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Experiences, with about 1500 cases of intravenous regional anesthesia in outpatient surgery of the limbs over 10 years are reported. In 1975, 158 operations out of 5960 were done using this technique. Intravenous regional anesthesia is suitable for surgery of the limbs, but time of operation should not exceed 90 min, nor should hemostasis be a major problem to consider and the course of surgery should be predictable. Contraindications for this type of anesthesia are hypertonia, lack of accessible veins, heart failure, children, as well as surgery of undefinite extent or for local sepsis. When these rules were followed, no serious complications were seen.
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PMID:[Intravenous regional anesthesia (author's transl)]. 59 9

Anesthetic indices for methoxyflurane, enflurane, and isoflurane in oxygen and halothane in nitrous oxide and oxygen (50:50), were determined in rats using measurements of heart and brain concentrations of the volatile agents at the endpoints of anesthesia, respiratory arrest and cardiac failure. The indices related respiratory arrest to anesthesia (respiratory index-A1r), cardiac failure to anesthesia (cardiac index-AIc) and respiratory arrest to cardiac failure (cardiorespiratory index-AIcr). Isoflurane had a significantly higher AIr (3.1) and AIc (5.7) than enflurane (AIr 1.8, AIc 3.3), methoxyflurane (AIr 2.2, AIc 3.7) and halothane in nitrous oxide and oxygen (AIr 2.4, AIc 3.7). These indices were also higher than those previously determined for halothane (AIr 2.3, AIc 3.0). Isoflurane had a higher AIcr (1.9) than halothane (1.6). Enflurane had a significantly lower AIr (1.8) than any of the other agents studied. These findings suggested a greater margin of safety for isoflurane, especially with respect to the heart, and a greater potential for respiratory depression for enflurane than for the other agents. Nitrous oxide decreased the amount of halothane necessary to produce anesthesia, but also that needed to produce respiratory arrest or cardiac failure. The addition of nitrous oxide, therefore, did not significantly enhance the overall safety of halothane anesthesia with respect to potential respiratory or cardiac depression.
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PMID:Anesthetic indices--further data. 62 24

In an attempt to assess cardiac risk in non-cardiac surgery, 1001 patients over 40 years of age who underwent major operative procedures were examined preoperatively, observed through surgery, studied with at least one postoperative electrocardiogram, and followed until hospital discharge or death. Documented postoperative myocardial infarction occurred in only 18 patients; though most of these patients had some pre-existing heart disease, there were few preoperative factors which were statistically correlated with postoperative infarction. Postoperative pulmonary edema was strongly correlated with preoperative heart failure, but 21 of the 36 patients who developed pulmonary edema did not have any prior history of heart failure. Nearly all of these 21 patients were elderly, had abnormal preoperative electrocardiograms, and had intraabdominal or intrathoracic surgery. In the absence of an acute infarction, bifascicular conduction defects, with or without PR interval prolongation, never progressed to complete heart block. Spinal anesthesia protected against postoperative heart failure but not against other cardiac complication. By multivariate regression analysis, postoperative cardiac death was significantly correlated with (a) myocardial infarction in the previous 6 months; (b) third heart sound or jugular venous distention immediately preoperatively; (c) more than five premature ventricular contractions per minute documented at any time preoperatively; (d) rhythm other than sinus, or premature atrial contractions on preoperative electrocardiogram; (e) age over 70 years; (f) significant valvular aortic stenosis; (g) emergency operation; (h) a 33% or greater fall in systolic blood pressure for more than 10 minutes intraoperatively. Notably unimportant factors included smoking, glucose intolerance, hyperlipidemia, hypertension, peripheral atherosclerotic vascular disease, angina, and distant myocardial infarction.
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PMID:Cardiac risk factors and complications in non-cardiac surgery. 66 58

Eighty-four infants with esophageal atresia and/or tracheosophageal (TE) fistula were treated from 1972 to 1977. Twenty-eight percent were premature and 24% weighed less than 2.0 kg. Major symptoms included excess salivation (56 patients), respiratory distress (28 patients), cyanosis (26 patients), and choking (nine patients). Pneumonia and or atelectasis occurred in 58% and associated anomalies in 68%. Seventy-three of 84 patients (87%) had proximal esophageal atresia and distal TE fistula (type C defect). Operation was carried out in 79 patients. Gastrostomy was performed in 75 patients, often under local anesthesia with subsequent delayed extrapleural thoractomy (mean, 3.9 days), when the infant's pulmonary condition was improved. Primary anastomosis was performed in 55 patients, division TE fistula and esophagostomy in ten, staged anastomosis in seven, cervical esophagostomy alone in three, division H fistual in two, ligation TE fistula alone in one, and gastrostomy alone in one. Complications were frequent, including need for ventilator support in 28 patients, atelectasis in 28, pneumonia in 18, jaundice in 13, heart failure in 11, anastomotic leak in 10, and stricture in four. Operative mortality was 5% (four of 79). Two deaths followed immediate thoracotomy and two were premature with anomalies. There were eight late deaths 4 to 39 months after operation. Seven had multiple anomalies. The overall mortality was 15%. Management of high-risk cases by preliminary gastrostomy and delayed extrapleural thoracotomy is associated with improved survival (67 to 79) (85%). Neonatal intensive care, detection of associated anomalies, and long-term follow-up are essential factors in reducing mortality.
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PMID:Esophageal atresia and tracheoesophageal fistula: Effect of delayed thoracotomy on survival. 68 29

Twenty-four neonates at 25-34 weeks' gestation with a weight range of 570-1530 g underwent ligation of patent ductus arteriosus (PDA). The infants had mild to severe respiratory distress syndrome at birth and later developed signs of heart failure as a result of left-to-right shunting through a PDA. Surgical closure of the PDA was performed within 2-31 days after birth. In the period before operation the heart rate was monitored constantly and the arterial blood-gases were assessed frequently. The trachea was intubated and respiration was controlled with a ventilator. Surgery was performed under controlled ventilation and no anaesthesia was used. Care was taken not to overventilate the lungs. Nine infants died. Death was associated with higher peak inspiratory ventilator pressures at the time of operation and with complications occurring during or after the operation. The most common complication was tension pneumomediastinum which appears to be related to excessive ventilator pressures during surgery.
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PMID:Ligation of patent ductus arteriosus in premature infants. 77 96

Changes in pulmonary hemodynamics and acid-base balance were recorded during induction of anesthesia using either intravenous administration of barbiturate (28 patients) or inhalation of N2O-O2-halothane (12 patients). The two types of induction resulted in equal elevations of pressures within the pulmonary circulation. The increase, proportional on the two sides of the heart, was most pronounced immediately before endotracheal intubation. Cardiac index decreased before and during intubation but subsequently increased to levels above control values. Systemic blood pressure increased more during barbiturate than during inhalation induction. Changes in acid-base balance were similar during the two types of induction: arterial blood PCO2 and PO2 increased, pH decreased, and standard bicarbonate remained unchanged. Changes in pulmonary arterial mean pressure and central venous pressure were correlated with changes in PACO2. Pulmonary capillary filtration pressure (i.e., pulmonary capillary wedge pressure minus plasma colloid osmotic pressure) was negative in every patient before anesthesia. During induction of anesthesia, filtration presures became positive in half the patients. Observed changes in circulation may have been caused by hypercapnia alone or by a combination of hypercapnia and vescular reflexes associated with instrumentation during intubation. The increased strain on the heart during induction of anesthesia may lead to cardiac failure in patients with diminished cardiac reserve.
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PMID:Pulmonary hemodynamics during induction of anesthesia. 84 81

Emergencies resulting in death of the patient are sufficient reason for insisting on only medically qualified people giving anaesthetics. Unlike in most other specialities, complications in anaesthesia usually will not await the arrival of the expert. Trauma provides the anaesthetist with some of his most testing occasions. Most problems are related, as with emergencies, to basic derangements of respiratory and circulatory physiology However, there is a steady progression with severe trauma cases that is not a common feature of the ordinary anaesthetic disaster. Respiratory problems are either of obstructive origin or due to failure to generate respiratory muscle activity. Circulatory problems, in the vast majority of cases, consist of low cardiac output because of relatively deficient circulatory blood volume. Overload of the circulation resulting in acute pulmonary oedema is often feared but uncommonly seen. Another cause of failure of output of the heart lies in the heart itself, either because heart muscle is not contracting well enough--myocardial failure, or because of disorder of rhythm.
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PMID:Problems in general anaesthesia. Emergencies and trauma. 88 Jan 36

In the last 3 years 93 cases of iliofermoral trombosis were treated by surgery. We prefer the method used by Brunner, but under general anaesthesia and using a Bentley-Autotransfusion-System (ATS). The average age of our patients was 55 years (age ranged between 17 and 87 years). No lethal pulmonary embolism was observed. 2, 1 percent of the patients died following apoplex or acute heart failure. Of 67 patients who were operated on 6 months ago or more 70 percent have no further complaints, 28 percent still have some residual edema and only 2 patients have a severe postthrombotic syndrome. 50 percent of 40 control-phlebograms demonstrated patency of all veins. 20 percent had short segmentary occlusions with definite signs of recanalisation, while in 27 percent of the cases occlusions of the lower leg and thigh were found, the iliac veins being free. Only 2 postoperative phlebograms showed a complete iliofemoral venous occlusion. Our results prove, that the operative thrombectomy is a successful method, with which the main complications of the iliofemoral thrombosis-pulmonary embolisation and postthrombotic syndrome-can difinitely be reduced. Also because of better long term results, the operative therapy of acute ilofemoral thrombosis should be generally prefered instead of conservative treatment.
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PMID:[Surgical treatment of acute deep leg and pelvic vein trombosis]. 91 58

Sodium nitroprusside is an excellent agent for lowering blood pressure in hypertensive emergencies, for producing controlled hypotension during anesthesia, and for treating acute myocardial infarction and chronic heart failure. Toxic effects of this drug have been reported and above-normal cyanide and thiocyanate concentrations have been observed in the blood of a small proportion of subjects receiving nitroprusside. Nitrite, syanide, and thiocyanate are major decomposition products of nitroprusside, resulting from an in vitro reaction with human blood. On the basis of the conversion mechanism, we suggest that, in the cyanide/thiocyanate cycle, only cyanide is directly responsible for any acute toxicity attributed to sodium nitroprusside. In this work, the extent of cyanide production by erythrocytes in vitro was studied. The rate of detoxification of cyanide by human liver in vitro was experimentally determined and data from a search for a possible inhibitor of the nitroprusside/hemoglobin reaction are presented. Also, the possible mechanism of the nitroprusside/hemoglobin reaction is discussed.
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PMID:Some aspects of sodium nitroprusside reaction with human erythrocytes. 92 83

Circulatory responses after thiamylal (4 mg/kg) and succinylcholine (SCh) (2 mg/kg) administration followed by direct laryngoscopy and tracheal intubation were measured in 20 patients before elective aortocoronary vein bypass graft operations. Compared with awake measurements, the mean arterial pressure (MAP) decreased 19 +/- 3 torr (mean +/- SE) and heart rate (HR) increased 9 +/- 3 bpm 1 minute after thiamylal-SCh. MAP was increased 39 +/- 4 torr and HR 20 +/- 3 bpm above awake levels in response to laryngoscopy and tracheal intubation. Blood pressure and HR returned spontaneously to near awake levels without additional anesthesia within 5 minutes of anesthetic induction. Stroke volume index was decreased significantly after tracheal intubation but cardiac index was not altered. The authors conclude that thiamylal-SCh followed by tracheal intubation is an acceptable anesthetic induction sequence for patients without evidence of left ventricular heart failure who require anesthesia for elective coronary artery revascularization.
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PMID:Circulatory changes in patients with coronary artery disease following thiamylal-succinylcholine and tracheal intubation. 94 83


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