Feasibility and preliminary effectiveness of preoperative therapeutic exercise in patients with cancer: a pragmatic study.

The aim of this pilot study is to determine the feasibility and preliminary effectiveness of an individually designed preoperative therapeutic exercise program (PreTEP), in patients recently diagnosed with cancer and awaiting elective surgery. The purpose is to improve their physical fitness levels during this waiting period with the intention of decreasing postoperative morbidity. A preexperimental pilot study was performed at the University Medical Center Utrecht, The Netherlands. Thirty-nine patients diagnosed with cancer, scheduled for elective abdominal/thoracic surgery, were referred to a multidisciplinary preoperative screening. Fifteen patients (38%) participated in PreTEP. Participants were satisfied and motivated during the period of training (on average 5 weeks) in which they attended 84% of the sessions. Cardiorespiratory fitness (A strand-test) and muscle strength (Handheld Dynamometry) increased significantly, from 25 to 33 mL/kg/min, respectively (p<0.01; 95% confidence interval [CI]=-0.011 to -0.004) and from 894 Newton (N) to 961N (p<0.01; 95% CI=-94.53 to -39.0). No adverse events occurred during the training period. PreTEP was shown to be feasible, safe, and well-tolerated and appreciated by participants. Despite the relatively short period of training, physical fitness improved in all participants.

Implementation of outpatient preoperative evaluation clinics: facilitating and limiting factors.

BACKGROUND: Several studies have shown that outpatient preoperative evaluation by anaesthetists increases quality of care and is cost-effective. The aim of this study was to gain insight into the factors that positively or negatively influence the implementation of outpatient preoperative evaluation clinics (OPE clinics). METHODS: After an extensive literature study and pilot interviews, we constructed written questionnaires that were sent to all Dutch hospitals. The respondents were members of the board of directors, members of the medical staff, anaesthetists, internists, and surgeons. RESULTS: Cooperation of anaesthetists was most frequently mentioned as facilitating factor for implementation of an OPE clinic across all medical specialists interviewed. Lack of finance was most frequently reported as limiting factor in all categories of hospitals (with a complete, partial, or no OPE clinic), but it was significantly more often reported in hospitals without OPE clinic (P<0.01). Perceived benefits and disadvantages, financial rewarding system, and organizational structure played a clear role in the implementation of OPE clinics. CONCLUSIONS: A variety of factors play a role in the implementation of an OPE clinic. Besides the more obvious ones, such as financing and cooperation of the professional groups involved, underlying factors, such as perceptions of the professionals involved, were found to be related to implementation of an OPE clinic. These underlying factors explain differences between different kinds of hospitals and between professional groups, regarding their resources and motivation to implement an OPE clinic.

Evaluation of two different epidural catheters in clinical practice. narrowing down the incidence of paresthesia!

Although epidural anesthesia is considered safe, several complications may occur during puncture and insertion of a catheter. Incidences of paresthesia vary between 0.2 and 56%. A prospective, open, cohort-controlled pilot study was conducted in 188 patients, ASA I-III, age 19-87 years, scheduled for elective surgery and epidural anesthesia. We evaluated a 20 G polyamide (standard) catheter and a 20 G combined polyurethane-polyamide (new) catheter. Spontaneous reactions upon catheter-insertion, paresthesia on questioning, inadvertent dural or intravascular puncture, and reasons for early catheter removal were recorded. The incidence of paresthesia reported spontaneously was 21.3% with the standard catheter and 16.7% with the new catheter. Systematically asking for paresthesia almost doubled the paraesthesia rate. Intravascular cannulation occurred in 5%. No accidental dural punctures occurred. An overall incidence of 13.3% of technical problems led to early catheter removal. The new catheter was at least equivalent to the standard regarding epidural success rate and safety : rate of paresthesia, intravascular and dural cannulation.

The effect of national guidelines on the implementation of outpatient preoperative evaluation clinics in Dutch hospitals.

BACKGROUND AND OBJECTIVES: Preoperative evaluation performed by anaesthesiologists primarily aims to estimate the risk of perioperative complications and to create opportunities to optimize the patients' condition before surgery. In this study an inventory was made of the current practice of preoperative evaluation in Dutch hospitals. It was estimated how many hospitals had implemented an outpatient preoperative evaluation clinic in 2004. Subsequently, current practice was compared with the results of a previous inventory (2000). It was also evaluated to what extent the guidelines of the Dutch Health Council and the Netherlands Society of Anaesthesiology were followed. METHODS: The study consisted of two phases. First, a literature research was performed and pilot interviews were constructed. The interviews were conducted face-to-face with anaesthesiologists in a sample of Dutch hospitals. Based on the results, written questionnaires were constructed. In the second phase these questionnaires were sent to all general and academic hospitals in the Netherlands. RESULTS: In 2004, 74% of the hospitals had an outpatient preoperative evaluation clinic, compared with 50% in 2000. The percentage of hospitals with an outpatient preoperative evaluation clinic available for all elective patients increased from 20% to 52%. CONCLUSIONS: The Dutch guidelines on preoperative evaluation seem to have influenced current practice. An increase in the number of outpatient preoperative evaluation clinics was seen after the guidelines were published. The implementation of an outpatient preoperative clinic seems to warrant that anaesthesiologists are carrying out the activities prescribed by the guidelines. Most hospitals without a clinic aim to implement one in the future.

Axillary brachial plexus blockade for the reflex sympathetic dystrophy syndrome.

The reflex sympathetic dystrophy syndrome (RSD) is a neurogenic pain syndrome that is characterized by pain, vasomotor and dystrohic changes and often motor impairments. Although the exact pathogenesis of RSD is unknown, for long the sympathetic nervous system was thought to play a dominant role and pharmacological and surgical sympathectomies have been a mainstay in treatment procedures. However, there is growing evidence of a pivotal role of C- and A delta-fibres in the aetiology of RSD. These fibres subserve a dual sensory-effector function. Besides the initiation of afferent impulses, they release neuropeptide mediators that cause a peripheral neurogenic inflammatory reaction and central neuroplastic reactions. Brachial plexus blockade (BPB) with local anaesthetic drugs interferes with the conduction of action potentials along both sympathetic efferents and the somatosensory C- and A delta-afferents and therefore seems a potential treatment modality in RSD. The aim of this study was to draw attention on this regional anaesthetic technique that is not commonly used in RSD. In this study six patients with severe RSD of an upper extremity in varying stages were treated with BPB in the multidisciplinary setting of an out-patient rehabilitation clinic with a follow-up of 12 to 21 months. The study was not placebo controlled. Three patients responded well. In these cases the treatment interval varied from 3 to 6 months, one case had RSD stage 1 and the two others stage 2. Three patients showed poor response. In one of these patients the initial effect was good but due to an infection at the insertion site of the catheter BPB had to be discontinued. The other two poor-responders had treatment intervals of 7 and 25 months and both had stage 3 RSD. We conclude that there is theoretical and clinical support to further evaluate the effect of BPB as a treatment modality in the early stages of RSD.

Extradural ropivacaine and bupivacaine in hip surgery.

We studied 126 patients undergoing elective hip surgery; they received 20 ml of 0.5%, 0.75%, 1.0% ropivacaine or 0.5% bupivacaine extradurally in a double-blind design. Sensory block (pinprick), motor block (modified Bromage scale), quality of analgesia and neuromuscular block were assessed intermittently. Heart rate and arterial pressure were measured at regular intervals. A total of 115 patients were evaluated for efficacy. Onset of analgesia, onset of motor block and maximum cephalad spread (T4) did not differ between the groups. Duration and quality of analgesia and motor block increased with the concentration of ropivacaine. Ropivacaine 1.0% provided a longer duration of analgesia and motor block, more intense motor block and more patients with satisfactory analgesia than 0.5% bupivacaine. More patients treated with the higher concentrations of ropivacaine required treatment for hypotension and bradycardia.

Cardiovascular effects of epidural local anaesthetics. Comparison of 0.75% bupivacaine and 0.75% ropivacaine, both with adrenaline.

The cardiovascular effects of 20 ml 0.75% bupivacaine with adrenaline 5 micrograms/ml injected epidurally were compared with those of 20 ml 0.75% ropivacaine with adrenaline. Cardiovascular measurements were performed with a transthoracic electrical bioimpedance monitor. The maximum mean arterial blood pressure decreased significantly from baseline values after both solutions, but the decrease after 20 minutes was more pronounced with bupivacaine (21%) than with ropivacaine (9.6%). Stroke volume increased significantly in both groups (52% for bupivacaine and 29% for ropivacaine). Cardiac output increased significantly from baseline values 2 minutes after epidural administration; the mean of the maximum increase was 64% for bupivacaine and 53% for ropivacaine (NS). The mean of the maximum increase of the ejection fraction was 13% in the bupivacaine group and 9% in the ropivacaine group, but was only significantly different from baseline values following bupivacaine. There was no difference in the onset time or height of the sensory block between the groups. The cardiovascular changes can be ascribed to sympathetic blockade and to systemic absorption of the local anaesthetics and adrenaline.

Hemocue--a new haemoglobinometer in the clinic.

The accuracy of the Hemocue, a portable haemoglobinometer, was tested on 29 patients undergoing open-heart surgery, and the results were compared with the haemoglobin values obtained from the hospital laboratory. Special attention was paid to the lower range of haemoglobin values and the simplicity and speed of operating the meter. The correlation between the methods was good (r = 0.965). The limits of agreement were 0.0323 +/- 0.705 mmol l-1 (95% confidence level).

Comparison of 0.75% ropivacaine with epinephrine and 0.75% bupivacaine with epinephrine in lumbar epidural anesthesia.

Forty-three ASA physical status I and II patients, scheduled for elective urologic surgery, were randomly entered into a randomized double-blind study using 20 ml bupivacaine 0.75% or 20 ml ropivacaine 0.75%, both with 5 micrograms/ml epinephrine. Two patients were excluded from evaluation of efficacy due to technical failure. After a test dose of 3 ml bupivacaine 0.75% with epinephrine or ropivacaine 0.75% with epinephrine, 17 ml of either solution was given in incremental doses over 4 minutes (4, 4, 4, and 5 ml). Analgesia was satisfactory for surgery in all patients except for one in each group. The onset time of analgesia was short: after administration of ropivacaine and bupivacaine, the T12 dermatome was blocked within 6-8 minutes. Mean maximum upper level of analgesia was similar in the groups--T8 +/- 0.6 and T7 +/- 0.6 (mean +/- SEM)--for ropivacaine and bupivacaine, respectively. Duration of analgesia at the T10 level was 190 +/- 12 minutes in the ropivacaine group and 234 +/- 20 minutes in the bupivacaine group and was significantly shorter for ropivacaine at T10, L2, and S5 segments. Frequency of complete motor block was significantly lower in the ropivacaine group (7/21) than in the bupivacaine group (16/20). No differences were found in onset to various degrees of motor block, however, the duration of degree 1 motor block was significantly shorter in the ropivacaine group. Hypotension and bradycardia requiring treatment were experienced by seven and three patients, respectively, in the bupivacaine group, and by two and one patient, respectively, in the ropivacaine group. No postoperative adverse events related to anesthesia were observed. Ropivacaine 0.75% with epinephrine is an effective long-acting local anesthetic. Duration of sensory block is similar to that of bupivacaine 0.75% with epinephrine; however, the motor block is less profound and of shorter duration.

Hemodynamic monitoring in epidural blockade: cardiovascular effects of 20 ml 0.5% bupivacaine with and without epinephrine.

Twenty patients scheduled for elective urologic surgery received epidural anesthesia with 20 ml 0.5% bupivacaine. Ten patients received an epinephrine-free solution and ten patients received epinephrine 5 micrograms.ml-1 added to the local anesthetic solution. The mean maximum level of sensory blockade was not different between the two groups (T7 and T8). After epidural administration of 20 ml of either solution, the mean arterial blood pressure decreased significantly from pre-blockade values. After administration of 0.5% bupivacaine with epinephrine, cardiac output, stroke volume and end diastolic volume increased significantly from pre-blockade control values. These changes occurred within two to four minutes after injection of the local anesthetic solution and are caused by the systemic effects of epinephrine. After 15 minutes, the ejection fraction in the plain bupivacaine group decreased significantly from pre-blockade control values and the bupivacaine with epinephrine group. The differences in hemodynamic effects of the two solutions can be explained by the vasoactive effects of epinephrine and the cardiodepressive effects of bupivacaine.

An open study comparison of 0.5%, 0.75% and 1.0% ropivacaine, with epinephrine, in epidural anesthesia in patients undergoing urologic surgery.

Ropivacaine 0.5%, 0.75% and 1.0% with epinephrine 5 micrograms/ml was investigated in an open, multi-center study for lumbar epidural anesthesia in 46 patients undergoing urologic surgery. The onset time for analgesia to T12 was 5-7 minutes after the end of the ropivacaine injection. Maximum segmental levels of analgesia (T4-6) were not different between the groups. Complete motor blockade was obtained in 3/15, 7/15 and 10/15 patients in the 0.5%, 0.75% and 1.0% groups, respectively. Duration of analgesia at the T10 level was 2.5 hours in the 0.5% group, and increased to 4 hours in the 1.0% group. Analgesia was satisfactory for surgery in all patients except for 2/15 in each of the 0.5% and 0.75% groups and 1/15 in the 1.0% group. Hypotension was experienced by three, six and three patients in the 0.5%, 0.75% and 1.0% groups, respectively. Bradycardia was seen in two patients in the 0.5% group and one patient in the 1.0% group. Backache was experienced by seven patients (four in the 0.5%, two in the 0.75% and one in the 1.0% group). No late-occurring adverse experiences were observed. In conclusion, 0.5%, 0.75% and 1.0% ropivacaine with epinephrine provide adequate analgesia and motor blockade for urologic surgery.

Dextran determination in human serum with the aid of an enzymatic glucose method.

A method is presented for the determination of dextran concentrations. Following acid hydrolysis and partial neutralization, the resulting glucose is determined with the aid of glucose oxidase. Specificity is better than that of previously applied methods. Mean recovery is 100.2 +/- 1.6% (SD) for concentrations from 180 mg.l-1 to 6000 mg.l-1. Coefficients of variation are 2.2% for 240 mg.l-1, 1.2% for 600 mg.l-1 and 1.8% for 1200 mg.l-1. When used for volume measurements, the accuracy is 99.3 +/- 2.1% (SD) for volumes of 2.5 to 3 liters.