Sandra Kampe

Large-dose hydroxyethyl starch 130/0.4 does not increase blood loss and transfusion requirements in coronary artery bypass surgery compared with hydroxyethyl starch 200/0.5 at recommended doses.

Background Hydroxyethyl starch (HES) 130/0.4 may impair blood coagulation less than other HES solutions and, thus, may be used at larger doses without increasing the risk of postoperative bleeding. This study tested the hypothesis that volume replacement with 6% HES 130/0.4 at a dose of up to 50 ml/kg does not increase blood loss and transfusion requirements in elective coronary artery bypass surgery compared with 6% HES 200/0.5 at a dose of up to 33 ml/kg. Methods One hundred twenty adult patients scheduled for elective coronary artery bypass surgery were randomized to receive up to 50 ml/kg of 6% HES 130/0.4 or up to 33 ml/kg of 6% HES 200/0.5 for volume replacement during surgery and until 24 h thereafter. Volume requirements in excess of the respective maximum dose of HES were treated with gelatin. Colloid use was at the discretion of the attending physicians and not dictated by protocol. The primary outcome variable was chest tube drainage volume during the first 24 h after surgery. Results The data from 117 patients (HES 130/0.4, 59 patients; HES 200/0.5, 58 patients) who completed the study according to protocol were analyzed. The median volumes of HES administered were 49 and 33 ml/kg in the HES 130/0.4 and HES 200/0.5 groups, respectively (P < 0.001). Consequently, patients in the HES 130/0.4 group required less gelatin in addition to HES than those in the HES 200/0.5 group (medians: 7 ml/kg vs. 20 ml/kg, P < 0.001). The combined volumes of HES and gelatin were similar for both groups (P = 0.21). The 24-h chest tube drainage (medians: 660 ml vs. 705 ml, P = 0.60) did not differ significantly between the groups, nor did transfusion outcome. Conclusion Six percent HES 130/0.4 at a median dose of 49 ml/kg did not increase blood loss and transfusion requirements in coronary artery bypass surgery compared with 6% HES 200/0.5 at a median dose of 33 ml/kg.

Postoperative Analgesia with No Motor Block by Continuous Epidural Infusion of Ropivacaine 0.1% and Sufentanil After Total Hip Replacement

UNLABELLED We assessed the analgesic efficacy of postoperative epidural ropivacaine 0.1% with and without sufentanil 1 microgram/mL in this prospective, randomized, single-blinded study of 30 ASA physical status I-III patients undergoing elective total hip replacement. Lumbar epidural block using 0.75% ropivacaine was combined with either propofol sedation or general anesthesia for surgery. After surgery, the epidural infusion was commenced. Fifteen patients in each group received either an epidural infusion of 0.1% ropivacaine with 1 microgram/mL sufentanil (R + S) or 0.1% ropivacaine without sufentanil (R) at a rate of 5-9 mL/h. All patients had access to i.v. piritramide via a patient-controlled analgesia device. The R + S group consumed six times less piritramide over a 48-h infusion period than the R group (median 12.7 vs 73.0 mg; P < 0.001). Motor block was negligible for the study duration in both groups. Patient satisfaction was excellent. The incidence of adverse events, such as nausea, was similar. We conclude that a continuous epidural infusion of 0.1% ropivacaine with 1 microgram/mL sufentanil is more effective than ropivacaine alone in treating pain after elective hip replacement without motor block. IMPLICATIONS This is the first randomized study comparing the efficacy of the epidural combination of ropivacaine 0.1% and sufentanil 1 microgram/mL versus plain ropivacaine 0.1% in treating pain after hip replacement. We found that ropivacaine 0.1% and sufentanil 1 microgram/mL led to a sixfold reduction in opioid requirements after total hip replacement by producing a negligible motor block.

Comparison of continuous epidural infusion of ropivacaine and sufentanil with intravenous patient-controlled analgesia after total hip replacement

We assessed the efficacy of an epidural infusion of ropivacaine 0.1% and sufentanil 1 µg.ml−1, comparing it with intravenous patient‐controlled analgesia using piritramide in this prospective, randomised, double‐blind study of 24 ASA physical status I–III patients undergoing elective total hip replacement. Lumbar epidural block using ropivacaine 0.75% was combined with either propofol sedation or general anaesthesia for surgery. Epidural infusion and patient‐controlled analgesia were started after surgery. Twelve patients received an epidural infusion of ropivacaine 0.1% and sufentanil 1 µg.ml−1 at a rate of 5–9 ml.h−1 and an intravenous patient‐controlled analgesia device loaded with saline. Eleven patients received an epidural infusion of saline at the same rate and intravenous piritramide via the patient‐controlled analgesia device. Motor block was negligible in both groups. The epidural ropivacaine group had significantly lower visual analogue pain scores at rest 4 h after surgery (p < 0.01), and on movement 4 h (p < 0.01) and 8 h (p < 0.05) after surgery, than the intravenous piritramide group. The piritramide group experienced significantly more adverse events than the epidural group (p < 0.001), especially hypotension (p < 0.01) and vomiting (p < 0.05). Patients in the epidural ropivacaine group were more satisfied with the pain management (p < 0.05). We conclude that the epidural infusion of ropivacaine 0.1% and sufentanil 1 µg.ml−1 is superior to intravenous opioid by patient‐controlled analgesia in preventing pain after total hip replacement, with fewer adverse effects and greater patient satisfaction.

Clinical equivalence of IV paracetamol compared to IV dipyrone for postoperative analgesia after surgery for breast cancer

ABSTRACT Objective: To assess clinical efficacy of IV paracetamol 1 g and IV dipyrone 1 g on a 24.h dosing schedule in this randomised, double-blinded study of 40 ASA I–III (American Society of Anesthesiologists classification of physical status) patients undergoing surgery for breast cancer. Research design and methods: General anaesthesia using remifentanil and propofol was performed for surgery. The patients were randomly allocated to two groups, receiving infusions of paracetamol 1 g/100 mL (Para Group) or of dipyrone 1 g/100 mL (Dipy Group) 30 min before arrival in the recovery area and every 6 h up to 24 h postoperatively. All patients had unrestricted access to opioid rescue medication via an IV patient-controlled analgesia (PCA) device. Main outcome measures: The primary variables for clinical equivalence were the differences between the mean values for pain scores at rest and pain scores on coughing over 30 h postoperatively. The equivalence margin was determined as ±10 mm on the visual analogue scale (VAS). Results: Regarding pain scores at rest, the 90% CI of the mean differences between the treatment groups over 30 h postoperatively was found to be within the predefined equivalence margin [+7.5/–6.2], and the CI values for pain scores on coughing [+7.3/–9.0] were similar. The two groups did not differ in cumulative opioid rescue consumption (Dipy-Group 14.8 ± 17.7 mg vs. Para Group 12.1 ± 8.8 mg, p = 0.54) nor in piritramide loading dose (Dipy Group 0.95 ± 2.8 mg vs. Para Group 1.3 ± 2.8 mg, p = 0.545). Five patients in the Dipy Group experienced hypotension in contrast to none in the Para Group ( p = 0.047). There were no significant between-treatment differences for other adverse events, patient satisfaction scores ( p = 0.4) or quality of recovery scores ( p = 0.3). Conclusion: IV paracetamol 1 g is clinically equivalent to IV dipyrone 1 g for postoperative analgesia after surgery for breast cancer.

A comparison between IV paracetamol and IV metamizol for postoperative analgesia after retinal surgery

ABSTRACT Objective: To assess clinical efficacy of IV paracetamol 1 g and IV metamizol 1 g on a 24‐h dosing schedule in this randomized, double-blinded, placebo-controlled study of 38 ASA physical status I–III patients undergoing retinal surgery. Research design and methods: General anaesthesia using remifentanil, propofol, and desflurane was performed for surgery. The patients were randomly allocated to three groups, receiving infusions of paracetamol 1 g/100 mL (Para Group), of metamizol 1 g/100 mL (Meta Group), or of 100 mL of saline solution as placebo control (Plac Group) 30 min before arrival in the recovery area and every 6 h up to 24 h postoperatively. All patients had unrestricted access to intravenous opioid rescue medication. Main outcome measures: The primary efficacy variables were pain scores at rest over 30 h postoperatively analysed by using repeated ANOVA measurement. Secondary efficacy variables were pain scores on coughing, also analysed by repeated ANOVA measurement. Results: Five patients in the Plac Group and one patient in the Meta Group interrupted the study protocol. Regarding pain scores at rest, Mauchly-test of sphericity was significant ( p = 0.03). For the time effects a significant result was detected ( p < 0.001). The main effect between the three treatment groups was significantly different ( p = 0.01). The Bonferroni adjusted pair wise comparisons between the Plac Group and the Para Group showed a significant difference in favour of IV paracetamol ( p = 0.024; mean difference 14.8; 95% CI 1.6–28.0), between the Plac Group and the Meta Group in favour of IV metamizol ( p = 0.025; mean difference 14.4; 95% CI 1.5–27.4), and no significant difference between the Para Group and the Meta Group ( p = 1.0; mean difference 0.4; 95% CI –12.8 to 13.6). Pain scores on coughing showed a significant different main effect between the three treatment groups ( p = 0.022). The Bonferroni adjusted pair wise comparisons between the Plac Group and the Para Group showed a significant difference in favour of IV paracetamol ( p = 0.032; mean difference 17.9; 95% CI 1.3–34.6), a difference, though not reaching statistical significance, in favour of IV metamizol between the Plac Group and the Meta Group ( p = 0.081; mean difference 15.0; 95% CI –1.4 to 31.4), and no significant difference between the Para Group and the Meta Group ( p = 1.0; mean difference 2.9; 95% CI –13.8 6 to 19.6). None of the patients experienced itching; one patient in the Meta Group developed a mild erythema. There was no statistical difference in the incidence of nausea (Plac vs. Para Group: p = 0.94, Plac vs. Meta Group: p = 0.98, Para vs Meta Group: p = 0.95) or vomiting (Plac vs. Para Group: p = 0.73, Plac vs. Meta Group: p = 0.85, Para vs Meta Group: p = 0.86) between the groups. Patients in the Plac Group experienced significantly more often sedation than patients in the Meta Group ( p = 0.049). There was a trend of higher sedation in the Plac Group than in the Para Group, which did not reach statistical significance ( p = 0.07). There was no difference in sedation between the Meta and the Para Groups ( p = 0.84). Conclusion: IV paracetamol 1 g has a similar analgesic potency as IV metamizol 1 g for postoperative analgesia after retinal surgery.

Impact of tranexamic acid vs. aprotinin on blood loss and transfusion requirements after cardiopulmonary bypass: a prospective, randomised, double-blind trial.

Summary Introduction: Aprotinin (AP) reduces blood loss and transfusions after cardiopulmonary bypass (CPB), but may sensitise patients and is expensive. Tranexamic acid (TA) has less side-effects, but data regarding its efficacy are controversial. The aim of our prospective, randomised, double-blind study was to compare the impact of AP vs. TA on drainage blood loss and transfusion requirements in patients undergoing first time CABG on CPB. Materials and Methods: One hundred and twenty adult patients were randomised to receive either high-dose AP according to Hammersmith or a total of 2 g TA. Perioperative blood products were transfused in a standardised fashion. Blood loss was measured up to 24 h. Demographic and clinical patient data were collected until hospital discharge. Results: The data from 118 patients (TA: n = 58, TA appears to be a cost-effective alternative to AP AP: n = 60) who completed the study according to protocol were analysed. Blood loss at 24 h postoperation in TA patients was significantly higher (896 ± 354 ml) as compared to AP patients (756 ± 347ml; p = 0.03). TA patients received 1.5 ± 1.5 units of red blood cells (AP: 1.5 ± 1.7, p = 1.0), 1.3 ± 2.0 units of fresh frozen plasma (AP: 1.0 ± 2.0, p = 0.38) and 0.5 ± 1.4 units of platelets (AP: 0.2 ± 0.7, p = 0.15). Clinical data, including perioperative myocardial infarction rate, acute renal failure, mechanical ventilation, hospital stay and mortality, were not significantly different between either group. Conclusion: Our data show a difference in blood loss between TA and high-dose AP. Although statistically significant, it has little clinical relevance, because perioperative transfusion requirements were similar for both groups. Thus, TA appears to be a cost-effective alternative to AP in primary CABG patients.

Antiplatelet therapy preceding coronary artery surgery: implications for bleeding, transfusion requirements and outcome

Background and objective: Bleeding after cardiac surgery correlates with morbidity and mortality. The aim of this study was to determine the influence of antiplatelet therapy on bleeding and transfusion rates in coronary artery bypass grafting. Methods: Forty patients receiving aspirin and/or clopidogrel/ticlopidine within 7 days prior to surgery were retrospectively compared to 40 control patients lacking antiplatelet therapy for at least 8 preoperative days. Blood loss was assessed as chest‐tube drainage during the first 12 h after surgery. Units transfused were recorded intraoperatively and during stay in the intensive care unit. Results: Both groups were comparable for pre‐ and intraoperative data. Irrespective of single or combined antiplatelet therapy, treated patients demonstrated lower fractions of the creatine‐kinase isoenzyme MB (5.8 ± 3.1 vs. 8.2 ± 4.1%; P = 0.004) and infarction rates (0 vs. 3; P = 0.240) than control patients, but had significantly more haemorrhages (940 ± 861 mL vs. 412 ± 590 mL; P = 0.002) and transfusion requirements (red cells: 4.5 ± 4.9 vs. 1.5 ± 2.3, plasma: 4.9 ± 6.4 vs. 1.3 ± 2.5, platelets: 1.5 ± 1.3 vs. 0.1 ± 0.2; all P ⩽ 0.001). The differences to control patients were more pronounced for only short antiplatelet therapy free intervals or ongoing antiplatelet therapy (P⩽2 days ⩽ 0.019). For antiplatelet therapy free intervals longer than 2 days, bleeding and transfusion rates (except for platelets) were nonsignificantly higher as compared to control patients (P ⩾ 0.058). Conclusions: To overcome increased blood loss and transfusion rates, antiplatelet therapy should be discontinued for at least 2 days before elective coronary surgery. Whether patients at high risk for myocardial infarction might benefit from ongoing antiplatelet therapy remains to be investigated.

Human Error: The Persisting Risk of Blood Transfusion: A Report of Five Cases

UNLABELLED It is common experience that virus transmission, particularly transmission of the human immunodeficiency virus (HIV), is a principal concern of patients and physicians regarding blood transfusion (1). Many physicians are probably unaware that transfusion-transmitted HIV infection is approximately 50 to 100 times less likely to occur than transfusion error (2-4). This misconception may have been encouraged by the scarcity of reports on transfusion error relative to the tremendous public attention focused on HIV infection. We present five cases illustrating how anesthesiologists, intensivists, and emergency physicians are particularly vulnerable to the risk of administering blood to the wrong recipient. All five cases were collected during a 4-yr period. Transfused units of packed red cells totaled approximately 50,000 U during this period in our department. IMPLICATIONS Human error leading to the transfusion of blood to an unintended recipient is a major source of transfusion-related fatalities. We report five cases that highlight some specific areas in which transfusion error is likely to occur.

Epidural block with ropivacaine and bupivacaine for elective caesarean section: maternal cardiovascular parameters, comfort and neonatal well-being*

SUMMARY Objective: To determine cardiovascular effects and neonatal outcome of ropivacaine 0.75% and bupivacaine 0.5% for elective epidural caesarean section. Research design and methods: Healthy pregnant women, scheduled for elective caesarean section, were enrolled in this randomised, double-blind study. Epidural block was obtained with 20-30 ml of ropivacaine 0.75% (Group R) or bupivacaine 0.5% (Group B) and surgery did not commence until anaesthesia was achieved bilaterally to T6. Main outcome measures: Maternal heart rate and blood pressure were assessed before the main dose of local anaesthetic and at 5-min intervals until 35 min. Neonatal umbilical pH and Apgar scores were determined after delivery. Ten, twenty and thirty minutes after the main dose, sensory and motor block characteristics were determined. Quality of analgesia was assessed by the anaesthetist, surgeon and the patient. Adverse events were recorded. Results: Sixty-two patients were enrolled and the data of 60 of them were eligible for analysis: 31 in Group R and 29 in Group B. The area under the curve (AUC) for maternal heart rate decreased significantly less in Group B than in Group R (p = 0.038). Twenty-five and thirty minutes after administration of the main local anaesthetic dose, heart rate decreased significantly less in Group B than in Group R (p = 0.006 and p = 0.007). There was no difference in AUC for maternal blood pressure (p = 0.32). Repeated measurement analysis showed no difference between groups in motor block (p = 0.78) and in spread of the sensory block (lower level: p = 0.83, upper level: p = 0.88). There was no statistical difference in neonatal umbilical pH (p = 0.22) and Apgar score (p = 0.59). Multiple linear regression analysis showed a significant influence of maternal body mass index on neonatal pH (p = 0.004), but not of maternal blood pressure (p = 0.323), nor of maternal heart rate (p = 0.12). The quality of analgesia and incidence of adverse events were similar in both groups. Conclusions: Both drugs produced equally satisfactory epidural block. Although ropivacaine 0.75% resulted in a greater decrease of maternal heart rate, this effect did not influence neonatal well-being. Both ropivacaine 0.75% and bupivacaine 0.5% can therefore be recommended for epidural anaesthesia in elective caesarean section.

Postoperative analgesia and flap perfusion after pedicled TRAM flap reconstruction – continuous wound instillation with ropivacaine 0.2%. A pilot study

Transverse rectus abdominis musculocutaneous (TRAM) flap surgery is a complex procedure characterised by an extensive wound site. We present a pilot study with 17 patients receiving continuous wound instillation with ropivacaine or isotonic saline. Patients undergoing TRAM flap surgery were included in the study and randomised to the ropi group or the control group. Two catheters were placed subcutaneously before wound site closure. At the end of surgery patients received a single shot dose of 20 ml ropivacaine 0.2% or isotonic saline. After surgery the continuous instillation of ropivacaine or isotonic saline was commenced at an infusion rate of 10 ml/h per catheter. The perfusion of the TRAM flap was measured intraoperatively and postoperatively over 48 h. Pain scores, patient satisfaction, and the quality of recovery score were also assessed postoperatively over 48 h. Ropivacaine plasma levels were quantified 24 and 48 h after start of infusion. Pain scores at rest and on coughing were lower for the ropi group and reached significance in the first 8h at rest (P=0.007). Patient satisfaction, quality of recovery score, and adverse events were also comparable between the groups. Patients of the ropi group had bowel movement earlier than the control group (P=0.003). No differences were seen in the flap perfusion. Ropivacaine plasma levels were within therapeutic range. Our data show a trend that continuous wound instillation of ropivacaine 0.2% increases pain relief after TRAM flap surgery with earlier bowel movement than intravenous opioid patient controlled analgesia (IV-PCA) alone. A does of 960 mg of ropivacaine daily did not result in toxic plasma concentrations. Ropivacaine 0.2% did not show a vasoconstrictor effect.