Neuroaxial anesthesia methods combined with general anesthesia for beating heart surgery ...

63 Pages·2012·0.55 MB·English

BritishJournalofAnaesthesia108(S2):ii215–ii277(2012)
doi:10.1093/bja/aer485
OTHER
Paper No: 1.00 neurological complication associated to neuraxial blockade
wasnotobserved.
Conclusions: The multimodal anesthetic methods are more
Neuroaxial anesthesia methods combined effectives, with theya superior perioperative patients evolu-
with general anesthesia for beating heart tion were obtained. Key words: Coronary surgery without
extracorporeal circulation, intrathecal opioids, high epidural
surgery
blockade, spinal anesthesia, epidural anesthesia, multimod-
Aguero Martinez, Maria Oslaida, alityanesthesia.
Rosa Jimenez Paneque, Idoris Cordero Escobar,
Raul Cruz Bouza and Antonio Cabrera Pratts References
HermanosAmeijeirasHospital.Havana.Cuba 1 LenaP,BalaracN,LenaD,DelaChapelleA,ArnulfJJ,MihoubiA,
BonnetF.Fast-trackanesthesiawithremifentanilandspinalanal-
Introduction: In Cuba more than 50% of the coronary gesiaforcardiacsurgery:Theeffectonpaincontrolandqualityof
surgery is carried out with the beating heart modality. recovery. J of cardiothorac and vasc anesthesia 2008; 22(4):
536–42.
Endotracheal general anesthesia has been the technique
2 Yapici D, Ozer ZO, Atici S, Bilgin E, Doruk N, Cinel I, et al. Post-
used in our service. Neuraxial Anesthesia combined
operative effect of low-dose intratecal morphine in
with the general anesthesia method, in this last
coronary artery bypass surgery. J Card Surg 2008; 23:
decade, has prevailed in a certain number of the cardio-
140–45.
vascular centers of the world, due to their undeniable
3 Tenenbein PK, Derouwere R, Maguire D, Duke PC, Muirhead B,
advantages. Enns J, et al. Thoracic epidural analgesia improves pulmonary
Objectives:To evaluate the effects of the general anesthe- function in patients undergoing cardiac surgery. Can J Anesth
sia combined with high thoracic epidural blockade or intra- 2008;55(6):344–50.
thecal administration of morphine/ fentanyl on the 4 CaputoM, AlwairH,RogerCA,GintyM,MonkC,TomkinsS,et al.
intraoperative analgesia, time of extubation, intensive Myocardial, Inflamtory,andStressResponsesinoff-pumpcoron-
aryartery bypass surgery with thoracicepidural Anesthesia. Ann
care unit and hospital stay. To identify the frequency of
ThoracSurg2009;87:1119–26.
appearance of adverse effects related with the spinal ad-
5 Moraes L, Canavi V, Canavi S, Sa Malbouissan LM, Carvalo CJ.
ministration of opioides and the frequency of appearance
Intrathecal morphine plus general anesthesia in cardiacsurgery:
of complications related with regional anesthetic’s
Effect on pulmonary funtion, post operative analgesia and
method. plasma morphine concentration. Clinics (Sao Paulo) 2009; 64(4):
Methods: A controlled randomized trial was conducted in 279–85.
patients with diagnosis of coronary heart disease, pro-
grammed for off pump coronary artery bypass graft
surgery.This patients were assigned to one of the following Paper No: 63.00
three groups: Control group (n¼30): Endotracheal general
anesthetic method. Multimodal group (n¼29) with thoracic Candedemia in intensive care unit
epidural anesthesia: bupivaca¨ana 0,5% (50mg) 10ml/single
Prof. Chandralekha1, I. Xess1 and Fahmi Hasan2
dose and 5mg of morphine. Multimodal group with intra-
thecal administration of opioides (n¼29): fentanil 1,5 mcg/ 1Dept.ofAnesthesiologyand2DepttofMicrobiology
kgand morphine8mcg/kg.
Results: The total doses of sistemic fentanyl were Introduction: There is a need to understand the epidemi-
smaller in the multimodal groups (2793 micrograms ologyandriskfactorsassociatedwithcandidemiaincritically
+2915.94 vs 1300 +2 392.79 vs 998 +229.10; p,0.001) illpatients.Theriseinincidenceofnon¨Calbicanscandidemia
The time of extubation (7.83 hours +25.24 vs 4.57 + and emergence of antifungal resistance have made such a
2 2.87 vs 1.72+2 1.07; p, 0.001) and the intensive care study necessary. Candidemia in Intensive Care Units (ICUs)
un it stay (CG¼2.83+22.42 days, GMOI¼1.92+21.23, settingare of specialconcern dueto highmortality rate.
GMET¼1.41+20.75, p¼0.005) were smaller too, in both Objective: The aim of this study was to evaluate epidemi-
multimodal groups, wihtout differents beetwen then, but ology of Candidemia, associated risk factors and outcome
this methods didn’t influence in the hospital stay. A ofthediseaseandantifungalresistanceamongICUpatients.
&
TheAuthor[2012].PublishedbyOxfordUniversityPressonbehalfoftheBritishJournalofAnaesthesia.Allrightsreserved.
ForPermissions,pleaseemail:[email protected]
Downloaded from https://academic.oup.com/bja/article-abstract/108/suppl_2/ii215/2919735
by guest
on 30 January 2018
BJA
AbstractspresentedatWCA2012
Methods: The study was carried out at an Indian tertiary- Cardiopulmonary bypass is associated with immense stress
care teaching hospital, New Delhi, India from a period of response and high levels of intraoperative cortisol levels
three years. January 2005 to December 2008. Prospective which is detrimental to the patient and involves large
analysis of 85 cases of Candida blood stream infection doses of Fentanyl, propofol and vecuronium requirement to
(BSI) donefrom January 2005 to December2008. Out of85 maintain hemodynamic stability intraoperatively. We evalu-
patients, 38 patients were getting repetitive BSI infection ated the effect of Indian classical music therapyon cortisol
and 47 patients got Candida infection only once during levels and the above drugs requirement during cardio pul-
their hospital stay. Follow up study was done till discharge monarybypass.
or death of the patients and data were analyzed. Isolates Materials&Methods:AfterobtainingclearancefromInstitu-
were characterized and antifungal susceptibility test was tionalEthicalCommitteeandwritteninformedconsentfrom
doneagainstfluconazoleandamphotericin B. patients, 34 patients were assigned to either Group I Music
Results: Non- C. albicans species accounted for majority of group (n¼17) and Blank CD Group II (n¼17). The patients
episodes of candidemia as reported by our previous study. awareness level and depth of anesthesia was monitored by
Patients in ventilators and foleys catheter along with old BIS(Bispectralindex),Fentanylandpropofolinfusiontitrated
age were significantly associated with persistence of infec- toaBISscoreof50andneuromuscularmonitoringwasdone
tion(P¡U¨ 0.05).Overallmortalitywas(65.8%)56of85incan- by Post tetanic count (PTC) in the Aductor Pollicis muscle.
didemiapatients.Thetimeandthechoiceofantifungalsfor Vecuronium was repeated whenever a PTC count of 7 was
the treatment of candidemia were significantly associated achieved, in both the groups. Music therapy or blank CD
with the clearance of the infection (P¼0.01) but not with was played by earphone, in the patient’s ear in both the
mortality (P¼0.23). 30% of the isolates showed decreased groups, from 30 mins before induction to till the patient
susceptibility to fluconazole. wasshifted to theICU.
Conclusion: There is a shift in the epidemiology of candide- Result: We found significant decrease in the cortisol levels
mia and the timely institution of antifungals and combin- both after Sternotomy and after aortic crosscalmp release.
ation therapy suggest the better outcome of the patients. In the Music group (Group I) which was 30% less than the
Presence of azole resistances is a matter of concern in our BlankCDgroup(GroupII).Fentanyl,propofolandvecuronium
isolates. requirementintheMusicgroupwerereducedby30%and25
%and 25% respectively, which were statistically significant
(P,0.05)
References
Conclusion:IntraoperativeIndianclassicalmusictherapyef-
1 BeheraB,SinghRI,XessI,MathurP,HasanF,MishraMC,Candida
fectively reduced the intraoperative stress (as revealed by
rugosa: a possible emerging cause of candidemia in trauma
reduced levels of cortisol) and reduced the requirement of
patientsInfections2010;38:387–393
drugs(Fentanyl,PropofolandVecuronium)duringCardiopul-
2 SinghRI,XessI,MathurP,BeheraB,GuptaB,MishraMC,Epidemi-
monaryBypass.
ologyofcandidemiaincriticallyilltraumapatients:experiencesof
alevelItraumacentreinNorthIndia.JMedMicrobiol2011;60:
342–348 References
3 BartonRC,Candidarugosa:anewfungalpathogenemerging,but
1 Bagchi,Kalyan.(Ed)(2003)Music,MindandMentalHealth.New
fromwhere?JMedMicrobiol2011;Editorial265
Delhi.
2 TonyWigram,IngeNygaardPedersenandLarsOleBonde.Jessica
KingleyPublishersPhiladelphia2002:A comprehensiveguideto
Paper No: 68.00 musictherapy,Theory,clinicalpracticeResearch&Training.
3 Nisson,RawalN,UnossonM,Acomparisonofintra-operativeor
postoperative exposure to music–a controlled trial of the
Effect of Indian Classical Music (Raga
effects on postoperative pain. Anaesthesia. 2003 Jul;
Therapy)on Fentanyl, Vecuronium, Propofol 58(7):699–703.
requirement and cortisol levels in 4 YaleUniversitySchoolofmedicine2003Effectsofmusictherapy.
Cardiopulmonary Bypass 5 Sairam TV, (2004a) Medicinal Music. Chennai: Nada Centre for
MusicTherapy
Sandeep Kumar Kar1, Chaitali Sen2 and 6 SairamTV,(2004b)RagaTherapy.Chennai:NadaCentreforMusic
Anupam Goswami3 Therapy
7 SairamTV,(2004c)WhatisMusic?Chennai:NadaCentreforMusic
1InstituteofPostGraduateMedicalEducation&ResearchKolkata
Therapy
India2I.P.G.M&RKolkataINDIAand3I.P.G.M.E&R
8 Lewis.AnesthAnalg2004;98:533–6
9 Yapici N, Tarhan IA, Kehlibar T, Coruh T, Arslan Y, Yilmaz M,
Introduction: Indian classical music has immense healing
YapiciF,OzlerA,AykacZ,BloodCortisolLevelsOnCardiopulmon-
potential and considerable stress reducing capabilities ary Bypass After Methylene Blue Administration . The Internet
which has been harnessed since the Mughal era. Music is JournalofThoracicandCardiovascularSurgery.2008;2.
regarded as the medicine with no side effects. 10 Miller7theditionNeuromuscularmonitoringchapter47
ii216
Downloaded from https://academic.oup.com/bja/article-abstract/108/suppl_2/ii215/2919735
by guest
on 30 January 2018
BJA
AbstractspresentedatWCA2012
Paper No: 69.00 Paper No: 112.00
PAI-1 and t-PA/PAI-1 complex potential
Why so much fear to anesthesia? fibrinolytic markers for postoperative
bleeding in cardiopulmonary bypass
Horacio Bonchini
patients
HospitalEscuelaEvaPero´n,GranaderoBaigorria,Dpto.Rosario,
Argentina Agnese Ozolina, Eva Strike, Inta Jaunalksne and
Indulis Vanags
Introduction:Thereareonlyafewoccasionsinthecourseof
RigaStradinsUniversity,DepartmentofPaulsStradinsClinical
a person’s life, in which one faces the biggest existential
UniversityHospital,ClinicalPaulsStradinsClinicalUniversity
problem of humanity, fear of death. This seems to happen
Hospital,DepartmentPaulsStradinsClinicalUniversityHospital,
when one has the need to undergo an anesthetic-surgical
DepartmentofAnaesthesiologyandCardiacsurgery,Latvia
procedure; it is then when the bare possibility of harm and
death appears. And it compulsorily reminds us the finite Introduction: Excessive bleeding (EB) remains a serious
natureof human life. problem following cardiac surgery. Bleeding after cardiac
Objective:Toverifyifitistruetheobservationthatfearofan- surgery is multifactorial in aetiology but fibrinolysis plays a
esthesia is generalized among our patients; and to define determinantrole.
which would be the possible causes that more frequently Objectives:Wehypothesizedthatlowerpreoperativelevelof
provoke this fear. Finally, it will be evaluated if they are Plasminogen activator inhibitor type-1 (PAI-1) and lower
related to the innate fear of death. Material and methods: ratio of tissue – plasminogen activator/PAI-1 complex
A survey was designed to be answered anonymously, with (t-PA/PAI-1) after surgery maybe associatedwith enhanced
eightquestion.Twowereopenanswers:thedefinitionofAn- fibrinolyticactivityandincreased bleeding.
esthesiaandtowhathe/sheassociatedthewordAnesthesia. Method: A total of 88 adult cardiac surgical patients (mean
The other questions were multiple choices. 456 Patients age66+10years,48%men)whodidnotreceiveantifibrino-
between 18 to 70 years old, were surveyed; xx were facing lytic prophylaxis were enrolled in a prospective study. Vari-
scheduled surgeryand XXwere not. ables were collected preoperatively (T0); at admission in
Results:48%answeredtheywouldbeafraidofanesthesiaif intensive care unite (T1), at 6 and 24 hours (T6, T24) after
they had to be operated. 48.9% were worried the same by surgery. To allow comparison between patients, two groups
the anesthetical act as by the surgical one. 75% of the were made according to 24-hour postoperative bleeding
patients recognized they had never been interested in volume: group I.500ml/24h, group II ? 500ml/24h. Correl-
getting information about how anesthesia is done. 68.8% ationofbloodamountwithroutinecoagulationtestsandfi-
knew the anesthesiologist is a physician. Only 5% could brinolysis parameters (PAI-1, t-PA/PAI-1 complex, D-dimer)
define correctly the word anesthesia. Those peopleyounger wereanalysedusingSPSS17.0aslinearregression(Pearson’s
than 30 years old were more afraid of anesthesia; being correlation coefficient). Comparisons between groups were
their biggest fear to feel pain or not to be asleep enough. done with two-sample t-test for continuous data, with chi-
Thesamehappenedtothoseoneswhohadneverhadanan- square test for categorical data. The statistical significance
esthetic experience. While those over 30, who had already wasdefinedaspvalue,0.05.
been anesthetized, felt less fear. They were afraid of dying Results: Nine patients were excluded from the studydue to
inthe operating room. surgical bleeding. 45% of patients (n¼38) had blood
Discussion:Sincemostofthesurgicalpatientswereover30, loss.500ml/24 hours and were registered as I group. Post-
and agreeing with the other studies on this matter, it could operative bleeding volume significantly correlated with the
be inferred that the biggest fear of our patients is to die preoperative level of PAI-1 (r¼- 0.3, p¼0.009), with haemo-
during anesthesia. Anyway, the group that expressed fear globin and platelet count at T6 after surgery (r¼20.42,
tosufferpainbecauseofinsufficientanesthesia,wassurpris- p,0.001; r¼- 0.3, p¼0.02). Level of preoperative PAI-1 and
ingly bigger than expected. What called our attention was t-PA/PAI-1 complex after surgery significantly differed
thelittleinterest,ofthispopulation,toknowmoreaboutan- between I group (n¼38) and II group (n¼41): PAI-1
esthesia andtheanesthesiologist’s role. 19+8.3 vs. 29+13, p,0.001; t-PA/PAI-1 3+1.4 vs.
Conclusion:Althoughthefearofdeaththatourpatientsface 4.2+2.4,p¼0.012.PatientsinIgroupshowedasignificantly
whentheyaregoingtobeanesthetizedmaynotbealtered, higher level of D-dimers after surgery: at T1 - 318 vs. 228,
weconsiderwemustreducetheunfoundedfearofnotbeing p¼0.05; at T6 – 333 vs. 234, p¼0.03; at T24 – 300 vs. 197,
sufficiently asleep or feeling pain, by getting closer to the p¼0.007.
patient to dissipate the myth of insufficient anesthesia. Discussion:EBaftercardiacsurgeryisassociatedwithdiffer-
Thatwaywewillhave added comfortto ourpatients. entfibrinolyticactivity.Therearepatientswithalowerinhibi-
tory potential for fibrinolysis who could benefit most from
Keywords: Anesthesia;fear; pain; death
antifibrinolytic prophylaxis.
ii217
Downloaded from https://academic.oup.com/bja/article-abstract/108/suppl_2/ii215/2919735
by guest
on 30 January 2018
BJA
AbstractspresentedatWCA2012
Conclusion: A lower preoperative level of PAI-1 and lower PAI-1 did not statistically differed between 3 genotypes.
level of t-PA/PAI-1 complex just after surgery may lead to The highest level of t-PA/PAI-1 complex had patients with
higher levels of D-dimer later on and could be used as fi- the 4G/5G genotype (4G/5G – 3.9+2.1; 5G/5G – 3.6+2.4,
brinolytic system markers of enhanced fibrinolysis and 4G/4G – 3.1+1.8).Correlationwasfoundin4G/5Ggenotype
increased bleeding tendency. between PAI-1 level and blood loss (r¼2 0.4, p¼0.01) and
t-PA/PAI-1complexandbloodloss(r¼20.32,p¼0.04).Asso-
ciation between PAI-1 and t-PA/PAI-1 complex (r¼0.5,
Paper No: 133.00 p¼0.02) was observed in4G/4G genotype.
Conclusions: PAI-1 promoter - 675 (4G/5G) polymorphism
Influence of PAI-1 promoter polymorphism affectsPAI-1concentration,D-dimerlevelandbloodlossin-
to fibrinolytic activity of patients after dicatingthatpatientswith5G/5Ggenotypehasenhancedfi-
on-pump cardiac surgery brinolyticactivity.
Agnese Ozolina1, Eva Strike1, Inta Jaunalksne1,
Liene Nikitina-Zake2 and Indulis Vanags2 Paper No: 170.00
1PaulsStradinsClinicalUniversityHospital,Departmentof
AnaesthesiologyandCardiacsurgery,Latvia2LatvianBiomedical
Antiallodynic effects of curcumin in
ResearchandStudyCentreand3RigaStradinsUniversity,
inflammatory and postoperative pain
Departmentof
in rats
Introduction:Lowplasminogenactivatorinhibitor-1(PAI-1)
Myung Ha Yoon, Jeong Il Choi and Yeo Ok Kim
and tissue – plasminogen activator/PAI-1 (t-PA/PAI-1)
complex are associated with increased bleeding after DepartmentofAnesthesiologyandPainMedicine,MedicalSchool,
on-pump cardiac surgery. PAI-1 levels are influenced by ChonnamNationalUniversity,Gwangju,Korea
genetic factors. The PAI-1 gene promoter contains -
675(4G/5G) polymorphism. Introduction: Although curcumin, the major component of
Objectives: Investigate effect of the PAI-1 promoter - turmeric, has recently been shown to have antinociceptive
675(4G/5G) polymorphism on PAI-1, t-PA/PAI-1 concentra- effect in some pain states, the effects on inflammatoryand
tions andon bleedingvolumeaftercardiac surgery. postoperative pain remains to be determined. Thus, in the
Methods:Ninetypatientswhodidnotreceiveantifibrinolytic present study, we investigated the effect of curcumin on
prophylaxis were included in the prospective study. Study suchpain.
was approved by the institutional Committee of Ethics. We Methods: Inflammatory pain was induced by a subcutane-
obtained informed written consent from all patients for ous injection of 100¥`ıl of a 2% carrageenan solution into
their inclusion in the study. Seven patients were excluded the left hindpaw. For postoperative pain, a 1-cm longitudin-
duetosurgicalbleeding.Eighty-threepatientswereclassified al incision was made on the plantar aspect of the left
according to PAI-1 genotype: 4G/4G (n¼21), 4G/5G (n¼42), hindpaw of anesthetized rats and closed with 5-0 nylon.
5G/5G (n¼20). Data of fibrinolysis were recorded: PAI-1 Withdrawal threshold to von Frey filament application
level preoperatively, D – dimer at 0h, 6h and 24 hours near the injury site was determined before and after the
after surgery, t-PA/PAI-1 complex 24 hours postoperatively. drug administration. All drugs were injected
The groups were compared concerning factors which might intraperitoneally.
influence the postoperative bleeding: age, gender, body Results: After both carrageenan injection and plantar
mass index, surgical parameters, hemoglobin, platelets and incision, the paw withdrawal threshold was significantly
fibrinogen. Postoperative bleeding volume was registered as decreased in injured sites. Intraperitoneal administration
milliliters 24 hours after surgery. Association between of curcumin at doses from 10 to 100mg produced antiallo-
genetic polymorphism, fibrinolysis parameters and post- dynic effects in a dose-dependent manner in both pain
operative 24-hour blood loss were analyzed using SPSS 18 states.
(Student T-test, X2, Fischer’stest,Pearson coefficient). Conclusions:Intraperitonealcurcuminalleviatedmechanical
Results: Patients with the 5G/5G genotype had significantly allodyniainducedbypawcarrageenaninjectionandplantar
lower preoperative PAI-1 levels (17+10.8 vs. 24+9.6, incision. Thus, systemic curcumin may be a useful in the
p¼0.04), higher D-dimer levels at 6h (371+227 vs. 232+ management ofinflammatoryandpostoperative pain.
184, p¼0.03)and at 24h (326+207 vs.209+160, p¼0.05)
and greater postoperative blood volume (641+210 vs.
Paper No: 195.00
432+167, p¼0.001) compared with 4G/4G genotype. Pre-
operative PAI-1 level also statistically significantly differed
between5G/5G and 4G/5G genotypes (17+10.8 vs. 27+13,
Situation diagnosis of postoperative pain
p¼0.004). There were no significant differences in blood
loss between 5G/5G and 4G/5G genotypes. Complex of t-PA/ Cristian Humberto Bosio
ii218
Downloaded from https://academic.oup.com/bja/article-abstract/108/suppl_2/ii215/2919735
by guest
on 30 January 2018
BJA
AbstractspresentedatWCA2012
Pain is an “unpleasant sensory and emotional experience, dolor postoperatorio en un hospital de tercer nivel: situacio´n
related to actual or potential tissue damage, or described inicial previa a la implantacio´n de un programa de calidad. Esp.
in terms of such damage”. 1 Postoperative pain is a type of Anestesiol. Reanim. (2006); 53 :408–418. Available at: http://
www.sedar.es/restringido/2006/n7_2006/3.pdf. Visited in October
acute pain iatrogenic through the surgery with him being
2010.
excluded biological function. Today the consequences of
5 Zas-Ros BLa satisfaccio´n como indicador de excelencia de la
poor postoperative management are known. 2,3,4 Satisfac-
calidaddelosserviciosdesalud;Rev.Electro´nicaPsicologiaCien-
tion is currently used as an indicator of excellence in the tifica. Available at:http://www.psicologiacientifica.com/bv/
quality of care and improvement programs are intended to psicologia-80-1-la-satisfaccion-como-indicador-de-excelencia-en-
standardize quality pain care.5,6 The overall objective of la-calidad-d.html.VisitedinOctober2010.
thisstudywastoevaluatepostoperativepainpatientsadmit- 6 GallegoJl,Rodriguez-de-la-TorreMR,GallegoVasques-GuerreroJC,
ted to surgical wards and thus provide data to assist in the Gallego Gil M; :Estimacio´n de la prevalencia e intensidad del
dolor postoperatorio y su relacio´n con la satisfaccio´n de los
strategic policy planning for treatment and sizing the need
pacientes. Rev. Esp. Soc Esp. Dolor. (2004); Vol 11 n.4. Available
for furthereffortsto improve the qualityof care. In January
at: http://scielo.isciii.es/scielo.php?pid¼S1134-80462004000400
2011, a descriptive cross sectional study was done with
003&script¼sci_arttext.VisitedinOctober2010.
patients scheduled for elective surgery who agreed to
7 Valent´ın-Lopez B, Garcia-Caballero j, Mun˜oz-Ramo´n JM,
collect data in a survey during the preoperative and post- Aparicio-GrandeP,Diez-Sebastia´nJ;Criado-jimenez,OpCit.
operative period. Also collected information on painkillers
treatments prescribed. Were processed data obtained from
the descriptive analysis of variables in examination. The Paper No: 199.00
study observed that 79% of respondents during the pre-
operative (n¼44), thinksthatthe pain in the firstdays after
surgery, is unbearable. 78% of respondents in the post- Effect of single dose gabapentin on
operative period (n¼55) expressed pain in the first 24 postoperative pain and opioid consumption
hours following surgery, 54% of these, reported some following total abdominal hysterectomy:
degreeofinadequateanalgesiaatthetimeoftheinterview.
A Dose Finding Study
We also found a significant relationship between greater
levelsofpainandgreaterpatientdemandforextraanalgesic Anand Kumar
dosesaccordingtoFisher’sexacttest(p¼,0.05).Thisstudy
showedahighprevalenceofincorrecttreatmenttomeetthe Introduction: The multimodal analgesia involves the use of
needsofanalgesiainpostoperativepain.Diclofenacwasthe different analgesics is recommended in current practice to
drugmostusedin91%ofcasesandtherewasa80%over- providesuperiorpainreliefandtoreduceopioidconsumption
doseofit.Onlyonecaseofopioidanalgesicsprescriptionas and its side effects. Gabapentin in different dosages has
partoftreatmentwasreported.93%ofcaseswereclassified been found effective to reduce opioid consumption and de-
as inadequate analgesic treatment because of: (i) lack of creasing postoperative pain. We designed this study to find
extra analgesic dose prescription in the presence of pain minimumoptimaldoseofgabapentintobeusedwithpeth-
(93%);(ii)overdosagewithNSAIDs(78%);(iii)inadequatean- idinein ourpopulation.
algesia(62%); (iv)dangerous associations between drugs of Objective: To determine the minimum effective dose of
thesamegroup(25%).Thelevelofpatientsatisfactionwith gabapentin for postoperative pain and reduced opioid con-
analgesic therapy implemented by health personnel was sumption in patients undergoing total abdominal
very high as evidenced in previous studies.7 It is recom- hysterectomy.
mended that a committee of acute pain to make analgesia Methodology: After informed consent eightyseven patients
protocols. Also the creation of a unit for pain to control the were included in this double blinded randomized control
patients,monitortheanalgesicmethodsandteachingactiv- study. Patients were assigned randomly to one of the three
ities forallthe staff involved. groupsto receive capsule gabapentin orally 300mg, 600mg
and900mgrespectively,onehourbeforesurgery.Postopera-
tively pethidine consumption, pain score and side effects of
References
gabapentin were monitored for 24 hours. Rescue analgesia
1 FinkelDM,SchlegelHR.Dolorpostoperatorio,conceptosba´sicosy wasgiven andmonitored.
fundamentosparauntratamientoadecuado.Availableat:http:// Results: The groups did not differ demographically for age,
www.sld.cu/galerias/pdf/sitios/anestesiologia/dolor_postop.pdf.
weight and height. Mean pethidine consumption in all
VisitedinOctober2010.
threegroupswas331mg/24hourswithnostatisticaldiffer-
2 BolibarI,CatalaE,CadenaR:Eldolorenelhospital:delosesta´n-
ence among the groups. The results support the use of
daresdeprevalenciaalosdecalidad.Rev.Esp.Anestesiol.Reanim.
300mg single oral dose of gabapentin in reducing pethidine
(2005);52:131–140.Availableat:http://www.sedar.es/restringido/
2005/3/131.pdf.VisitedinOctober2010. consumption for postoperative analgesia Rescue analgesia
3 FinkelDM,SchlegelHR.Op.Cit. and number of goods and demands on PCIA data were
4 Valent´ın-Lopez B, Garcia-Caballero j, Mun˜oz-Ramo´n JM, also well matched with no statistical significance. The
Aparicio-Grande P, Diez-Sebastia´n J, Criado-jimenez Atencio´n del groups also did not differ for side effects of gabapentin like
ii219
Downloaded from https://academic.oup.com/bja/article-abstract/108/suppl_2/ii215/2919735
by guest
on 30 January 2018
BJA
AbstractspresentedatWCA2012
nausea, vomiting, somnolence and dizziness, howeverextu- tothetrainoffour(TOF)andanalyzedwiththeIONMat0,1
bation wasdelayed in 900mggroup. and 2minutes.
Conclusion: A single oral dose of gabapentin 300mg given Results:After2minutesoftheadministrationofsugamma-
preoperatively is as effective as higher dose of dex,allpatients had aTOF.0.9.
600-900mgforpostoperativeanalgesiawithreducedpethid- Conclusion:Theutilizationofarocuroniumspecificantagon-
ineconsumption. istwasefficientinpromotingthenormalizationofthemotor
conduction-responsetothestimulioftheIONMinapredict-
abletime.
References
1 VandeVusseAC,Stomp-vandenBergSG,KesselsAH,WeberWE.
Randomised controlled trial of gabapentin in Complex Regional Paper No: 228.00
PainSyndrometype.BMCNeurol.2004;4:13.
2 SeibRK, PaulJE. Preoperativegabapentinforpostoperativeanal-
gesia:Ameta-analysis.CanJAnesth.2006;53:461–9. Pharmacologic interaction between
3 KYHo,GanTJ,HabibAS.Gabapentinandpostoperativepain – A
intrathecal cannabinoid and cox-2 inhibitor
systematic review of randomized controlled trials. Pain. 2006;
126:91–101. in bone tumor pain model of rats
4 DierkingG,DuedahlTH,RasmussenML,etal.Effectsofgabapentin
Myung Ha Yoon and Jeong Il Choi
onpostoperativemorphineconsumptionandpainafterabdominal
hysterectomy:Arandomized,double-blindtrial.ActaAnaesthesiol DepartmentofAnesthesiologyandPainMedicine,MedicalSchool,
Scand.2004;48:322–7. ChonnamNationalUniversity,Gwangju,Korea
5 RorariusMF,MennanderS,SuominenP.Gabapentinforthepreven-
tionofpostoperativepainaftervaginalhysterectomy.Pain2004; Introduction: We evaluated the efficacy of nonselective
110:175. cannabinoid (CB) receptor agonist (WIN 55,212-2) and
6 DierkingG,DuedahlTH,RasmussenML,FomsgaardJS,MøinicheS, COX-2 inhibitor (DUP 697) on bone tumor pain in the spinal
RømsingJ,etal.Effectsofgabapentinonpostoperativemorphine
cordofrats,andalsotoexaminethepropertiesofdruginter-
consumption and pain after abdominal hysterectomy: a rando-
action between two drugs, further to clarify the role of CB1
mized, double-blind trial. Acta Anaesthesiol Scand. 2004Mar;
and CB2receptorson theeffect ofWIN55,212-2.
48(3):322
Methods: Bone tumor pain was induced by injection of
7 PengPW,WijeysunderaDN,LiCC.Useofgabapentinforperiopera-
tive pain control – a meta-analysis. Pain Res Manag. 2007 MRMT-1 tumor cells (1 x 105) into the tibia of female
Summer;12(2):85–92. Sprague-Dawley rats under sevoflurane anesthesia. A
polyethylene-10 catheter was inserted into the intrathecal
space for drug administration. For pain assessment, a with-
Paper No: 214.00 drawal threshold was measured using von Frey filament
being applied to the tumor cell inoculation site. The effects
ofintrathecalWIN55,212-2andDUP697wereinvestigated.
The Use Of Sugammadex In Orthopedic
Isobolographic analysis was used forevaluation of pharma-
Surgeries For The Correction Of Idiopathic
cologic interaction. And then, the role of CB receptors on
Scoliosis With Evoked Potentials the antinociception of WIN 55,212-2 was determined with
Monitorization selective CB1 (AM 251) and CB2 receptor (AM 630) antago-
nists, and selective CB1 (ACEA) and CB2 receptor (AM 1241)
Jorge Barrios Alarcon, Wagner Kouno,
agonists. The expression of CB receptors and COX-2 in the
Ricardo Ferreira, Oswaldo Cavalari and
spinal cord was examined with RT-PCR and Western blot
Luis Sergio Marques analysis.
Results:Intra-tibialinjectionofMRMT-1tumorcellsproduced
Sugammadex is a newpharmacologic agent utilized for the a bone tumor. Also, the paw withdrawal threshold was
rapid reversal of non-depolarizing muscle relaxants. The significantly decreased (mechanical allodynia) in tumor
purpose of this study was to demonstrate the possibility of developing site. Intrathecal WIN 55,212-2 and DUP 697
the use of sugammadex for reversal of rocuronium-induced dose-dependently increased the withdrawal threshold. Iso-
muscle relaxation before the start of intraoperative neuro- bolographic analysis revealed an additive interaction after
physiologic monitoring (IONM) during idiopathic scoliosis intrathecaldeliveryofWIN55,212-2andDUP697.Theanti-
with somatosensoryevoked potentials(SSEP). nociceptiveeffectofWIN55,212-2wasantagonizedbyboth
Methods: 20 adult patients, with a mean age of 34+10 AM 251 and AM 630. Both intrathecal ACEA and AM 1241
years, ASA I or II were involved in the study. They all had increased the withdrawal threshold. RT-PCR showed that
the diagnosis of scoliosis and were scheduled for surgeryto CB1, CB2 receptors and COX-2 mRNA were detected in the
correct their scoliosis with the use of SSEP. Immediately spinal cord of sham rats, while COX-2 mRNA, but not CB1,
before the start of the surgical instrumentation and the CB2 receptors mRNA, expression was increased in bone
startoftheIONM,sugammadexwasadministeredaccording tumor rats. Western blot analysis indicated that CB1, 2
ii220
Downloaded from https://academic.oup.com/bja/article-abstract/108/suppl_2/ii215/2919735
by guest
on 30 January 2018
BJA
AbstractspresentedatWCA2012
receptors and COX-2 protein were expressed in the spinal References
cordofshamandbonetumorrats,andnosignificantdiffer-
1 RoweR,CohenRA.AnEvaluationofaVirtualRealityAirwaySimu-
ences were seen in the expression level between sham and
lator.AnesthAnalg2002;95:62–6.
bonetumor rats.
2 Rosenstock C et al. Qualitative analysis of unanticipated difficult
Conclusions: Intrathecal WIN55,212-2 and DUP697reduce airwaymanagement.ActaAnaesthesiolScand2006;50:290–7
bone tumor-related pain behavior, and interact additively 3 MayroseJetal.UtilizationofVirtualrealityforendotrachealintub-
with each other. The effect of WIN 55,212-2 is mediated ationtraining.Resuscitation2003;59:133–8
through bothCB1 andCB2 receptorsin thespinal cord. 4 GoldmannK,SteinfeldtT.Acquisitionofbasicfiberopticintubation
skillswithavirtualrealityairwaysimulator.J.ofClinicalAnaesthe-
sia2006;18:173–8.
Paper No: 234.00 5 Blum MG, Powers TW, Sundaresan S. Bronchoscopy Simulator Ef-
fectivelyPreparesJuniorResidentstoCompetentlyPerformBasic
ClinicalBronchoscopy.AnnThoracSurg2004;78:287–91
6 CrawfordSW,ColtHG.VirtualRealityandWrittenAssessmentsof
PotentialValuetoDetermineKnowledgeandSkillinFlexibleBron-
Inexperienced doctors get remarkable
choscopy.Respiration2004;71:269–275
skills in fiberoptic intubation after specific 7 LetterfromCamillaLindholmRasmussenCand.Jur.
training in a virtual airway simulator
Pernille Vaabengaard and
Paper No: 240.00
Michael Seltz Kristensen
Rigshositalet,Blegdamsvej,Afd2073,Copenhagen,Slagelse Local anesthesia for awake craniotomy
Sygehus,Anaestesiafdelingen,4200Slagelse,Denmark
Angel Mario Ruiz, Sandra Ximena and
Jaramillo Jairo Moyano
Introduction: It is very essential for anaesthesiologist to be
incontrolwhendealingwithadifficultairway.Thereforestu- HospitalUniversitarioFundacionSantaFedeBogotaHospital
dents need to be trained in this discipline. The sooner the UniversitarioFundacionSantaFedeBogotaHospitalUniversitario
better. A somewhat newer method is the use of virtual FundacionSantaFedeBogota
airwaysimulators.
Objectives: The purpose of this study was to see whether The intracranial tumor resection on eloquent motorareas are
completionofsimulatortrainingwithasatisfactoryandspe- at high risk of developing neurological deficit intrasurgery.
cific endpoint could improve doctors ability to make a fiber Many anesthetic techniques are used to perform this surgical
optic intubation significantly faster and more confident procedure with sedation or intermittent anesthesia Actually,
thaninexperienceddoctors. notdescribedmultimodaltechniquescombiningregionalanes-
Methods: This study was a randomized clinical study. Ten thesia, sedation and systemic analgesia in these patients. We
doctors were included equally split between the control use a technique awake, consistent with the implementation
groupandthesimulatorgroup.Fivedoctorsreceivedtraining ofacompleteblockadeofscalpplussedationandanalgesia.
intheEducationalLabatTheUniversityHospital“Rigshospi- Objective: To assess the quality of anesthesia, reliability
talet” in Copenhagen, Denmark. Within a week they had to neurologicalmonitoring andcontrolof anxiolysis
perform a real fiber optic intubation on an anaesthetized Methodology: The study included 6 patients diagnosed with
patient in the operating room. The endpoint was time tentorialtumorinneighborhoodtoeloquentareaswithradio-
spendduring theprocedure. logicalsignsofintracranialhypertension.Patientswithoutpul-
Results:Theffivedoctorsinthesimulatorgrouppracticedin monaryorcardiacpathologywithMidazolamwastitratedwith
average54minutes+8minutesandcompletedbetween22 doses of 0.2 to 04mg / kg IV dose and remifentanil 0.03 to
and33virtualfiberopticalintubations.Thentheyhadtopass 0.05 ug / kg / min plus and scalp block with lidocaine 2%
a test with specific endpoints: time used (less than 60 WOE and bupivacaine 0, WOE 5% at level of greater and
seconds), numberofcollisions (maximum 10) endeffective- lesser occipital, supraorbital and inferior trochlear and man-
ness (greater than 80%). Doctors in the control group were dibular nerves. Antiemetic prophylaxis. We evaluatednausea,
significantly slower to FOI compared to doctors who joined vomiting and respiratory depression, cooperative patient, oc-
the simulator group. Using Mann-Whitney test finding a currenceofneurologicaldeficit,andpostoperativepain.
p-value ,0.05.Themediandifferenceis266and95%confi- Results: All patients were partners (in our scale level of co-
denceinterval[232to 542]. operation was good) and were able to perform adequately
Conclusion: The use of the virtual airway simulator should neurological assessment. The average operative time was
become a compulsory part of educating the first year resi- between 1–5 hours, the most common tumors were
dents in the management of difficult airways. The doctors gliomas located in eloquent 50% air and 50% in motor
can gain significant better experience in the use of a fiber areas. Neurological changes were monitored during surgery
opticscopebeforemeetingapatientintheoperatingroom. in48%ofpatients.Adverseeventsattributabletoanesthesia
weremoderatehypercapniain16%withoutotherassociated
ii221
Downloaded from https://academic.oup.com/bja/article-abstract/108/suppl_2/ii215/2919735
by guest
on 30 January 2018
BJA
AbstractspresentedatWCA2012
complications. One patient (16%) showed a complication plus 1 MAC of desflurane On arrival to the postanesthesia
transoperative, presented a focal motor seizures, which care unit (PACU), each patient received a PCA pump pro-
yielded spontaneously. 84% of patients does’t require sys- grammed to deliver an initial morphine bolus of
temicanalgesics in thefirst6hours postoperative 0.05mg.kg-1 at 7min intervals if pain was more than 60 on
Discussion:Theimplementationofthistechniqueaswellas the VAS. On discharge from the PACU the pump was repro-
being innovative in neurosurgical patients turns out to be a grammed for a morphine bolus of 1.5mg and a 7min
safe technique to avoid the continual changes in patient’s lockout interval and no background infusion. The primary
anesthetic depth and therefore hemodynamic changes to a outcome measure was pain relief and patient satisfaction
patient with intracranial hypertension should not besubject which evaluated by using 100mm VAS (0-100). Secondary
toalterationincerebralautoregulationandthelossofcom- outcomes were morphine consumption, and side effects in-
pliance, so we recommend the use of this technique in a cluding nausea, vomiting, pruritus, sedation, fatigue and re-
properpatientselectioninrelationtoanxietyandpreexisting spiratory depression. Outcome measures were recorded by
comorbidities for resection of tumors that allow continuous the same trained nursing staff. at 30min., 1, 3, 6, 12, 24
neurologic payment in intra-and postoperative . We saw and48hpostoperatively.Inapilotstudy20patientsenrolled
thesamemannerasthepatientshadadequatepaincontrol toGOSunderGAconsumedanaverageof57+21mgofmor-
Conclusion:Blockadeofthescalpinassociationwithmidazo- phineinthe first 48hwithPCA pump.Toachieve aone-third
lamandremifentaniliseffectiveandsafeforadministration reduction of opioid consumption with an a´ error of 0.005
in awake craniotomy for tumor resection in, allowing andapowerof90%,weneeded26patientsineachgroup.
optimum collaboration and neurologicalassessment. Results: Fifty six women (28 intrathecal and 28 plasebo)
completed the study. No differences were noted with
respecttoage,weight,height,timeofsurgeryandoperation
Paper No: 273.00 typebetweenthegroups.Significantdifferencewasdemon-
strated in morphine consumption(19.25+13mg and
The effects of intrathecal morphine on 54.23+22mg in group 1 and group 2 respectively) and
patient-controlled analgesia morphine fatique scores. Satisfaction scores and side effects were
similar in both groups. Conclusion In conclusion, 0.3mg
consumption, postoperative pain scores
intrathecal morphine in gynecologic oncologic surgery
and satisfaction in patients undergoing
couldimprovepostoperativeanalgesiaandreducemorphine
gynecologic oncologic surgery under consumptionwithout anyserious sideeffects.
general anesthesia
References
Inci Kara, Seza Apiliogullari, Bahar Oc,
1 JemalA,SiegelR,XuJ,WardE.Cancerstatistics.CACancerJClin
Jale Bengi Celik and Ates Duman
2010;60:277–300
SelcukUniversity,SelcukluMedicalFaculty,Departmentof 2 Chen LM, Weinberg VK, Chen C, Powell B, Chen LL, Chan JK,
AnesthesiologyandIntensiveCare Burkhardt DH. Perioperative outcomes comparing patient con-
trolledepiduralversusintravenousanalgesiaingynecologiconcol-
Introduction: Gynecologic cancers represent a major health ogysurgeryGynecologicOncology115(2009)357–361
problem among women(1). Gynecologic oncologic surgery 3 Kehlet H, Holte K. Effect of postoperative analgesia on surgical
outcome.BrJAnaesth2001;87:62–72
includes a wide variety of surgical procedures. (2). Post-
operative pain is a majorconcern in these patients because
it affects multiple systems and induces physiological, im-
Paper No: 275.00
munological,and psychological changes(3)
Objectives:Weaimedtocompareintrathecalmorphineplus
Heterotopic cardiac transplant
patient-controlled analgesia with patient-controlled anal-
gesia alone on morphine consumption, pain relief and Nelson Ruiz and Claudio Burgos
patients satisfaction after gynecologic oncologic surgery
(GOS)undergeneralanesthesia Introduction: Heterotopic cardiac transplant is avalid alter-
Metods: In this double-blinded, randomized, controlled native:(i)whentherecipientisaffectedbypulmonaryhyper-
study, 60 women undergoing GOSwere allocated to receive tension secondary to his left chronic cardiomyopathy and
either intrathecal morphine 0.3mg (Group 1) or placebo thereisimminentriskofacuterightventriculardysfunction;
group(Group2).Fortheplacebogroup,theskinwaspunctu- (ii) in patients with heart disease with healing possibilities
redwiththedentalneedle,butitwasnotadvancedbeyond and no long lasting mechanic assist devices available; and
the subcutaneous tissue. Monitoring and anesthesia were (iii) whenthe donor hasamismatch higherthan20%.
standardized.Anesthesiawasinducedwith2mg.kg-1ofpro- Objetives: Describe the surgical procedure and the experi-
pofol and 2mg.kg-1 of fentanyl. and 0.6mg.kg-1. of rocuro- enceof thisdepartment.
nium. After tracheal intubation, anesthesia was maintained Material and Method: We studied eleven patients whose
with a mixture of air (0.5L/min) and oxygen (0.5L/min) prevalent pathologies were idiopathic dilated
ii222
Downloaded from https://academic.oup.com/bja/article-abstract/108/suppl_2/ii215/2919735
by guest
on 30 January 2018
BJA
AbstractspresentedatWCA2012
cardiomyopathy,hypertensivecardiomyopathy.Sinusrhythm Objective: Evaluation of sugammadex effectiveness in fast
was predominant in most cases. The average waiting time trackextubationprotocol(60-90min)ofpatientsundergoing
was of 271 days. Eight transplants were elective, one cardiac surgerywith cardiopulmonary bypass (CPB).
urgent andtwo emergencies.Thetechnique: Materials and methods: From February to August 2011
DonorRecipient:PulmonaryArteryRightAtriumLeftAtrium twenty patients, 12 males and 8 females undergoing
Left Atrium Aorta Artery Aorta Artery (end-to-side) Closed cardiacsurgerywithCPBwereenrolledinthefasttrackextu-
VenaeCavae bation protocol. The age ranged from 25 to 61 years (mean
age49,4+5,3),andmeanweighwas74,3+6,7kg.Eighteen
† Donor LVejectstowardsAo, inits diastole.
patientsunderwentvalverepair/replacementsurgeryand2-
† RecipientLVejects duringdonor’s diastole.
combinedvalvereplacementandCABG.MeanCPBtimewas
—if this is not the case, there will be blood stasis with 78,9+10,4 (50-129) min and aortic cross clamping was
arrhythmias, displacement of interventricular septum, 62,1+8,2 (38-111) min. All patients had anesthesia
thromboembolic phenomenon, cardiac arrest. In order to induced with midazolam (0,1mg/kg), propofol (1,0–1,5mg/
achieve the above, both hearts were synchronized with 2 kg)androcuronium1,0mg/kg.Formaintenanceofanesthe-
dual-chamberpacemakers (DDDR). sia before, during, and after bypass, all patients received a
Pacemaker-1: ABEE connected to recipient’s RA VBEE con- continuousinfusionofrocuronium(0,4mg/kg/hr),12received
nected to donor’sRA sevoflurane and 8 propofol. Analgesia was maintained with
Pacemaker-2: ABEE connected to recipient’s RV VBEE con- fentanyl (3,1+0,2mcg/kg/h). At the end of surgery 4mg/kg
nected to donor’sLV sugammadex was administered for reversal of rocuronium.
Another option is using one pacemaker (DDD). Pacemaker-1: Central hemodynamic parameters, level of neuromuscular
ABEEconnectedtorecipient’sRVVBEEconnectedtodonor’sLV blockade(TOF),BISindex,recoveryofspontaneousbreathing
—with this we are able to: Simplify synchronization and AV and time to ensure full recovery before extubation were
interval programming Userecipient’s sinus node to manage monitored.
both hearts Improve ejection times Reduce costs Control Results:ThroughoutsurgerymeanTOFlevelwas0,17+0,03
through hemodynamics and transoesophageal (0,1-0,2). BIS index was 32+6 (30-40%) during surgeryand
echocardiogram gradually increased after stopping sevoflurane or propofol
Results:Ofeleventransplantstherewere2deaths – onedue andreached67+3(65-70%)atendofsurgery.Aftersugam-
tohepatopathybecauseofalcoholismandoneduetoacute madex administration patients regained consciousness,
vascular rejection. breathed spontaneously, were alert, central hemodynamic
Discussion:Theheterotopiccardiactransplanthassomedif- parameters were stable and TOF increased to 0,9 within 5
ficulties such as incorrect synchrony if donor’s heart rate is minutes. All patients were extubated in the operating room
higher than recipient’s one; supraventricular arrhythmias of within 57,0+10,4 (30–120) minutes after injecting sugam-
recipient’sordonor’sheart.Whenchoosingonepacemaker, madex;theyweretransferredtoICUwithgoodspontaneous
thedonor’sheart,whosesinusnodewaselectrocoagulated, breathing, stable cardiac function, and good biochemical
allowsthenativehearttoachievesynchronyattheventricu- analyses. Mean ICU stay was 18 hours, one patient needed
lar level, generating a physiological synchronysince the au- apacemakerandstayed inICU for48 hours.
tonomous nervous system is preserved and acts on the Conclusion:Administrationofsugammadexwas effective in
cardiac rhythmof therecipient’s heart. fast track extubation of patients undergoing cardiac
Conclusion: In the world there are more than 100 people surgery withcardiopulmonary bypass.
with two hearts. Our experience, the only one in Latin
America, shows that heterotopic cardiac Tx is a valid
therapy when there is more than 10% donor/recipient mis- Paper No: 374.00
match orsevere pulmonary vascular resistance.
Concept of total myocardial protection by
Paper No: 298.00 sevoflurane during cardiac surgery with
cardiopulmonary bypass: preliminary
results
Fast track protocol of extubation after
Vladimir Pichugin1, Nickolay Melnikov2,
cardiac operations with cardiopulmonary
Alishir Gamzaev2, Olga Shirokova2 and
bypass: the role of sugammadex
Alexander Medvedev1
Vladimir Pichugin1, Victor Bober2,
1NizhnyNovgorodStateMedicalAcademy2NizhnyNovgorod
Mikhail Bodashkov2, Victor Prytkov2 and
CardiacandVascularSurgery
Leckwantee Rittoo1
1NizhnyNovgorodStateMedicalAcademyand2NizhnyNovgorod Introduction: The protective properties of sevoflurane on
CardiacandVascularSurgery myocardium have been attributed to anesthetic pre- and
ii223
Downloaded from https://academic.oup.com/bja/article-abstract/108/suppl_2/ii215/2919735
by guest
on 30 January 2018
BJA
AbstractspresentedatWCA2012
postconditioning. Clinically this effect is enhanced when Undergoing Coronary Surgery with Cardiopulmonary Bypass Are
sevoflurane is administered throughout the surgical proced- Related to the Modalities of Its Administration// Anesthesiology
ure (De Hert et al., 2002; De Hert et al., 2004; Cromheecke 2004;101:299–310
S. et al., 2006). When the aorta is cross-clamped coronary 3 Stefanie Cromheecke, Veronik Pepermans, Ellen Hendrickx, et al.
CardioprotectivePropertiesofSevofluraneinPatientsUndergoing
blood flow ceases and sevoflurane cannot be delivered to
Aortic Valve Replacement with Cardiopulmonary Bypass// Anesth
myocardium. To address this problem we propose the use
Analg2006;103:289–96
of ante- or retrograde coronary perfusion. In some studies
4 NaderND,LiCM,KhadraWZ,ReedyR,PanosALAnestheticmyo-
sevoflurane 2% was added to the cardioplegic solution cardial protection with sevoflarane//jJ. Cardiothor. Vasc.Anesth.-
(Nader N.D. et al., 2004; Nader N.D. et al., 2006) but there 2004.-Vol.18.P.269–274.
were no conclusive data concerning its effect on the hypo- 5 Nader ND, Karamanoukian HL, Reedy RL, Salehpour F, Knight PR
thermicmyocardium. Inclusionofsevofluraneincardioplegiareducesneutrophilactivity
Objectives:Toevaluatetheeffectivenessoftotalmyocardial during cardiopulmonary bypass// J. Cardiothor.Vasc.Anesth.-
2006.-Vol.20.-P.57–62.
protectionbysevoflurane(TSMP)duringcardiacsurgerywith
cardiopulmonary bypass(CPB).
Material and Methods: After ethical approval and written
Paper No: 377.00
informed consent TSMP was used in 5 patients undergoing
valve surgery (replacement ofmitralvalve – 2;replacement
of aortic valve -1; mitral and tricuspid valves repair -2) with Cardiac surgery in patients with
normothermic CPB from July to August 2011. The study heparin-induced thombocytopenia
included 2 males and 3 females aged 36 to 62 years
Miomir Jovic, Dusko Nezic, Branko Calija,
(mean 47.4+5.9) with an ejection fraction ranging from 20
Milorad Borzanovic and Aleksandar Knezevic
to 40%. TSMP was achieved by administering sevoflurane
throughoutwholeprocedure:forinductionandmaintenance DedinjeCardiovascularInstitute,MedicalSchool,Universityof
of anesthesia in pre- and post bypass periods. During CPB Belgrade,Serbia
sevofluranewasadministeredviaavaporizerwhichwascon-
nected totheoxygenatorgas supplyline. Allsurgerieswere Introduction:Heparininducedthrombocytopenia(HIT)isco-
performed on “the beating heart” with constant antegrade agulation disorder in patients treated by nonfractioned
or retrograde coronary perfusion. For coronary perfusion heparin or (rear) by low molecular weight heparine
bloodenrichedwithsevoflurane(2-3vol%)fromoxygenator (LMWH). In the most patients (pts) nonimmune form of
wasusedthusallowingconstantsupplyofsevofluranetothe HIToccurs,characterisedbyamilddecreaseinintheplatelet
myocardium even during aortic cross clamping. Mean CPB count and is not harmful. The second type, immune-
time was 68 +14min. and aorta cross clamping was 53 mediated HIT, occures much less frequently, thrombocyto-
+16minutes. penia is the first clinical sign followed by reduced number
Results: Dobutamine (2-3 mcg/kg/min) was used in 2 of platelets, less then 100 000 mm3 or reduced number
patients. All patients underwent early extubation in OR more then 50%. Sometimes, reduction of platelets number
before transfer to ICU. The post operative levels of CK-MB mightbeless(30-40%).In20–50%ofptsthrombocytopenia
were lower than in non TSMP group. Three hours after is severe and often associated with thrombo-embolic and
surgery CK-MB level in TSMP group was lower by 38,1% haemorrhagic events. Usually, 5–15 days after the first ad-
and 13,3%; 8 hours after surgery lower by 45,9% and ministration of heparin, immune-mediated HIT occures.
27,7%; 24 hours after surgery lower by 42,0% and 32,6% Heparin forms antigen complex with pletlet factor 4 (PF4)
and lower by 29,7% and 17,4% 48 hours after surgery that is released by platelets. Specific antibodies, formed
compared to propofol(12 patients) and sevoflurane(11 against complex heparin-PF4, bind to this complex and
patients) groups respectively. Normalization of CK-MB destroy the platelets. The desruption of platelets, stimulate
level was registered earlier in TSMP group (within 24 the formation of new blood clots with consequence of
hours), in propofol (more than 48 hours) and sevoflurane deepveinthrombosis,pulmonaryembolism,orevenmyocar-
(in 48 hours) groups. dial infarction orstroke.
Conclusion:Ourtechniqueimprovedmyocardialprotectionin Objectives: HITmight be life-threatening in patients under-
high riskcardiac patients butlarger prospective randomized going open heart surgery, due to thromboembolic events,
trials are needed to definitively assess the cardioprotective thrombocytopeniaandbleeding.Ifcardiacsurgerywithcar-
effects ofthistechnique. diopulmonary bypass (CPB) is necessary, anticoagulation
therapy will be based on usage of danaparoid or direct
References thrombininhibitors.
Methods: Female patient was switched from per oral anti-
1 StefanG,DeHert,PieterW,tenBroecke,ElsMertens,etal.Sevo-
coagulanttherapytolowmolecularheparintherapyprepar-
fluranebutNotPropofolPreservesMyocardialFunctioninCoronary
SurgeryPatients//Anesthesiology,V97,No1,Jul2002 ing for reredo mitral valve replacement due to endocarditis
2 StefanG,DeHert,PhilippeJ,VanderLinden,StefanieCromheecke andartificialvalvethrombosis.Innext10days,thrombocyto-
et al. Cardioprotective Properties of Sevoflurane in Patients penia was obvious (Tr 302 000 mm3 to 11 000 mm3), and
ii224
Downloaded from https://academic.oup.com/bja/article-abstract/108/suppl_2/ii215/2919735
by guest
on 30 January 2018