venting through a needle inserted in the ascending aorta and manual inflation of the lungs were performed with the patient head down. The passive filling was still low, and the accumulated air in the heart was not detected by TEE at that time. Immediately after unclamping of the aorta, the TEE detected microbubbles coming from the left atrium and massively from the right pulmonary veins. Although the venting was maintained, with the heart beating, an abrupt increase in myocardial reflectivity was observed (Fig 1). This myocardial opacification involved right ventricular and septal walls and was followed by significant ST-segment elevation in inferior leads on the electrocardiogram (ECG) (Fig 2). Severe depression of the regional LV function occurred, followed by severe distention of the LV cavity and by refractory ventricular fibrillation. It was decided to clamp the ascending aorta again in order to avoid systemic air embolism and to administer crystalloid retrograde cardioplegia (300 mL) to eliminate the intracoronary air, while the heart was manipulated in