Enforced mobilization, early oral feeding, and balanced analgesia improve convalescence after colorectal surgery.

OBJECTIVE: A postoperative regimen using a multimodal approach with enforced mobilization and early oral nutrition has been reported to improve convalescence but has not been compared with other postoperative regimens. METHODS: Forty patients undergoing elective colorectal surgery were randomly allocated to an intervention group receiving comprehensive information on the importance of mobilization, balanced anesthesia, and postoperative analgesia including epidural local anesthetics and enforced postoperative mobilization or a control group receiving anesthesia without epidural local anesthetics, postoperative analgesia with epidural morphine, and mobilization without fixed goals. All patients were offered early oral nutrition. The regimens were compared by means of ambulation time and physical activity, voluntary muscle strength, pulmonary function, and body composition. RESULTS: The ambulation time improved substantially within 22 h in the intervention group versus 3 h in the control group on day 1 (P = 0.0004) and within 8 h versus 2 h on day 4 (P = 0.0003). The voluntary strength of the quadriceps muscle decreased by 3% in the intervention group versus 15% in the control group on day 7 (P = 0.04). Two months postoperatively, the difference between groups was the same (P = 0.02). CONCLUSION: This active per- and postoperative regimen based on a multimodal approach improved ambulation time and muscle function during admission and late convalescence.

The effects of atropine on dynamic compliance in healthy intubated adults.

In order to compare the effect of atropine and sodium chloride on the dynamic compliance of the respiratory system after tracheal intubation, we studied 20 patients allocated randomly into two groups to receive either: atropine after 5 min of steady state and sodium chloride after 10 min (group A) or in reverse order (group B) intravenously. The study was conducted in a randomized double-blinded manner. The patients were anaesthetized with thiopental 5 mg kg(-1) followed by thiopental 50 mg intravenously, as required. Intubation was facilitated by atracurium 0.5 mg kg(-1) intravenously and fentanyl 200 microg intravenously. During fixed volume ventilation (100 mL kg(-1), f=10), compliance and end-tidal carbon dioxide were measured every 10 s by a Datex AS/3-respiratory module connected to a portable IBM-pc. Five minutes was allowed to establish a steady state then either atropine or sodium chloride was administered according to the protocol. Respiratory dynamic compliance increased significantly after intravenous administration of atropine (P < 0.05). We conclude that atropine 1.0 mg given intravenously provides protection against an intubation-induced decline in respiratory dynamic compliance.

[Angiotensin-converting enzyme inhibitors and anesthesia]. / Angiotensinkonverterende enzym-haemmere og anaestestei.

The increasing usage of ACE-inhibitors in the treatment of hypertension and chronic heart failure may increase the incidence of adverse anaesthetic occurrences. Four such cases are described. In two of these cases, the patient reacted with severe hypotension when general anaesthesia was supplemented with epidural bupivacaine. Another patient suffered a heart fatality after severe hypotension in conjunction with the administration of a spinal anaesthetic. Finally, one patient suffered sudden fatal pulmonary oedema after completion of uneventful general anaesthesia, possibly due to late resumption of ACEI-treatment. The cases are discussed in detail, with particular reference to the possible underlying mechanisms. Preoperative discontinuation of ACEI-treatment is controversial. We present some of the issues involved. Most authors lean towards continuing ongoing treatment, even though there is firm evidence that this increases the risk of hypotensive episodes due to hypovolaemia, arguing that such events may be predicted and antagonized with fluid therapy.

[Severe hypoglycemia and clouding of consciousness caused by deficiency of the connecting link acyl CoA dehydrogenase]. / Svaer hypoglykaemi og bevidsthedssløring forårsaget af mangel på mellemkaedet acyl-CoA dehydrogenase.

A case of severe hypoglycaemia precipitated by fasting in a child is described. As a result of the hypoglycaemia, the patient became brain damaged. The mechanism causing the hypoglycaemia was a defect in the fatty acid beta-oxidation enzyme, the connecting link acyl-CoA dehydrogenase. During a prolonged fast, fatty acids are not converted to acetyl-CoA and ketone bodies which participate in Kreb's cycle for production of energy to a sufficient extent. This result in non-ketotic hypoglycaemia with excretion of organic acids in the urine. As a rule, the symptoms occur for the first time during the first to second years of life in connection with common infectious diseases, with vomiting followed by clouding of consciousness and possibly coma, but the condition may also present with sudden unexpected death. Treatment consists of intravenous glucose. The diagnosis is established by testing the urine for hexanoylglycin and other substances and is confirmed by culture of skin fibroblasts and measurement of beta-oxidation activity. The disease is an autosomally recessive inherited condition. In families where there have been cases of unexplained hypoglycaemia and clouding of consciousness and cases of unexplained death in infancy or "near misses", all of the family members should be offered examination for the above mentioned enzyme deficiency.

[Follow-up of spinal analgesia with somatosensory evoked potentials and biotesiometry]. / Efterundersøgelse af spinalanalgesi med somatosensory evoked potentials og biotesiometri.

In order to estimate the possible neurotoxicity of spinal analgesia with bupivacaine (Marcain), a total of ten patients were examined neurologically prior to spinal analgesia and seven days afterwards with somatosensory evoked potentials (SEP) and biotesiometry. The objective neurological examination results and SEP were entirely unchanged. At control examination with biotesiometry, altered vibration sense bilaterally over the medial malleoli was found in one patient but not on the pulp of the great toe bilaterally. Alterations in vibration in this patient were within the intraindividual variation as described by Fagius & Wahren. The method of examination employed here has not previously been employed systematically for follow-up investigation or elucidation of neurological deficits following spinal analgesia.

Familial spontaneous pneumothorax.

In a three generation family with 27 members we examined a relationship could be found between spontaneous pneumothorax and HLA-haplotypes, alpha 1-antitrypsin phenotypes or concentration or lung volumes and ventilatory capacity. Eight individuals in the family suffered from spontaneous pneumothorax. No relationship with the investigated markers could be found in this informative family. All patients showed normal lung volumes and ventilatory capacity after recovery.

[Postoperative analgesia with morphine versus morphine and paracetamol. A double-blind clinically controlled study with a placebo]. / Postoperativ smertebehandling med morfin vs. morfin og paracetamol. En dobbeltblind klinisk kontrolleret undersøgelse med placebo.

The effect of paracetamol on the postoperative employment of morphine was investigated in a double-blind clinically controlled investigation with a placebo. The operations concerned were elective gynaecological laparotomies and hip replacements. During the first 60 hours postoperatively, the employment of morphine was reduced significantly in the patients who received paracetamol. Reductions of 16, 22 and 26% were concerned. The differences between the various types of operation were not significant. Patients for joint replacements who had been treated preoperatively with non-steroid anti-inflammatory preparations did not have any significantly greater consumption of morphine postoperatively but the reduction in consumption of morphine in the paracetamol group was significantly greater with a saving of 43%. Patients who had received treatment with morphine preparations preoperatively had significantly greater consumption of morphine postoperatively but the additive analgesic effect of paracetamol remained unchanged at approximately 25%.

[Transdermal scopolamine to prevent postoperative nausea and vomiting after uterine curettage and termination of pregnancy. A double-blind clinically controlled study with placebo]. / Transdermal skopolamin som profylakse mod postoperativ kvalme ved abrasio uteri og abortus provocatus. En dobbeltblind klinisk kontrolleret undersøgelse med placebo.

A randomized double-blind clinically controlled investigation with a placebo was undertaken to investigate the prophylactic effect of transdermal scopolamine on postoperative nausea and vomiting after dilatation and curettage and termination of pregnancy. No significant difference was found between the placebo and transdermal scopolamine. On the other hand, the patients in the scopolamine group had significantly more postoperative discomforts which were attributable to the anticholinergic effect of scopolamine. Transdermal scopolamine cannot be recommended for the prophylaxis of postoperative nausea and vomiting following uterine curettage and termination of pregnancy.