Anesthesia and analgesia
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Anesthesia and analgesia · Oct 1999
Intraoperative hemodynamic predictors of mortality, stroke, and myocardial infarction after coronary artery bypass surgery.
Evidence that intraoperative hemodynamic abnormalities influence outcome is limited. The purpose of this study was to determine whether intraoperative hemodynamic abnormalities were associated with mortality, stroke, or perioperative myocardial infarction (PMI) in a large cohort of patients undergoing coronary artery bypass grafting. Risk factors and outcomes were queried from a state-mandated cardiac surgery reporting system at two hospitals in New York, NY. Intraoperative hemodynamic abnormalities were derived from computerized anesthesia records by assessing the duration of exposure to moderate or severe extremes of hemodynamic variables. Multivariate logistic regression identified independent predictors of perioperative mortality, stroke, and PMI. Among 2149 patients, there were 50 mortalities, 51 strokes, and 85 PMIs. In the precardiopulmonary bypass (pre-CPB) period, pulmonary hypertension was a predictor of mortality (odds ratio [OR] 2.1, P = 0.029), and bradycardia and tachycardia were predictors of PMI (OR 2.9, P = 0.007 and OR 2.0, P = 0.028, respectively). During CPB, hypotension was a predictor of mortality (OR 1.3, P = 0.025). Post-CPB, tachycardia was a predictor of mortality (OR 3.1, P = 0.001), diastolic arterial hypertension was a predictor of stroke (OR 5.4, P = 0.012), and pulmonary hypertension was a predictor of PMI (OR 7.0, P < 0.001). Increased pulmonary arterial diastolic pressure post-CPB was a predictor of mortality (OR 1.2, P = 0.004), stroke (OR 3.9, P = 0.002), and PMI (OR 2.2, P = 0.001). Rapid intraoperative variations in blood pressure and heart rate were not independent predictors of these outcomes. These findings demonstrate the prognostic significance of intraoperative hemodynamic abnormalities, including data from pulmonary artery catheterization, to adverse postoperative outcomes. It is not known whether interventions to control these variables would improve outcome. ⋯ Intraoperative hemodynamic abnormalities, including pulmonary hypertension, hypotension during cardiopulmonary bypass, and postcardiopulmonary bypass pulmonary diastolic hypertension, were independently associated with mortality, stroke, and perioperative myocardial infarction over and above the effects of other preoperative risk factors.
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Anesthesia and analgesia · Oct 1999
Comparative StudyMolar potency is not predictive of the speed of onset of atracurium.
In an effort to determine the extent to which atracurium may represent an exception to the rule that molar potency predicts onset time, we studied the onset profile of atracurium after a dose selected to produce approximately 95% twitch depression. We compared these results with data obtained in a previous study after the administration of vecuronium, rocuronium, and cisatracurium. Eighteen ASA physical status I and II patients were studied. After the induction of anesthesia, tracheal intubation was accomplished without relaxants. The evoked electromyographic response to 0.10-Hz single stimuli was continuously recorded. After baseline stabilization, a single bolus of atracurium, averaging 0.21 mg/kg, was administered. If peak twitch depression did not fall within the range of 90%-98%, the patient was excluded. The time to 50% and 90% of peak effect was recorded. The time to 90% of maximal effect (192 +/- 23 s) was not different from that previously observed for vecuronium (201 +/- 20 s). The time to 50% of peak effect (110 +/- 15 s) was shorter (P < 0.05) after atracurium administration than after vecuronium (125 +/- 9 s). The onset times recorded for atracurium were slower than previously observed after rocuronium and more rapid than that which was seen after cisatracurium (P < 0.001). The observed onset profile of atracurium was considerably slower than anticipated, based on the drug's molar potency. The 95% effective dose (microM/kg) may not be a reliable predictor of a muscle relaxant's onset time, when the drug administered is a mixture isomers of varying potency. ⋯ The speed of onset of atracurium is slower than predicted, based on its molar potency. Potency of a relaxant may not be a reliable predictor of its time to peak effect, when the drug administered is a mixture of isomers with widely different neuromuscular activities.
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Anesthesia and analgesia · Oct 1999
Practice Guideline GuidelineASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography.
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Anesthesia and analgesia · Oct 1999
The continuous assessment of cerebrovascular reactivity: a validation of the method in healthy volunteers.
Using transcranial Doppler ultrasonography, we investigated the moving correlation between slow waves in arterial blood pressure (ABP) and blood flow velocity (FV) at different levels of cerebrovascular vasodilation provoked by changing PETCO2. Fourteen healthy volunteers were examined. The FV in middle cerebral arteries, PETCO2, and ABP were recorded during normocapnia, hypercapnia, and hypocapnia. The moving correlation coefficients between ABP and mean FV (FVm) or systolic FV (FVs) during spontaneous fluctuations in ABP were calculated for 3-min epochs and averaged for each investigation, thus yielding the mean index (Mx) and systolic index (Sx). As a reference method, Aaslid's cuff tests were performed to obtain the rate of regulation (RoR). RoR, Mx, and Sx significantly depended on PETCO2 (analysis of variance, P < 0.00001). At high PETCO2, cerebrovascular reactivity was disturbed as reflected in RoR values of < 0.17/s for all volunteers and increased values of Mx (> 0.4 in 86% of volunteers) and Sx (> 0.2 in 79% of volunteers). Overall, there was a reasonably good correlation of both Mx and Sx with RoR (R2 = 0.65 and 0.58, respectively). ⋯ Indices derived from the correlation between spontaneous fluctuations of blood flow velocity wave form and arterial blood pressure may be used for the noninvasive continuous monitoring of cerebrovascular reactivity.
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Anesthesia and analgesia · Oct 1999
Low-flow anesthesia and reduced animal size increase carboxyhemoglobin levels in swine during desflurane and isoflurane breakdown in dried soda lime.
After institutional approval, we studied the effect of animal size, anesthetic concentration, and fresh gas flow (FGF) rate on inspired carbon monoxide (CO) and carboxyhemoglobin (COHb) during anesthesia in swine, using soda lime previously dried to 1 +/- 0.1% water content. To ascertain the effect of anesthesia, eight adult pigs were anesthetized with either 1 minimum alveolar anesthetic concentration (MAC) desflurane or isoflurane and, to characterize the effect of the FGF rate, it was doubled in four pigs. To determine the effect of animal size, four small and four large pigs received 1 MAC desflurane or isoflurane, and to determine the effect of the anesthetic concentration, a group of four swine was exposed to 0.5 MAC. CO and COHb concentrations were larger with desflurane (5500 +/- 980 ppm and 57.90% +/- 0.50%, respectively) than with isoflurane (800 ppm and 17.8% +/- 2.14%, respectively), especially in the small animals. Increasing the FGF rate significantly reduced peak CO and COHb concentrations resulting from both anesthetics; however, when each anesthetic was reduced to 0.5 MAC, the concentrations obtained were similar. We conclude that CO intoxication is more severe with desflurane than with isoflurane, that small animals are at higher risk for CO poisoning, and that low FGF can increase COHb concentrations. ⋯ The present study shows that the use of desflurane with desiccated carbon dioxide absorbents in pediatric anesthesia can produce a dangerous carbon dioxide intoxication, especially with low-flow anesthesia.