Summary

The ‘wet vs. dry’ philosophy in patients undergoing abdominal surgery is a subject of substantial debate. It has been suggested that restricting fluid input would significantly reduce complications and improve outcome following abdominal surgery. Keeping the patients dry may be a two-edged sword because the resulting hypovolaemia may result in compromised organ perfusion and poor tissue oxygenation. A review of the literature from 1990 to 2004 revealed that only very few studies on this subject have been published. Unfortunately, most of the ‘dry’-supporting studies used fixed amounts of volume instead of a fluid concept adapted to the patients' need (‘goal-directed’) and there is no generally accepted definition of ‘restricted’, ‘dry’ or ‘overload’. Not only the amount but also the kind of administered fluid appears to be important. Current evidence indicates that using crystalloids exclusively may cause overloading of the interstitial compartment with considerable negative sequelae, whereas using colloids may improve microperfusion and tissue oxygenation. This review shows that the meagre literature on a restricted volume replacement strategy in abdominal surgery patients cannot clearly support the ‘dry’ approach. Further well-performed studies are necessary to elucidate the ideal amount and type of fluid replacement and determine how to guide fluid therapy.

A prospective multicentre pilot study was undertaken in 20 Italian hospitals to assess the influence of a routine pre-operative chest radiograph on anaesthetic management and to characterise which patients might benefit from it. A total of 6111 patients undergoing elective surgery and submitted for routine pre-operative chest radiograph were enrolled. Abnormal pre-operative chest radiographs were reported in 1116 patients (18.3%). Pre-operative chest radiograph altered the anaesthetic management (i.e. useful pre-operative chest radiograph) in 313 patients (5.1%). Male sex, age >60 years, ASA classes ≥3, respiratory diseases, and the presence of two or more co-existing diseases were significantly related to the probability of a useful pre-operative chest radiograph using multivariate analysis (P<0.01). The classification of the surgical intervention and, of the co-existing diseases, the presence of cardiac disease had a very low influence when determining the probability that a pre-operative chest radiograph would be useful. A simple equation includes the effects of all the variables studied and allows calculation of the probability of a useful pre-operative chest radiograph. This study indicates that in healthy, female, ≤60-year-old patients, submitted for standard surgery, the probability of a useful pre-operative chest radiograph ranges from 0.2% to 3.5% according to the hospital. The probability increases in male or elderly subjects, or in the presence of co-existing respiratory diseases, or in ASA classes ≥3, but there is a wide variation between hospitals.

Summary

Background and objective: The combination of non-opioid analgesic drugs, though widely used, has been rarely evaluated. The aim of this study was to compare the efficacy of propacetamol and the non-steroidal analgesic drug ketoprofen, alone or in combination, on pain relief after thyroid surgery performed using remifentanil.

Methods: Ninety-seven patients were randomly allocated to one of the three groups: propacetamol 2 g (32), ketoprofen 100 mg (33) and propacetamol 2 g + ketoprofen 100 mg (32). Each regimen was administered intravenously (i.v.) 30 min before the end of surgery and then every 6 h. If pain was not relieved, patients received an i.v. bolus of tramadol 100 mg. Tramadol consumption and pain intensity using a visual analogue scale was recorded at 1, 2, 8 and 14 h after the end of surgery.

Results: Pain scores were significantly higher with propacetamol compared with ketoprofen 2 h after surgery (35 ± 3.7, 21 ± 2.6, respectively; P < 0.01). The number of patients receiving tramadol was higher with propacetamol alone compared with the two other groups, 1 h (14/32, 4/33, 2/32, respectively; P > 0.01) and 2 h (24/32, 6/33, 8/32, respectively; P < 0.01) after surgery. There was no difference between ketoprofen alone and ketoprofen plus propacetamol, and there was no difference between the three groups from the 8th hour onward.

Conclusions: In the immediate postoperative period after thyroid surgery performed using remifentanil, the concomitant use of propacetamol and ketoprofen does not improve analgesia compared with ketoprofen alone.

Fifty children (2–9 years) scheduled for tonsillectomy were enrolled in a double-blind randomized prospective study to compare postoperative analgesia provided with propacetamol/paracetamol (acetaminophen) or tramadol. A standard anaesthetic technique was used; each patient received sufentanil 0.25 μg kg−1 intravenously followed with either i.v. propacetamol 30 mg kg−1 or tramadol 3 mg kg−1 before surgical incision. For postoperative analgesia, each child received either tramadol drops (2.5 mg kg−1) or paracetamol (acetaminophen) suppositories (15 mg kg−1), 6 and 12 h after surgery the first day and three times a day during postoperative days 2 and 3. This dosage of paracetamol is lower than the current recommended dosage, which is 40 mg kg−1 loading dose followed by 20 mg kg−1 8 h−1. Rescue medication consisted of i.v. diclofenac (1 mg kg−1) during the first six postoperative hours and oral ibuprofen (6–9 mg kg−1) afterwards. Postoperative pain scores (Children's Hospital of Eastern Ontario Pain Scale) in recovery, numerical pain scale in the ward and at home, and rescue analgesic use were significantly lower in the tramadol group. No serious adverse effects were observed.

Summary

Background and objective: Whereas the protective effect of anaesthetic and ischaemic preconditioning has been described for several organs, it is uncertain whether this mechanism is also effective in the kidney. We compared the effect of preconditioning with sevoflurane and preconditioning with short episodes of ischaemia on renal ischaemia/reperfusion injury in the rat in vivo. Methods: Fourteen days after right-sided nephrectomy, anaesthetized male Wistar rats were randomly assigned to a sham-operated group (no arterial occlusion, n = 5) or underwent 45 min of left renal artery occlusion (control group, n = 9) followed by 3 days of reperfusion. Two further experimental groups of animals were preconditioned prior to ischaemia either by administering 1 MAC sevoflurane for 15 min followed by 10 min of washout (sevoflurane group, n = 10) or by subjecting the animals to three short episodes of renal ischaemia (ischaemia-preconditioned group, n = 8). Blood creatinine was measured during reperfusion and morphological damage was assessed by histological examination. Results: Baseline creatinine values were similar in all four groups (0.7 ± 0.2 mg dL−1; mean ± SD) and remained unchanged in the sham-operated animals after 3 days (0.8 ± 0.2 mg dL−1). Creatinine levels increased in the ischaemic preconditioning group (3.3 ± 1.2 mg dL−1) and sevoflurane preconditioning group (4.0 ± 1.1 mg dL−1) compared to the control group (1.6 ± 0.6 mg dL−1). Morphological damage was less severe in the control group, i.e. in animals without preconditioning, than in both preconditioning groups. Conclusion: Neither sevoflurane nor ischaemic preconditioning preserves renal function or attenuates cell damage in the rat in vivo.

Summary

Background and objective: Cardiopulmonary bypass is associated with changes of intra- and extravascular volume status often resulting in cardiopulmonary dysfunction. The purpose of this prospective double-blind study was to evaluate the influence of different priming solutions of the extracorporeal circuit on intra- and extravascular volume status and haemodynamics in patients undergoing elective mitral valve replacement. Methods: Twenty-two patients with mitral valve insufficiency were randomly allocated into two equal groups. In Group 1 cardiopulmonary bypass was primed with a nearly isooncotic solution consisting of 4% albumin. The second group received a pure crystalloid priming solution. The thermo-dye indicator dilution technique was used for the assessment of cardiac output, central and pulmonary blood volume, right ventricular end-diastolic volume and total blood volume. Results: Patients in the crystalloid group showed increased intraoperative fluid requirements. Significantly more fluid was accumulated in the extravascular space whereas total blood volume was decreased after surgery. Stroke volume index (SVI) was significantly decreased in the immediate postoperative period when compared to baseline. As indicated by the increase in extravascular fluid content after surgery, both colloid and crystalloid priming volumes were transferred to the extravascular space. Conclusion: The use of colloid priming solutions in patients with mitral valve insufficiency leads to less fluid requirements and significantly reduced fluid shift in the interstitium. However, these changes are not associated with changes in haemodynamic parameters or short term outcome.

In recent years, day surgery rates have risen in many countries in the world. In 1998–99, 65% of elective surgery was performed as day procedures in the UK and about 70% in the USA. The future has the potential for an increase in day surgery as less well-performing countries and hospitals catch up with the best, and new surgical, anaesthetic and analgesic techniques are introduced. Consolidation and development of best management practices are necessary for sustained day surgery development.

Background and aim We evaluated the costs and benefits of total intravenous anaesthesia compared with a balanced anaesthesia regimen.

Methods One-hundred and twenty-four patients undergoing cataract surgery were randomized to either a pro-pofol/remifentanil or an isoflurane/fentanyl group. In the propofol/remifentanil group, both drugs were used for induction and maintenance of anaesthesia; in the isoflurane/fentanyl group, anaesthesia was induced with etomi-date and fentanyl and maintained with isoflurane and fentanyl. All patients received mivacurium for muscle relaxation and the lungs were ventilated mechanically. The use of propofol and remifentanil resulted in a faster emergence and an overall savings per case of € 12.25 due to a reduction in personnel costs which outweighs the higher drug acquisition costs.

Results In the propofol and remifentanil group, more patients were satisfied and would accept the same anaesthetic again.

Conclusion We conclude that propofol and remifentanil is more cost-effective than isoflurane/fentanyl due to its better recovery profile, reduced total direct costs and higher patient satisfaction.

Summary

Background and objective: The aim of this study was to assess time dependent cumulative effects of three different inhalation anaesthetics on QTc interval during the maintenance of anaesthesia.

Method: Seventy-five ASA I–II male patients undergoing inguinal herniorrhaphy were randomly allocated into three groups. No premedication was given. Anaesthesia was induced with thiopental and tracheal intubation was facilitated by vecuronium in all groups. Anaesthesia was maintained with 0.8% halothane (Group I) (n = 25), 1% isoflurane (Group II) (n = 25), or 2% sevoflurane (Group III) (n = 25) and 66% nitrous oxide in oxygen. Three lead electrocardiogram recordings were taken before induction, 2, 5, 10, 15, 30 and 45 min after induction and after extubation. Heart rate, systolic, diastolic, mean arterial pressure and SPO2 were recorded at the same time. Heart rate and corrected QT interval were evaluated by using Bazett's formula. Multivariate analysis of variance for repeated measures was used to determine intergroup and intragroup differences.

Results: There was no statistically significant difference in the baseline QTc values of the groups. There was no difference between QTc values with halothane and sevoflurane. There was a difference between QTc values with isoflurane and those with the other two inhalation anaesthetics (P < 0.05). Although QTc values in the isoflurane group were higher at all times, the critical value of 440 ms was not exceeded.

Conclusion: We conclude that halothane 0.8%, isoflurane 1% and sevoflurane 2% do not prolong QTc interval.

Decision-making at the end-of-life in the United States has evolved over the last 50 yr, beginning with the development of the concept of brain death as a criterion for permitting patients who are in a state of ‘irreversible coma’ to be considered as ‘dead’ for purposes of ventilator withdrawal and organ transplantation. Since then, a firm consensus has emerged in American law and ethics that ‘Patients have a virtually unlimited right to refuse any unwanted medical treatment, even if necessary for life itself.’ With regard to patients who are unable to make decisions for themselves, both Europe and the United States are converging toward a view that respects a role for surrogates in decision-making while recognizing the need to limit their authority. Beyond decisions to withdraw and withhold treatments, both the United States and Europe are experimenting with active hastening of the dying process through euthanasia and physician-assisted suicide. In the author’s opinion, the next big question to be addressed in end-of-life decision-making is ‘Just how bad does the neurological condition and prognosis need to be before it is acceptable to allow a decision to withdraw life support’? Although the practices described here have wide acceptance throughout the United States and Europe, the worldwide emergence of religious fundamentalism and the associated vitalistic view about the sanctity of life may result in significant changes over the next few decades.

Summary

Background and objective: The use of a pneumatic tourniquet can induce muscular and neurological complications in the operated limb. The genesis of these injuries could involve an ischaemia/reperfusion phenomenon and a compression under the cuff. We evaluated effects of an antioxidant, acetylcysteine and ischaemic preconditioning on the rhabdomyolysis and postoperative pain following a knee ligamentoplasty using a pneumatic tourniquet. Methods: We included 31 patients scheduled for a knee ligamentoplasty randomly assigned in three groups (control, acetylcysteine 1200 mg the day before and 600 mg at the operative day, ischaemic preconditioning). Results: There was a moderate rise in myoglobin and creatinine phosphokinase with no significant difference between the three groups. The muscular functional parameters were similar in all the groups. However, the morphine consumption within the first 48 h was smaller in the treatment groups (0.22 ± 0.31 mg kg−1 and 0.22 ± 0.23 mg kg−1 in the preconditioning and antioxidant groups, respectively) than in the control group (0.47 ± 0.33 mg kg−1, P <0.05). Conclusions: Acetylcysteine and ischaemic preconditioning do not decrease the extent of rhabdomyolysis related to the use of a pneumatic tourniquet and do not improve the postoperative muscle recovery. On the other hand, they allow a significant reduction in the postoperative morphine consumption.

Eighty patients were recruited into a double-blind, randomized trial to find the optimal dose of droperidol for addition to the patient-controlled analgesia (PCA) morphine infusate for female patients undergoing gynaecological surgery. A standardized anaesthetic technique was employed. Post-operative analgesia was provided by PCA morphine. Patients were allocated at random into one of four treatment groups receiving with each PCA morphine bolus: (1) droperidol 0.05 mg; (2) droperidol 0.10 mg; (3) droperidol 0.15 mg; and (4) droperidol 0.20 mg, respectively. The incidence of post-operative nausea and vomiting (PONV), requests for rescue anti-emetic medication, and incidence of side effects were recorded. The number of symptom-free patients in each group increased as the droperidol dose increased, but although there was a significant inverse association between the total dose of droperidol received and the severity of PONV (P<0.05), there were no significant differences between individual groups. In each group, patients were significantly less sedated at 24 h compared with 12 h (P<0.01). However, after 24 h, patients in group 4 were significantly more sedated than patients in groups 1 and 2 (P<0.05). There were no significant differences between the groups in terms of the incidence of anxiety or other side effects attributable to droperidol. The present authors suggest that, although the results demonstrate few statistically significant differences between the four groups, a PCA bolus dose of droperidol of 0.10 mg mL−1 appears to provide the optimal balance between anti-emetic efficacy and an acceptable incidence of side effects.

Background and objective The effects of sepsis on gut mucosal blood flow have not been fully clarified. We designed an experiment to explicitly describe the effects of sepsis on gut mucosal blood flow in rats using an advanced intravital microscopy technique.

Methods This work was performed as a prospective, controlled laboratory experiment. Twenty-four hours after sham laparotomy or laparotomy and caecal ligation and perforation to create sepsis, rats were anaesthetized and their lungs mechanically ventilated (n = 7 per group). Intravital videomicroscopy was performed on 6–12 villi of ileum mucosa. Video recordings were analysed off-line using computerized image analysis.

Results Intercapillary area size (inversely related to capillary density) was increased in sepsis as compared with the control group (941 ± 92 vs. 669 ± 79 μm2, P < 0.05). In the central villus arteriole, blood flow was similar between groups (control: 3.5 ± 0.4 nL min−1; caecal ligation and perforation group: 3.6 ± 0.5 nL min−1). There were no relevant changes in arteriolar red cell velocity and diameter.

Conclusions In the gut mucosa of rats, sepsis resulting from caecal ligation and perforation depressed the perfused capillary density without affecting blood flow in the central villus arteriole. Mucosal hypoperfusion at the level of the capillary networks may occur in the presence of precapillary shunting in the villus microcirculation.

Summary

Background and objective: To compare the effects of remifentanil and fentanyl on intraocular pressure during the maintenance and recovery of anaesthesia in patients undergoing elective non-ophthalmic surgery.

Methods: Thirty-two patients (ASA I–II) were randomized into two groups to receive either a continuous infusion of remifentanil (0.25–0.5 μg kg−1 min−1, n = 16, Group R) or an intermittent bolus of fentanyl (2–5 μg kg−1, n = 16, Group F) during the maintenance of anaesthesia. For the induction of anaesthesia, Group R received remifentanil 1 μg kg−1 and Group F received fentanyl 2 μg kg−1; both groups then received propofol 2 mg kg−1 with vecuronium 0.1 mg kg−1. Anaesthesia in both groups was maintained with a continuous infusion of propofol 4–8 mg kg−1 h−1. Ventilation of the lungs was controlled to a constant end-tidal PCO2 of 4.7–5.4 kPa. Blood pressure, electrocardiography, heart rate and oxygen saturation were monitored throughout anaesthesia. Intraocular pressure was determined before surgery, during the maintenance of anaesthesia, 2 min after emergence and in the recovery room using a Perkins hand-held applanation tonometer by an ophthalmologist blinded to the anaesthetic technique.

Results: After induction of anaesthesia, a significant decrease in intraocular pressure in the remifentanil group from 13.6 ± 2.6 to 7.1 ± 3.1 mmHg (P < 0.001) and in the fentanyl group from 13.7 ± 2.2 to 9.7 ± 3.4 mmHg (P < 0.001) was observed and maintained during anaesthesia. Thirty minutes after the end of anaesthesia, intraocular pressure returned to baseline values in both groups (remifentanil: 13.9 ± 2.8 mmHg, P = 0.28; fentanyl: 13.6 ± 2.3 mmHg, P = 0.59). The intraocular pressure and haemodynamic variables did not differ significantly between the two groups (intraocular pressure, P = 0.7327; blood pressure, P = 0.1295; heart rate, P = 0.8601).

Conclusions: Remifentanil maintains intraocular pressure at an equally reduced level compared with fentanyl.