Premedication with pregabalin 75 or 150 mg with ibuprofen to control pain after day-case gynaecological laparoscopic surgery.

BACKGROUND: Multimodal pain management has been suggested to improve postoperative analgesia. In this study, we evaluated the quality of analgesia in women undergoing day-case gynaecological laparoscopic surgery, after premedication with pregabalin 75 mg (P75) or 150 mg (P150), compared with diazepam 5 mg (D5). All patients were given ibuprofen 800 mg orally. METHODS: Altogether 90 consenting women were anaesthetized in a standardized fashion. Postoperative analgesia was provided by ibuprofen 800 mg twice a day with fentanyl i.v. on request in the recovery room (RR), and combination tablets with acetaminophen and codeine after the RR. The visual analogue scale (VAS) scores for pain and side-effects and the amounts of postoperative analgesics were recorded for 24 h after surgery. The areas under the curves (AUC) were calculated for the VAS scores for pain at rest, pain in motion, and pain at cough 1-8 and 1-24 h after surgery. RESULTS: The median AUC values for VAS scores for pain at rest (P=0.048) and in motion (P=0.046) 1-8 h after surgery were lower in the P150 group than that in the D5 group. The amounts of rescue analgesics or the degree of drowsiness did not differ in the three study groups. CONCLUSIONS: Analgesia was better after premedication with pregabalin 150 mg than after diazepam 5 mg, both with ibuprofen 800 mg, during the early recovery after day-case gynaecological laparoscopic surgery. Pregabalin 150 mg did not reduce the amount of postoperative analgesics required.

Acute renal injury and dysfunction following elective abdominal aortic surgery.

OBJECTIVES: To evaluate the incidence of kidney injury and acute renal dysfunction (ARD) and associated risk factors in open abdominal aortic surgery. MATERIALS AND METHODS: 69 patients undergoing elective infrarenal aortic repair were included in a prospective study. Anaesthesia and haemodynamic management were standardised targeting a mean arterial pressure (MAP) of 70-90 mmHg, pulmonary artery occlusion pressure of 12-14 mmHg and cardiac index >or=2.4 l/min/m(2). Urinary albumin-creatinine and N-acetyl-B-D-glucosaminidase-creatinine ratios were measured as indicators of kidney injury. The definition of ARD was based on the RIFLE criteria. RESULTS: Kidney injury was found in most patients. ARD developed in 22% of the patients, and acute renal failure in 4%. The patients with ARD were older, and had lower plasma creatinine and estimated GFR before surgery. ARD was associated with intraoperative hypotension (MAP <60 mmHg >15 min), low cardiac index (<2.4 l/min/m(2)), rhabdomyolysis, and early reoperation. Intraoperative hypotension and postoperative low cardiac output were independent risk factors for ARD in multivariate analysis. CONCLUSIONS: Kidney injury occurs in most patients undergoing infrarenal aortic surgery, but only 22% develop acute renal dysfunction. Hypotension and low cardiac output are risk factors that could be avoided by optimizing perioperative management.

Evolution and predictive power of serum cystatin C in acute renal failure.

AIMS: The serum concentration of cystatin C has recently been proposed as a better indicator of glomerular filtration rate (GFR) than plasma creatinine. Little is known about cystatin C in critical illness. We assessed serum cystatin C as a marker of renal function in acute renal failure (ARF) and its power in predicting survival of ARF patients. MATERIAL: 202 consecutive adult patients admitted into the intensive care unit (ICU) during a period of 9 months. METHOD: Serum cystatin C, plasma creatinine and plasma urea were measured on admission, daily during the first 3 days, and 5-7 times a week during the rest of the ICU stay. The patients with and without ARF were compared by the Mann-Whitney U-test. The correlation between different variables was calculated by Spearman's correlation. Forward stepwise multiple regression analysis was performed to test independent predictors of mortality. The positive predictive value of serum cystatin C and plasma creatinine for ARF and mortality was calculated by ROC analysis. RESULTS: ARF occurred in 54 patients (27%). Serum cystatin C showed excellent positive predictive value for ARF in critical illness by ROC analysis. In acute renal dysfunction, abnormal values of serum cystatin C and plasma creatinine appeared equally quickly (median 3 days). The diagnosis of ARF, the day 1 Apache II score and admission plasma creatinine appeared as independent predictors of hospital mortality. ROC analysis showed only weak predictive power for serum cystatin C and plasma creatinine regarding hospital mortality. CONCLUSIONS: Serum cystatin C was as good as plasma creatinine in detecting ARF in intensive care patients. Neither marker was clinically useful in predicting mortality.

Hepatic and splanchnic oxygenation during liver transplantation.

OBJECTIVE: To evaluate hepatic and splanchnic oxygenation during liver transplantation. DESIGN: Prospective study. SETTING: University hospital. PATIENTS: Ten adult patients undergoing liver transplantation. INTERVENTIONS: Standardized surgery and anesthesia without venovenous bypass. MEASUREMENTS AND MAIN RESULTS: Hepatic oxygenation was assessed by analyzing oxygen tension, oxygen saturation, and lactate concentration in hepatic venous blood. Splanchnic oxygenation was assessed by analyzing oxygen tension, oxygen saturation, and lactate concentration in portal venous blood and by gastric tonometry. Before reperfusion, the grafts were flushed with 1000 mL of acetated Ringer's solution and 400 mL of portal venous blood. The effluent blood from the graft was wasted and showed a mean pH of 6.86 and a lactate concentration of 9.4 mmol/L. Five minutes after portal reperfusion, most of the grafts produced lactate. Portal-hepatic venous P(CO2) difference ranged from 3 to 16 torr (0.4-2.1 kPa). By the time of restoration of the infrahepatic caval flow mean 24 mins later, eight of the grafts had stopped producing lactate. Mean hepatic venous oxygen tension was 47 torr (6.3 kPa), stabilizing to 41 torr (5.5 kPa) at the end of surgery. Acidosis resolved without pharmacologic interventions. Mean gastric mucosal pH was 7.29 during the anhepatic phase and 7.40 at the end of surgery. One of the patients developed hepatic arterial thrombosis intraoperatively. Her data were analyzed separately. Later, the other patients recovered with good liver function, whereas the patient with hepatic arterial thrombosis was successfully retransplanted. CONCLUSIONS: The liver grafts received well-oxygenated portal venous blood during reperfusion, despite the low values of gastric mucosal pH immediately before reperfusion. Hepatic oxygenation became adequate soon after reperfusion. In the patient with hepatic arterial thrombosis, the recovery of hepatic oxygenation was impaired and lactic acidosis persisted.

Cardiac evaluation of liver transplant recipients: QT dispersion in electrocardiogram.

Increased QT dispersion, the interlead variability of the QT interval length in the 12-lead electrocardiogram, reflects uneven ventricular repolarization as a sign of cardiomyopathy. We analyzed QT dispersion in the preoperative electrocardiogram of 100 adult liver transplant recipients and 20 healthy control subjects. In 12% of the liver recipients, QT dispersion was increased above 65 ms (mean + 3SD). Six of these patients had a liver storage disease (haemochromatosis, Wilson's disease or amyloidosis). Five had a history of cardiac disease. Severe intraoperative cardiac complications occurred in three patients with markedly increased QT dispersion (> or = 99 ms). In conclusion, in liver storage diseases the heart may be affected, leading to increased risk of cardiac complications, which might be predicted from increased QT dispersion. Analysis of QT dispersion, a noninvasive inexpensive technique, can be recommended to be included in the cardiac screening of liver transplant candidates.

Respiratory compliance during orthotopic liver transplantation.

After liver transplantation, respiratory complications are frequent. The purpose of this study was to assess if intraoperative monitoring of respiratory compliance is of clinical value in predicting such complications. Respiratory compliance was continuously monitored with a side-stream respiratory gas flow and pressure sensor (Datex, Helsinki, Finland) at the endotracheal tube in 18 adult patients undergoing orthotopic liver transplantation without veno-venous bypass. Respiratory compliance decreased along with blood volume expansion under anaesthesia before the start of surgery (P < 0.05). Compliance improved as ascites was removed at the beginning of laparotomy (P < 0.001). The highest compliance values were seen during liver surgery. In the patients without ascites preoperatively, compliance was lower at the end of surgery than at anaesthesia induction (P < 0.001). In the patients with ascites, compliance at the end of surgery was equally low as at anaesthesia induction. Compliance at the end of surgery was lower in the patients with bilateral than in those with right-sided or no pleural effusions in the postoperative chest X-rays (P < 0.001). In conclusion, intraoperative monitoring of respiratory compliance is one useful method for clinical use in predicting postoperative bilateral pleural effusions.

Changes in respiratory compliance at laparoscopy: measurements using side stream spirometry.

In order to quantify changes in total respiratory compliance (Crs) effected by peritoneal pressurization we measured, under standardized anaesthetic conditions and using side stream spirometry Crs in 32 patients scheduled for abdominal surgery through laparoscopic techniques. To qualify the changes in Crs as to the type (duration and patient's position) of surgery, 20 patients having cholecystectomy, eight having gastric fundoplication, and four having inguinal hernia repair were studied. At CO2 insufflation to a mean intraabdominal pressure of 11 cmH2O in the horizontal position, Crs decreased abruptly by 20% in each of the surgical sub-groups (P < 0.05-0.01). During the insufflation period a further deterioration was observed, most pronounced in inguinal hernia patients operated upon in a head-down tilt position (P < 0.05). In the cholecystectomy and fundoplication patients, operated upon in a head-up tilt, the recovery of Crs was immediate at deflation, whereas an incomplete recovery (P < 0.05 vs initial values) was seen in the hernia patients. In evaluating all patients none of the demographic factors, age, sex, body-mass-index, intraabdominal pressure, or duration of pressurization, were associated with the detected changes.