Perioperative predictors of colonic ischemia after ruptured abdominal aortic aneurysm.

PURPOSE: Colonic ischemia and colonic resection occur frequently after ruptured abdominal aortic aneurysm (rAAA). The purpose of this study was to identify the perioperative risk factors that might help to determine earlier in the postoperative period which patients are at risk for colonic ischemia and colonic resection. METHODS: The medical records of the 43 patients who underwent repair of rAAA from January 1989 to November 1997 were reviewed. The data were reviewed for the following factors: acidosis, pressor agents, lactate levels, guaiac status, cardiac index, coagulopathy, early postoperative bowel movement, the lowest intraoperative pH level, the temperature at the conclusion of the case, the location and duration of aortic cross clamping, the amount of fluid boluses administered after surgery, the amount of packed red blood cells administered during the case, and the average systolic blood pressure at admission and during surgery. Univariate analysis was performed with Fisher exact test, chi2 test, and Student t test. Multivariate analyses also were performed with the variables that were found to be significant on the univariate analysis. RESULTS: Thirteen of the 43 patients (30. 2%) had colonic ischemia, and seven of the 13 underwent colonic resection (53.8%). The overall mortality rate was 51.2% (22/43) five of the deaths were intraoperative and excluded from the study. In a comparison of the patients who had colonic ischemia with those who did not, statistically significant differences were found in the following variables: average systolic blood pressure at admission 90 mm Hg or less, hypotension of more than 30 minutes' duration, temperature less than 35 degreesC, pH less than 7.3, fluid boluses administered after surgery 5 L or more, and packed red blood cells 6 units or more. Multivariate analysis indicated that the number of these variables present correlated significantly with the positive predicted probability of colonic ischemia occurring. No patient with two factors or fewer had an ischemic bowel, and the positive predictive probability of colonic ischemia for those patients with six factors was 80%. CONCLUSION: The results of this study show that: (1) colonic ischemia after rAAA may be predicted with the presence of two or more specific perioperative factors, (2) the lack of a guaiac-positive bowel movement may be misleading for the early diagnosis of colonic ischemia, and (3) more than 50% of the patients with colonic ischemia will require a colonic resection. We recommend that any patient with rAAA with more than two perioperative factors undergo sigmoidoscopy every 12 hours after surgery for 48 hours to rule out colonic ischemia without waiting for early or guaiac-positive bowel movement.

Relationship of protamine dosing with postoperative complications of carotid endarterectomy.

Protamine sulfate (PS) neutralization of heparin (HEP) given during carotid endarterectomy (CEA) has been previously associated with an increased postoperative stroke rate. Dosing regimens of PS have varied in previous studies. The accuracy of PS dosing and its effect on postoperative complications was analyzed. The medical records of all patients undergoing elective CEAs from January 1993 to June 1996 in our institution were reviewed. A hematoma was defined as either an event requiring return to the operating room or when repeatedly identified in the medical record. The accuracy of dosing PS was determined utilizing a formula calculating the logarithmic exponential decay of HEP, which determined the residual HEP at the time of PS dosing. An ideal PS dose was then calculated and compared to the dose given. Statistical analyses was performed using a Fisher's exact test as well as the Student's t-test. Four hundred-seven CEAs were performed in 365 patients. There were 10/407 (2.5%) postoperative strokes (STROKE) and 11/407 (2.7%) hematomas, 3 of which required reoperation. Results indicate that (1) the administration of PS significantly reduced the incidence of postoperative hematoma; (2) there appears to be an association between the administration of PS and STROKE; (3) the inaccuracy in dosing PS appears to be based on a decision to dose PS to the total HEP given rather than the residual HEP on board at the time of neutralization. The effect of PS overdosing is unclear, but it may play a role in STROKE.

Naloxone benzoylhydrazone (NalBzoH) analgesia.

Naloxone benzoylhydrazone (NalBzoH) is a novel mixed agonist/antagonist. Against mu agonists, NalBzoH is a potent antagonist with a prolonged duration of action corresponding to its extremely slow rate of dissociation from mu receptors in binding assays. In the present studies, NalBzoH also antagonized mu analgesia, reversing both mu 1 and mu 2 analgesia independently elicited by intracerebroventricular or intrathecal [D-Ala2,MePhe4,-Gly(ol)5]enkephalin injections. It also antagonized kappa 1 analgesia elicited by U50,488H, and delta analgesia produced by intrathecal [D-Pen2,D-Pen5]enkephalin. Yet, at higher doses, NalBzoH alone produced analgesia in the tail-flick, hot plate and writhing assays. Neither the mu-selective antagonist beta-funaltrexamine, the delta-selective antagonist naltrindole, nor the kappa 1-selective antagonist norbinaltorphimine reversed NalBzoH analgesia in the tail-flick test. Analgesia observed with systemically administered NalBzoH was reversed easily by the antagonist WIN44,441 when it was given intracerebroventricularly, but not intrathecally. These observations confirm the opioid nature of NalBzoH analgesia and imply a supraspinal mechanism of action. In contrast, intrathecal, but not intracerebroventricular WIN44,441 reversed analgesia from systemic U50,488H quite potently. Thus, NalBzoH antagonizes mu, delta and kappa 1 actions while retaining its ability to elicit analgesia through a novel and distinct supraspinal kappa 3 system.