Transient Effects of Anesthesia on Leukocyte Apoptosis and Monocyte Cytokine Stimulation: A Clinical Study.

The effects of anesthetics on immune cell apoptosis and cytokine stimulation were studied in a prospective study. American Society of Anesthesiologists I/II patients underwent elective inguinal hernia repair or varicose veins stripping surgery and were randomized to either epidural anesthesia (n = 14) or general anesthesia with sevoflurane (n = 19) or propofol (n = 15). Blood was sampled before anesthesia induction (T0), at the end of surgery (T1), and 6 h later (T2). Apoptosis was determined by ANNEXIN-V staining of white blood cells; monocytes were isolated and stimulated for cytokine production. Results were compared with 10 healthy volunteers well-matched for age and gender. Apoptosis of lymphocytes and monocytes was increased in the epidural and sevoflurane groups at T2. Propofol group had increased production of interleukin-6 at T1 and sevoflurane and epidural groups had decreased production of tumor necrosis factor-alpha at T2. Results emphasize the modulation of immune function by epidural and sevoflurane but not propofol anesthesia in a clinical setting.

The effect of 0.5 L 6% hydroxyethyl starch 130/0.42 versus 1 L Ringer's lactate preload on the hemodynamic status of parturients undergoing spinal anesthesia for elective cesarean delivery using arterial pulse contour analysis.

PURPOSE: Fluid loading attenuates the hypotensive response to spinal anesthesia (SA). This study aimed to compare the preload efficacy of 0.5 L hydroxyethyl starch (HES) versus 1 L Ringer's lactate (R/L) in the prevention of hypotension after SA for elective cesarean delivery (CD). Assessment of maternal hemodynamic variables using FloTrac/Vigileo™ and neonatal outcome constituted secondary outcomes. METHODS: Thirty-two ASA I/II parturients scheduled for elective CD were preloaded with either 1 L R/L (Group R/L, n = 16) or 0.5 L HES 6% 130/0.42 (Group T, n = 16) approximately 25 min before SA. Hypotension, defined as a 20% decrease of systolic arterial pressure (SAP) from baseline or SAP <100 mmHg, was treated with vasopressors according to a predetermined algorithm. The overall duration of hypotensive episodes and the total amount of vasopressors administered determined the severity of the hemodynamic instability. RESULTS: The incidence of hypotension was 73.3% in Group R/L and 46.7% in Group T. HES compared to R/L preload was associated with a shorter overall duration of hypotensive episodes (p < 0.001), a significantly less usage of ephedrine and phenylephrine (p = 0.015 and p = 0.029, respectively) and a greater impact, although not statistically significant, on cardiac index (CI) and stroke volume index (SVI). Although no statistical difference was detected between groups over time, there was a significant drop in CI, SVI and SAP within groups (p < 0.001) up to 14 min after SA. No difference was recorded in neonatal outcome. CONCLUSIONS: Preloading with 0.5 L HES 130/0.42 produced more stable hemodynamics compared to 1 L R/L solution in obstetric patients.

Periarticular infiltration for pain relief after total hip arthroplasty: a comparison with epidural and PCA analgesia.

PURPOSE: Epidural and intravenous patient-controlled analgesia (PCA) are established methods for pain relief after total hip arthroplasty (THA). Periarticular infiltration is an alternative method that is gaining ground due to its simplicity and safety. Our study aims to assess the efficacy of periarticular infiltration in pain relief after THA. METHODS: Sixty-three patients undergoing THA under spinal anaesthesia were randomly assigned to receive postoperative analgesia with continuous epidural infusion with ropivacaine (epidural group), intraoperative periarticular infiltration with ropivacaine, clonidine, morphine, epinephrine and corticosteroids (infiltration group) or PCA with morphine (PCA group). PCA morphine provided rescue analgesia in all groups. We recorded morphine consumption, visual analog scale (VAS) scores at rest and movement, blood loss from wound drainage, mean arterial pressure (MAP) and adverse effects at 1, 6, 12, 24 h postoperatively. RESULTS: Morphine consumption at all time points, VAS scores at rest, 6, 12 and 24 h and at movement, 6 and 12 h postoperatively were lower in infiltration group compared to PCA group (p < 0.05), but did not differ between infiltration and epidural group. There was no difference in adverse events in all groups. At 24 h, MAP was higher in the PCA group (p < 0.05) and blood loss was lower in the infiltration group (p < 0.05). CONCLUSIONS: In our study periarticular infiltration was clearly superior to PCA with morphine after THA, providing better pain relief and lower opioid consumption postoperatively. Infiltration seems to be equally effective to epidural analgesia without having the potential side effects of the latter.

Cognitive function and oxidative stress after carotid endarterectomy: comparison of propofol to sevoflurane anesthesia.

OBJECTIVE: To examine the antioxidant role of propofol in ischemia-reperfusion during carotid endarterectomy (CEA) and its influence on cognitive dysfunction after CEA. DESIGN: A randomized prospective study. SETTING: Single-center study in a university hospital. PARTICIPANTS: Forty-four patients. INTERVENTIONS: Patients underwent elective CEA under general anesthesia with either sevoflurane (group S, n = 21) or propofol (group P, n = 23). MEASUREMENTS AND MAIN RESULTS: Cognitive function was assessed with the Mini-Mental State Examination (MMSE) before CEA, 1 hour after CEA, and 24 hours after CEA. Blood samples from the radial artery and the internal jugular vein were drawn before carotid clamping and 5 minutes following unclamping, and peripheral blood was obtained 24 hours postoperatively. Samples were analyzed for lactate, S100B, and P-selectin concentrations and for the antioxidative markers malondialdehyde/low-density lipoprotein ratio and nitrate + nitrite concentrations. Compared with group S, patients in group P exhibited a greater increase in their MMSE values 24 hours postoperatively. Patients who had their MMSE performance reduced at 24 hours also were significantly fewer in group P (13% v 43% in group S, p<0.05). Significantly lower levels of lactate and S100B were observed in arterial and jugular vein samples in group P. In addition, the jugular vein-arterial differences of malondialdehyde-to-low-density lipoprotein ratio and nitrates + nitrites concentrations were lower during propofol anesthesia. CONCLUSIONS: Propofol seemed to improve cognitive performance after CEA. This improvement was associated with decreased indices of ischemic cerebral damage and seemed to be due to antioxidative effect in the ischemic cerebral circulation.

Comparative effects of sevoflurane and propofol based general anaesthesia for elective surgery on memory.

INTRODUCTION: Unconscious processing of words during general anaesthesia has been suggested. We used the process dissociation procedure (PDP) to test memory performance during sevoflurane and propofol anaesthesia in relation to hypnotic depth. MATERIAL AND METHODS: One hundred participants anaesthetised for elective surgery (50 with propofol and 50 with sevoflurane) and 50 non-anaesthetized listened to a list of words. The bispectral index (BIS) of the anaesthetised patients was recorded. Within 36 h after word presentation, memory was assessed using a word stem completion task, based on Buchner's model applied on the PDP. RESULTS: There was evidence of memory for words presented during light (BIS 61-80) (p = 0.001) and adequate (BIS 41-60) (p = 0.008) but not deep anaesthesia (BIS 21-40) (p = 0.09). The PDP showed a significant implicit but not explicit memory contribution (mean total explicit memory scores: 0.04 ±0.07 in all BIS categories; mean implicit memory scores: 0.01 ±0.04, 0.1 ±0.08, and 0.05 ±0.09 at BIS = 21-40, 41-60, and 61-80, respectively). There was a statistically significant difference between the mean implicit memory score (I) of the propofol and sevoflurane group in the BIS category 41-60 in general (p = 0.016), and after incision (IA.I.) (p = 0.005) in particular, with propofol depressing I more than sevoflurane in both cases. Memory performance of nonanaesthetized participants was better, with a higher contribution of explicit and a comparable contribution of implicit memory. CONCLUSIONS: During general anaesthesia, implicit memory persists even in adequate hypnotic states. Sevoflurane affects the implicit memory of adequately anaesthetised subjects less than propofol.

Music's use for anesthesia and analgesia.

This review article provides an overview of published data regarding the involvement of music in anesthesia practice. Music is an important topic for research in different fields of anesthesiology. The use of music preoperatively is aimed at reducing anxiety, stress, and fear. However, the effect of music on perception of pain intraoperatively is controversial, according to studies of both adults and children undergoing various surgical procedures under general and/or regional anesthesia. In postoperative pain management, postanesthesia care, and neonatal intensive care, music can be a complementary method for reducing pain, anxiety, and stress. Music is a mild anxiolytic, but it is relatively ineffective when a pain stimulus is severe. However, music is inexpensive, easily administered, and free of adverse effects, and as such, can serve as complementary method for treating perioperative stress and for acute and chronic pain management, even though music's effectiveness depends on each individual patient's disposition and severity of pain stimulus.

Low-dose (1 microg/kg) clonidine premedication and hypotension after carotid artery surgery.

We investigated the role of low-dose clonidine intravenous (IV) premedication in arterial pressure variation during and after carotid endarterectomy (CEA). A total of 84 patients, American Society of Anesthesiologists (ASA) II-III, scheduled for elective CEA under general anesthesia participated in this study. The patients were divided into 2 groups: group P (n = 42) and group C (n = 42) and received N/S 0.9% (placebo) or clonidine 1 µg/kg IV, respectively, 15 minutes before induction of anesthesia. Recovery times, number of patients needed to be treated for circulatory events (hypertension, hypotension, and bradycardia), number of circulatory events per patient, and consumption of vasoactive drugs (nitroglycerine, phenylphrine, and atropine) intraoperatively and the first 6 hours postoperatively were recorded. Significantly less hypertensive episodes were observed intraoperatively, but more hypotensive episodes were observed postoperatively in patients receiving clonidine. Intravenous premedication with low-dose clonidine (1 µg/kg) seems to be effective in preventing hypertensive episodes during CEA under general anesthesia but seems to increase the incidence of hypotension postoperatively.

Preincisional versus postincisional administration of parecoxib in colorectal surgery: effect on postoperative pain control and cytokine response. A randomized clinical trial.

BACKGROUND: Preincisional pain management aims at reducing pain and inflammatory response. We investigated whether preincisional parecoxib administration reduces pain, opioid requirements, and cytokine production after surgery for colonic cancer. METHODS: Forty one patients whose American Society of Anesthesiologists (ASA) status was I-II and who were scheduled for colorectal cancer surgery were randomly divided in two groups according to the timing of parecoxib administration: Group PRE (preincisional) received parecoxib 40 mg intravenously 30 min before skin incision and group POST (postincisional) received the same dose 30 min after skin incision. Postoperative analgesia involved the administration of patient-controlled analgesia (PCA) morphine to all patients. We recorded verbal rating scale (VRS) scores and morphine consumption at 1, 6, 18, and 24 h after surgery and blood levels of interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-alpha (TNF-alpha) 30 min before skin incision, at peritoneal closure, and 24 h postoperatively. RESULTS: The VRS scores were similar between groups. Although morphine consumption was significantly lower in group PRE at 6, 18 and 24 h postoperatively (p = 0.044, p = 0.02, p < 0.001, respectively) morphine-related adverse effects did not differ between the two groups. The serum IL-6 was significantly (p = 0.042) elevated from the baseline value 24 h postoperatively in group POST. CONCLUSIONS: Preincisional parecoxib administration compared to postincisional administration reduced postoperative morphine consumption, but without affecting morphine-related adverse effects and attenuated IL-6 production 24 h after surgery for colorectal cancer.

The differential impact of volatile and intravenous anaesthetics on stress response in the swine.

OBJECTIVE: To compare the effects of various anaesthetics on stress response in the presence and absence of surgical stimulation. DESIGN: Twenty-nine pigs scheduled to undergo surgical central vein catheter placement were randomly allocated to receive only sedation with ketamine-midazolam (group SHAM, n=5) or general anaesthesia with either propofol 8 mg/kg/h (group PROP, n=8), sevoflurane 1.0 MAC (group SEVO, n=8) or desflurane 1.0 MAC (group DESF, n=8). Following surgery, anaesthesia was maintained for a total period of 4 hours. Thyroid hormones, noradrenaline, cortisol, corticotrophin (ACTH), beta-endorphin, interleukin-1beta and -6 and tumor necrosis factor-alpha were determined by appropriate methodology after premedication (t0), after surgical procedure (t1) and at the end of 4h (t2). RESULTS: At t1 ACTH and beta-endorphin increased in all groups, thyroxin in groups SEVO, DESF and PROP, noradrenaline in group SEVO and cortisol in the SHAM and PROP groups. At t2 cortisol and ACTH levels were lower in the PROP compared to SEVO group. Serum cytokines were not significantly altered in either group. CONCLUSIONS: The choice of the general anaesthetic did not affect thyroid hormones levels in either the presence or absence of surgical stimulus. In the presence of surgical stimulation, sevoflurane resulted in higher noradrenaline levels and in higher activity of the ACTH-cortisol axis compared to propofol.

Epidural haematoma after epidural catheter removal under multiple anticoagulant therapy: report of two cases.

We report two cases of epidural haematoma that probably developed after removal of the epidural catheter in patients receiving multiple anticoagulant and antiplatelet therapy. The first case is a 77-year-old male patient who underwent femoropopliteal artery bypass grafting surgery. The second case is a 77-year-old woman who underwent a semi-total replacement of the right hip, three days after she had a subtrochanteric fracture. Emergency laminectomy was performed in both patients but none experienced a full recovery.

Acetaminophen-induced liver injury and oxidative stress: protective effect of propofol.

BACKGROUND AND OBJECTIVE: We evaluated the effects of propofol on oxidative stress and acute liver injury and regeneration produced by acetaminophen administration in rats. METHODS: Acetaminophen (3.5 g kg(-1)) was administered by gastric tube to 50 adult male Wistar rats. One minute before acetaminophen, propofol was administered intraperitoneally (60 mg kg(-1)) to 25 rats and diethyl ether to the other 25 animals. All rats were sacrificed. Markers of oxidative stress (malondialdehyde levels, cholesterol/high-density lipoprotein cholesterol fraction and glutathione-S-transferase-pi activity), liver injury (aspartate aminotransferase alanine aminotransferase and alkaline phosphatase and histological signs of inflammation and in-situ apoptosis) and liver regeneration (rate of [3H]thymidine incorporation into hepatic DNA, activity of liver thymidine kinase and mitotic index in hepatocytes) were determined. Unpaired Student's t-test and one-way analysis of variance were used for statistical analysis and a P value of 0.05 or less was considered significant. RESULTS: All markers of oxidative stress were significantly decreased in propofol-treated animals. Biochemical and histological markers of liver injury and regeneration in propofol-treated animals did not show any significant decrease compared with those observed in the control group. CONCLUSION: The antioxidant capacity of propofol, verified in our study, did not manage to prevent liver injury and accelerate regeneration after acetaminophen administration in rats.

Excretion of ropivacaine in breast milk during patient-controlled epidural analgesia after cesarean delivery.

BACKGROUND: Few studies have been published concerning the excretion of bupivacaine and lidocaine into the breast milk and none concerning ropivacaine. AIM: The aim of this study was to determine the levels of ropivacaine in plasma and breast milk after combined spinal-epidural anesthesia for cesarean delivery and postoperative patient-controlled epidural analgesia (PCEA), as well as possible adverse effects from these levels on the neonate. METHODS: Twenty-five parturients admitted for cesarean delivery under combined spinal-epidural anesthesia participated in the study. The PCEA regimen was prepared as 0.15% ropivacaine and fentanyl 2 microg/mL (basal rate, 6 mL/h; demand dose, 4 mL/20 min). Blood samples were collected before anesthesia and from the umbilical cord immediately after birth, followed by blood and breast milk samples 18 and 24 hrs after initiation of PCEA. The newborns were clinically appraised with the Apgar score at delivery and Neurological and Adaptive Capacity Score 24 hrs later. Local anesthetic side effects were recorded. Ropivacaine levels were determined by high-performance liquid chromatography with a UV detector. RESULTS: Ropivacaine excretion into the breast milk produced concentrations that significantly correlated with those in the plasma 18 and 24 hrs after administration, achieving milk-plasma ratios (mean +/- SD) of 0.25 +/- 0.08 and 0.23 +/- 0.07, respectively. Most newborns had maximal Apgar and Neurological and Adaptive Capacity Scores. No adverse effects from ropivacaine were noted in mothers or neonates. CONCLUSIONS: The milk-plasma concentration ratio of ropivacaine was found to be lower than that reported for other local anesthetics It seems that PCEA with ropivacaine/fentanyl after cesarean delivery is not associated with excessive milk-plasma concentrations of ropivacaine.

Liver transplantation in pigs: NO, oxygen free radicals, pulmonary hemodynamics.

BACKGROUND: We determined the alterations of nitric oxide (NO) and oxygen free radicals during orthotopic liver transplantation (OLT) in healthy pigs and investigated their relationship to pulmonary hemodynamics. MATERIALS AND METHODS: Fourteen pigs served as donors and recipients for 7 OLT, under general anesthesia. Hemodynamic monitoring included: systemic and mean pulmonary arterial pressure, pulmonary capillary wedge pressure, cardiac output, cardiac index, pulmonary (PVR) and systemic vascular resistance. Serum NO concentration and serum total antioxidant capacity (TAC), which indirectly quantifies the oxygen free radicals in the serum were determined by spectroscopic method of luminol-dependent chemiluminescence, before laparotomy, before reperfusion, 30 and 60 min postreperfusion. RESULTS: PVR increased significantly during the anhepatic phase and remained at high levels at 30 and 60 min postreperfusion (P = 0.046). NO concentration decreased significantly until 60 min postreperfusion (P = 0.009). TAC decreased throughout the whole period of our measurements (P = 0.002). A significant positive correlation was found between NO concentration, TAC, and PVR (P = 0.026 and P < 0.01, respectively, Spearman correlation). CONCLUSIONS: Our study showed a significant correlation between increased PVR, reduced NO concentration, and increased serum oxygen free radicals levels in the early reperfusion period in healthy pigs undergoing OLT.

Anesthetic and perioperative management of intestinal and multivisceral allograft recipient in nontransplant surgery.

As the survival rate of the intestinal and multi-visceral transplant recipients continues to improve, an increasing number of these patients present for either elective or emergency surgery related or unrelated to transplantation. The aim of this review is to focus on clinical issues related to the anesthetic and perioperative management of the intestinal or multi-visceral transplant recipient for nontransplant surgery. Specific issues concerning perioperative assessment and medications, choice of anesthetic drugs and techniques, and postoperative care management are reviewed.

Norepinephrine in small-for-size liver grafts: an experimental study in pigs.

BACKGROUND: Norepinephrine plasma levels may play a role in small-for-size grafts dysfunction at the early posttransplant period. MATERIALS AND METHODS: The 18 pigs used as recipients were assigned to group 1 (n = 6), group 2 (n = 6), and group 3 (n = 6) and given grafts with graft-to-recipient volume ratios of 1:1, 2:3, and 1:3, respectively. Blood serum norepinephrine was measured by high-performance liquid chromatography with electrochemical detection at the following time points: pre-anhepatic period (baseline); anhepatic period; and 30, 60, 180, and 360 min after reperfusion. Graft arterial and portal vein flows were obtained 30, 60, 180, and 360 min after reperfusion by the aid of an ultrasonic flowmeter. Aspartate transferase (AST) and international normalized ratio (INR) were measured before the procedure (baseline), and at 180 and 360 min after reperfusion. RESULTS: Anhepatic phase was characterized by a significant increase (6- to 8-fold) of norepinephrine in all groups (P < 0.05). In groups 1 and 2 plasma norepinephrine returned to normal values 30 min after reperfusion. In group 3, plasma norepinephrine remained significantly increased at every time point of the study compared to groups 1 and 2 (P < 0.001). Hepatic artery and portal vein flows in group 3 were significantly (P < 0.05) reduced and increased, respectively, compared to groups 1 and 2 at all times measured. Liver function tests (AST and INR) 360 min after reperfusion were significantly higher in group 3 compared to groups 1 and 2. CONCLUSIONS: Norepinephrine levels are increased in very small-for-size grafts and this increase may be associated with early graft dysfunction.

Effects of mannitol in the prevention of lipid peroxidation during liver resection with hepatic vascular exclusion.

STUDY OBJECTIVE: To examine the efficacy of mannitol in the prevention of lipid peroxidation during major liver resections performed during hepatic inflow occlusion. DESIGN: Prospective, randomized, open-label study. SETTING: Aretaieion Hospital, a university-affiliated hospital. PATIENTS: 30 ASA physical status II and III patients, less than 75 years of age, scheduled for elective liver resection. INTERVENTIONS: All patients received combined general and epidural anesthesia. Laparotomy was performed through a bilateral subcostal incision, and hepatectomy was performed by inflow vascular exclusion (Pringle's maneuver). Before this maneuver, and if the patients were hemodynamically stable, they were randomized to receive either mannitol 20% 1.5 mL kg(-1) (group M) or normal saline 1.5 mL kg(-1) (group S) intravenously for 30 minutes. MEASUREMENTS: Venous blood malondialdehyde (MDA) concentration, as an index of lipid peroxidation, was measured spectrophotometrically at selected time points. MAIN RESULTS: Patients in both groups presented with raised MDA values (P < 0.05) for the period starting before the release of vascular occlusion until 6 days postoperatively. In patients receiving mannitol, lower MDA values were observed (P < 0.05) compared with group S at the end of operation. CONCLUSION: Mannitol has an antioxidant activity, but we were unable to confirm a positive impact on the postoperative clinical course.

Preoperative administration of rofecoxib versus ketoprofen for pain relief after tonsillectomy.

OBJECTIVES: We evaluated the analgesic efficacy and the opioid-sparing effect of oral rofecoxib compared with intramuscular (IM) ketoprofen in tonsillectomy. METHODS: Seventy-seven adult patients were randomized into 2 groups: group R (n = 39), which received a single oral preoperative dose of rofecoxib 50 mg, and group K (n = 38), which received 2 IM doses of ketoprofen 100 mg (before surgery and after 12 hours). In both groups, additional IM meperidine hydrochloride 1 mg/kg was given. All patients received general anesthesia. A pain score (visual analog scale, 0 to 100) was assessed both at rest and during swallowing at 30 minutes and at 4, 8, 12, 16, and 24 hours after operation. If the pain score exceeded 40, patients were given meperidine as rescue analgesia. RESULTS: The pain scores during rest and swallowing in group R were significantly lower (p < .05) than those of group K at 4, 8, and 12 hours after operation. Meperidine was given as rescue medication in significantly more patients of group K (76%) than of group R (38%; p < .05). CONCLUSIONS: Oral premedication with rofecoxib seems to be more effective than use of ketoprofen in decreasing postoperative pain and the need for opioid rescue medication after elective tonsillectomy. Both drugs seem to be relatively safe as far as postoperative bleeding is concerned.

Changes in oxyhemoglobin dissociation curve in intrabdominal organs during pig experimental orthotopic liver transplantation.

Liver transplantation has become a gold standard treatment for irreversible liver disease. Conventional measures of oxygenation are inadequate to understand the dynamics of regional oxygen metabolism during liver transplantation because they represent global markers of tissue dysoxia. Therefore, the addition of an assessment of the hemoglobin O(2) binding capacity can give a better insight into systemic and regional tissue oxygenation and can reflect a more accurate estimation of oxygen release to the tissues than can the hemoglobin, the PaO(2) and SaO(2) alone. This prospective study was designed to evaluate possible alterations in the oxyhemoglobin dissociation curve of vital end organs (small bowel, liver, and kidney) in an experimental liver transplantation model. Fifteen pigs with body weights ranging from 25 to 30 kg were used for the study. Five healthy pigs underwent a sham operation under general anesthesia (group A-control). Ten pigs underwent orthotopic liver transplantation (OLT). Five of them were healthy (group B), whereas the other five were in acute liver failure, which had been surgically induced (group C). Systemic arterial blood pressure, cardiac index, and pulmonary and systemic vascular resistance indexes were measured. Venous blood gas analysis was also performed from pulmonary artery, superior mesenteric, hepatic, and renal veins at well-defined timepoints during the course of the OLT. A statistically significant (P < 0.05) decrease of P(50) in groups B and C compared with group A was observed 30 minutes after reperfusion in the systemic circulation, hepatic, and renal veins. This coincided with a decrease in animal temperature 30 minutes after reperfusion. Regarding group C, after reperfusion of the newly transplanted liver there was a significant increase of P(50) in the small bowel in comparison to baseline values. In conclusion, these changes in P(50) may suggest the occurrence of abnormal tissue oxygenation after reperfusion.

Bispectral Index (BIS) monitoring in morbidly obese patients undergoing gastric bypass surgery: experience in 23 patients.

BACKGROUND: Early and uneventful postoperative recovery of morbidly obese patients remains a challenge for anesthesiologists. BIS monitoring is useful in providing fast recovery. METHODS: We describe the anesthetic management of 23 morbidly obese patients who underwent elective open Roux-en-Y gastric bypass (RYGBP) for morbid obesity. Thoracic epidural analgesia combined with light general anesthesia with propofol and nitrous oxide adjusted to keep the bispectral index (BIS) around 60 was performed. Intraoperative hemodynamic stability, early and intermediate recovery and patient satisfaction were assessed. RESULTS: The cardiovascular variables were fairly stable during surgery. Times to spontaneous respiration, response to orders, tube removal and orientation were 4 +/- 3, 6 +/- 2, 8 +/-3, and 13 +/- 7 respectively. Times until the patients were able to sit unassisted, stand unassisted and walk freely without assistance were 319 +/- 25, 803 +/- 78, 1070 +/- 75 respectively (values expressed as min, mean +/- se). CONCLUSION: Propofol-nitrous oxide anesthesia adjusted to keep BIS around 60, combined with thoracic epidural analgesia, seems to be effective in providing predictable and uneventful recovery to patients submitted to elective RYGBP.