Knotting of intracardiac flow-directed balloon catheter. Simple surgical method of removal.

A complete knot occurred in a 7F flow-directed balloon catheter inserted through the right internal jugular vein. The patient was intubated and placed under positive pressure ventilation. After gaining surgical exposure of the venipuncture site, a purse-string of Prolene 4--0 suture was placed around it. The patient was placed in the Trendelenburg position and the knotted catheter withdrawn, while the purse-string suture was immediately tightened avoiding uncontrollable hemorrhage or massive air embolism.

Effects of acute decrease in systemic afterload on accuracy of Doppler-derived left ventricular rate of pressure rise measurement in anesthetized patients.

OBJECTIVES: This study was designed to describe exactly the effects of acute decrease in systemic afterload on the accuracy of Doppler-derived left ventricular rate of pressure rise (LV DeltaP/Delta(t)) measurements compared with other routinely used indices of systolic function. METHODS: Twelve patients scheduled for coronary artery bypass grafting were studied. After induction of anesthesia (T0), afterload was modified by incremental administrations of nicardipine (T1-4). At each step of the procedure, thermodilution-derived cardiac index, left ventricular (LV) fractional area change, and LV DeltaP/Delta(t) were measured, and systemic vascular resistances were calculated. RESULTS: During the procedure, the systemic vascular resistances decrease averaged 13.4%. Systemic vascular resistances were correlated with LV DeltaP/Delta(t) (r = 0.843, P =.003) but inversely correlated with cardiac index (r = -0.782, P =.005) and LV fractional area change (r = -0.887, P =.003). CONCLUSION: In conclusion, and inversely to cardiac index or LV fractional area change, LV DeltaP/Delta(t) does not overestimate LV contractility in the presence of an acute decrease in systemic afterload.

Doppler-derived left ventricular rate of pressure rise determination in presence of severe acute mitral regurgitation in pigs.

Doppler-derived left ventricular (LV) rate of pressure rise (Dop LV DeltaP/Deltat) is described as an index of LV performance in the presence of mitral regurgitation (MR). This study was designed to define more accurately the accuracy of the method in the presence of severe MR. Ten pigs were anesthetized and monitored. MR was gradually created. At each grade of MR, preload was manipulated with the intent of modifying LV end-diastolic area value within a range of +/-20%. Concurrently, the mean left atrial pressure (LAP) was recorded, MR was quantified by the mitral to aortic velocity-time integral ratio (mitroaortic VTI ratio), Dop LV DeltaP/Deltat was calculated, and peak LV dP/dt was derived from LV catheterism data. During the procedure Dop LV DeltaP/Deltat gradually underestimated peak LV dP/dt. This difference was correlated to the mean LAP (P < 10(-5)) and mitroaortic VTI ratio (P < 10(-5)) and became clinically significant when the mean LAP was superior to 21 mm Hg.

I.V. Labetalol during coronary artery surgery.

The hemodynamic effects of a fixed dose of 10 mg i.v. Labetalol were evaluated in 9 CAD patients during a surgical procedure for myocardial revascularisation. The results show a significant mean decrease in heart rate (HR) (-13%), systolic blood pressure (SBP) (-16%) and rate pressure product (RPP) (-28%). Other hemodynamic parameters were not significantly affected. These results were confirmed by a clinical study where in a series of 110 CAD patients 21 were treated during the surgical procedure with incremental doses of Labetalol to control high systolic blood pressure and tachycardia. Administration of a mean dose of 24.3 mg of Labetalol resulted in a significant decrease of RPP (-38%). No side effects related to Labetalol were encountered.

Halothane versus isoflurane for short ENT procedures with spontaneous respiration in children.

This study compares halothane with isoflurane for short ENT procedures performed under spontaneous breathing in 80 children. Monitoring included ECG, arterial pressure, PECO2 and respiratory rate. Induction, maintenance and recovery durations were recorded. Induction time was further subdivided into an initial phase followed by a plateau according to delivered halogen concentrations. Inhalation induction was possible with isoflurane without major side effects as long as the drug concentration was increased slowly. This precaution was not needed with halothane. No respiratory depression could be attributed to either of the tested drugs. Isoflurane elicited a significant drop in arterial pressure with a concomitant increase in heart rate. Recovery times were shorter in the isoflurane group.

Pulmonary edema following acute upper airway obstruction.

During recovery, our patient presented an acute upper airway occlusion. After the removal of the airway obstruction, he developed a massive bilateral pulmonary edema with an acute hypoxemia. Hemodynamic measures following this incident show that mean and wedged pulmonary pressures are in the normal ranges. Several cases, associating acute upper airway obstruction, massive bilateral pulmonary edema and low or normal filling pressures, have been reported in literature. Three mechanisms have been postulated to explain this phenomenon; a dramatic increase of the negativity of the interstitial pulmonary pressure, a significative augmentation of the after-load and the hypoxic pulmonary reflex vasoconstriction.

Cryoanalgesia for post-thoracotomy pain relief.

A randomized study comparing the postoperative requirements of narcotics of three groups of patients (Group I: no analgesia; Group II: internal intercostal nerve block; Group III: cryoanalgesia) was conducted. This study was performed in order to assess the efficiency of cryoanalgesia versus internal intercostal nerve block to obtain pain relief after thoracotomy. Regarding post-operative narcotic requirements (Piritramide-Dipidolor), there was no significant difference between Group I and Group II patients, but patients from Group III required a significantly lower amount of narcotics during the first 36 postoperative hours (p less than 0.01). We conclude that, although cryoanalgesia does not provide complete post-thoracotomy pain relief, it is however an easy and safe method and is more efficient than internal intercostal nerve block for pain relief after thoracotomy.

TOF-tube, a new protection for acceleromyography, compared with the TOF-Guard/TOF-Watch arm board.

Neuromuscular blockade monitoring at the adductor pollicis has become easier using acceleromyography. In order to guarantee a reliable analysis of its acceleration, the thumb movement has to be free and protected from external influences. To this end, we describe here-in two hand fixation- and protection-devices for use with acceleromyography. After a bolus of 0.3 mg/kg rocuronium, we compared acceleromyography data obtained simultaneously on both hands with, on one side, the cumbersome TOF-Guard/TOF-Watch arm board, and the smaller and handier TOF-tube on the other. Results showed little differences between the two devices. Yet, a short and clinically irrelevant delay was observed for TOF-tube data during recovery. This was probably caused by a difference in thumb position and repositioning technique. In conclusion, the more convenient TOF-tube can be used as well as the TOF-Guard/TOF-Watch arm board in daily clinical practice.

[Risk factors, postoperative mortality and morbidity in pulmonary surgery]. / Facteurs de risque, mortalité et morbidité postopératoires en chirurgie pulmonaire.

In this retrospective study, the influence of preoperative risk factors on mortality and morbidity after pulmonary surgery is analysed. Sixty-five consecutive pulmonary resections are studied and compared with data from the literature. Age and lung function abnormalities are well known risk factors but a severe selection minimizes their negative effects: a good cardio-circulatory condition and the prediction of an acceptable postoperative lung function allows a mortality reduction down to 5% and minimizes the frequency of postoperative respiratory insufficiency. The importance of a good preoperative training of the patient and of the early detection and immediate treatment of any postoperative complication are stressed.

Persistent left superior vena cava: transoesophageal echocardiographic findings and surgical strategies.

Two cases of casual discovery of persistent left superior vena cava during cardiac surgery are reported. Diagnoses were suspected at the time of peroperative transoesophageal echocardiography in the first case, and of preoperative fluoroscopy during a Swan-Ganz catheter insertion procedure in the second case. For both patients, a peroperative echo contrast study permitted to confirm the anomaly before initialization of cardiopulmonary bypass. Embryology, echocardiographic findings and surgical management, including cardioplegia delivering and left upper venous system drainage, are reviewed.

Patent foramen ovale and implantable cardioverter defibrillator.

A case of patent foramen ovale opening was observed concomitantly to a defibrillation threshold determination in the setting of an internal cardioverter defibrillator implantation. The subsequent transient right-to-left shunt was confirmed by a peroperative transoesophageal echocontrast study. The underlying mechanism of this incident may be related to a transient reversal of the interatrial gradient, due to the pre-existence of pulmonary hypertension and tricuspid regurgitation, associated with ongoing mechanical ventilation and modifications of intracardiac pressures regimen secondary to the succeeding ventricular tachyarrhythmia and defibrillation. Paradoxical embolism can be an aetiology for neurologic injury during internal cardioverter defibrillator implantation.

Bronchospasm and hypotension during cardiopulmonary bypass after preoperative cimetidine and labetalol therapy.

A 64-yr-old asthmatic patient underwent a two-vessel aortocoronary vein grafting. Before surgery, the patient received cimetidine 400 mg and labetalol 650 mg. During the first 60 min of bypass, hypotension (40-45 mm Hg) was observed in spite of phenylephrine 14 mg. This initial hypotension was followed, during rewarming, by a slow increase in arterial pressure to 150 mm Hg. On cessation of bypass, bronchospasm was observed and was protracted. It is assumed that labetalol clearance and metabolism were reduced by cimetidine, that labetalol alpha-antagonism was responsible for the vasodilatation withstanding the phenylephrine, and that a combination of labetalol beta-antagonism and phenylephrine alpha-agonism initiated the bronchospasm. These observations indicate that, after labetalol therapy, higher doses of vasopressor agents such as phenylephrine may be necessary, but that such therapy may lead to bronchospasm in asthmatic patients.

Intravenous infusion of propofol for induction and maintenance of anaesthesia during endoscopic carbon dioxide laser ENT procedures with high frequency jet ventilation.

Fourteen patients of ASA grades 1-3 were anaesthetised with continuous infusions of propofol and alfentanil for endoscopic carbon dioxide laser ENT microsurgery. Their lungs were ventilated with an oxygen-air mixture using a high frequency jet ventilator. Propofol was given at an initial rate of 120 micrograms/kg/minute for 10 minutes after a bolus dose of 2.6 mg/kg, and then at 80 micrograms/kg/minute. Alfentanil was given at a rate of 0.5 micrograms/kg/minute. Arterial pressure decreased significantly after the bolus dose. It increased significantly for a few minutes after laryngoscopy and returned to baseline values during maintenance of anaesthesia. Heart rate increased significantly during induction and until laryngoscopy was performed but it decreased below its initial value after 5 minutes of maintenance. Platelet count and the degree of aggregation did not change during infusion of propofol.

Neuralgia following lumbar sympathectomy.

Between March and October 1986, 33 consecutive patients underwent unilateral lumbar sympathectomy in the Thoracic and Cardiovascular Surgical Unit of the Catholic University in Louvain, Belgium. Ten patients experienced postsympathectomy neuralgia. After a single epidural injection of fentanyl, 50 micrograms, and methylprednisolone 80 mg, pain disappeared completely in six patients. Neuralgia recurred in four patients requiring repeat epidural injection with relief of residual symptoms. Epidural infiltration is a reliable treatment for neuralgia after lumbar sympathectomy.

From laparoscopic training on an animal model to retroperitoneoscopic or coelioscopic adrenal and renal surgery in human.

So far, laparoscopic approaches to kidney and adrenal have been limited because of their retroperitoneal location. We here report eight renal and adrenal endoscopic procedures performed in seven patients: two adrenalectomies for hyperaldosteronism, one adrenalectomy for isolated metastasis from an adenocarcinoma of the lung; two nephrectomies for end-stage infected hydronephrosis, two partial nephrectomies for small circumscribed lesions of the kidney, and one endoscopic resection for pain relief of a voluminous cyst at the kidney. The approach was transperitoneal in two cases and retroperitoneal in five cases using the retropneumoperitoneum insufflation technique. One patient was operated by a combined approach using the retro- and transperitoneal routes. All procedures were successfully completed endoscopically. The retroperitoneoscopic approach of the kidney is safe and does not interfere with the peritoneal organs. Its working space is tenuous, but allows a direct access on the kidney with good exposure of its pedicle. For adrenal surgery, the retroperitoneoscopic dissection is more difficult, because movements of instruments are often impaired by the closeness of the costal margin and the iliac crest. However, in case of difficulties we found it very convenient to switch from a retroperitoneal endoscopic approach to a combined coelioscopic and retroperitoneoscopic operation. Far from excluding each other, both approaches are complementary, particularly for difficult situations (i.e., previous peritoneal or retroperitoneal surgery).

Propofol-alfentanil versus fentanyl-midazolam in coronary artery surgery.

OBJECTIVE: To compare intraoperative hemodynamics profiles and recovery characteristics of propofol-alfentanil with fentanyl-midazolam anesthesia in elective coronary artery surgery. DESIGN: Prospective, randomized study. SETTING: University hospital. PARTICIPANTS: Fifty patients with impaired or good left ventricular function. INTERVENTIONS: In group 1, (n = 25) anesthesia was induced with an infusion of propofol, 3 to 4 mg/kg/h, alfentanil, 500 micrograms, and pancuronium 0.1 mg/kg, and maintained with propofol, 3 to 6 mg/kg/h (variable rate), and alfentanil infusions, 30 micrograms/kg/h (fixed rate). Additional boluses of alfentanil, 1 mg, were administered before noxious stimuli; group 2 (n = 25) received a loading dose of fentanyl, 25 micrograms/kg, midazolam, 1.5 to 3 mg, and pancuronium, 0.1 mg/kg for induction, followed by an infusion of fentanyl, 7 micrograms/kg/h, for maintenance. Additional boluses of midazolam (1.5 to 3 mg) and fentanyl (250 micrograms) were administered before noxious stimuli. MEASUREMENTS AND MAIN RESULTS. Cardiovascular parameters at eight intraoperative time points as well as time to extubation, morphine consumption, and pain scores were recorded. Induction of anesthesia was associated in both groups with a small but significant decrease in mean arterial pressure (1: 15 mmHg (15%); 2: 8 mmHg (8%) with significant decreases in cardiac index (1: 8%; 2: 8%) and left ventricular stroke work index (1: 24%; 2: 21%). Throughout surgery, hemodynamic profiles were comparable between groups except after intubation when the MAP was significantly lower in group 1 (75 +/- 12 mmHg) than in group 2 (89 +/- 17 mmHg). Group 1 required less inotropic support. Extubation was performed faster in group 1 (7.6 h) than in group 2 (18.0 h). Morphine requirements and pain scores were comparable between groups. CONCLUSIONS: Propofol-alfentanil anesthesia provides good intraoperative hemodynamics and allows early extubation after coronary artery surgery.