Hemodynamic and hormonal stress responses to endotracheal tube and ProSeal Laryngeal Mask Airway™ for laparoscopic gastric banding.

BACKGROUND: The stress responses from tracheal intubation are potentially dangerous in patients with higher cardiovascular risk, such as obese patients. The primary outcome objective of this study was to test whether, in comparison with the endotracheal tube (ETT), the Proseal™ Laryngeal Mask Airway (PLMA™) (Laryngeal Mask Airway Company, Jersey, United Kingdom) reduces blood pressure and norepinephrine responses and the amounts of muscle relaxants needed in obese patients. METHODS: We assessed hemodynamic and hormonal stress responses, ventilation, and postoperative recovery in 75 morbidly obese patients randomized to receive standardized anesthesia with either an ETT or the PLMA™ for laparoscopic gastric banding. RESULTS: In repeated-measures ANOVA, mean arterial blood pressure and plasma norepinephrine were significantly higher in the ETT group than in the PLMA™ group. In individual pairwise comparisons, blood pressure rose higher in ETT than PLMA™ patients after insertion and removal of airway devices, and after recovery. In ETT compared with PLMA™ patients, plasma norepinephrine was higher after induction of carboperitoneum (mean ± SD, 534 ± 198 and 368 ± 147 and pg/ml, P = 0.001), after airway device removal (578 ± 285 and 329 ± 128 pg/ml, P < 0.0001), and after recovery in postanesthesia care unit (380 ± 167 and 262 ± 95 and pg/ml, P = 0.003). Compared with use of the ETT, the PLMA™ reduced cisatracurium requirement, oxygen desaturation, and time to discharge from both the postanesthesia care unit and the hospital. CONCLUSIONS: PLMA™ reduces stress responses and postoperative complaints after laparoscopic gastric banding.

Recovery profiles of general anesthesia and spinal anesthesia for chemotherapeutic perfusion with circulatory block (stop-flow perfusion).

BACKGROUND: Chemotherapeutic stop-flow perfusion is a new investigational treatment for locally advanced cancers that is usually performed under general anesthesia (GA), and, less frequently, under spinal anesthesia (SA). We designed this clinical trial to compare the clinical profiles of GA and SA for stop-flow perfusion. METHODS: Anesthesia and recovery times, scores on visual analog scales for postoperative pain, and postoperative nausea and vomiting, and admission to the postanesthesia care unit were measured in 40 cancer patients who randomly received either GA with propofol, nitrous oxide/sevoflurane, and fentanyl, or SA with bupivacaine hydrochloride for lower limb or pelvic stop-flow perfusion. RESULTS: GA and SA did not differ in times to achieve home readiness or patient satisfaction. Compared with GA, SA significantly (P < 0.05) reduced anesthesia times (34 vs 16 min), postoperative visual analog scale scores for pain (5 vs 0) and nausea (8 vs 2), and the number of admissions to the postanesthesia care unit (9 vs 0). CONCLUSIONS: For stop-flow perfusion, GA and SA are both effective, but SA provides faster recovery, superior analgesia, and less postoperative nausea and vomiting in the immediate postoperative period.

Atropine sulfate for treatment of bradycardia in a patient with morbid obesity: what may happen when you least expect it.

A 74-year-old morbidly obese man was scheduled for surgical repair of an incisional ventral hernia. Anaesthesia was induced with propofol and fentanyl, and maintained with desflurane. A second dose of fentanyl 0.2 mg, given before starting surgery, resulted in sinus bradycardia and mild decrease of arterial blood pressure. Atropine sulfate 0.5 mg was administered. One minute later, the ECG rhythm on the monitor changed to third degree atrioventricular block with a ventricular response rate of 40 beats/min associated with marked hypotension. Isoproterenol 0.02 mg reverted the atrioventricular block to sinus rhythm. Cardiac enzymes and ECG ruled out acute myocardial ischaemia. The surgical procedure and the recovery from anaesthesia were uneventful. The patient was discharged from the hospital on the fifth postoperative day. For the treatment of bradycardia atropine sulfate should be adjusted at least to lean body weight in order to avoid paradoxical heart rate response in patients with obesity.

Sugammadex allows fast-track bariatric surgery.

BACKGROUND: Morbidly obese (MO) patients are at increased risk for postoperative anesthesia-related complications. We evaluated the role of sugammadex versus neostigmine in the quality of recovery from profound rocuronium-induced neuromuscular blockade (NMB) in patients with morbid obesity. METHODS: We studied 40 female MO patients who received desflurane and remifentanil anesthesia for laparoscopic removal of adjustable gastric banding. NMB was achieved with rocuronium. At the end of the surgical procedure, complete reversal of NMB was obtained with sugammadex (SUG group, n = 20) or neostigmine plus atropine (NEO group, n = 20) in the presence of profound NMB. RESULTS: No difference in surgical time or anesthetic drugs was found between the groups. Anesthesia time was significantly greater in the NEO group than in the SUG group (95 ± 21 vs. 47.9 ± 6.4 min, p < 0.0001), which was mainly due to a longer time to reach a train-of-four ratio (TOFR) ≥ 0.9 in the NEO group (48.6 ± 18 vs. 3.1 ± 1.3 min, p < 0.0001) during reversal of profound NMB. Upon admission to the postanesthesia care unit, level of SpO2 (p = 0.018), TOFR (p < 0.0001), ability to swallow (p = 0.0027), and ability to get into bed independently (p = 0.022) were better in the SUG group than in the NEO group. Patients in the SUG group were discharged to the surgical ward earlier than patients in the NEO group were (p = 0.013). CONCLUSIONS: Sugammadex allowed a safer and faster recovery from profound rocuronium-induced NMB than neostigmine did in patients with MO. Sugammadex may play an important role in fast-track bariatric anesthesia.