EuroSCORE predicts poor health-related physical functioning six month postcoronary artery bypass graft surgery.

AIM: The objectives of this study are to test whether the European system of cardiac-operative risk evaluation score (EuroSCORE) is associated with preoperative health-related quality of life (HRQoL), and whether it is a predictor of mental and physical health-related quality of life six months after coronary artery bypass grafting (CABG). METHODS: A longitudinal observational study was carried out among 181 patients who underwent CABG. Physical and mental domains of quality of life were measured using SF-36 and risk stratification was estimated using the EuroSCORE. A post hoc test (with Bonferroni correction) was used to determine whether EuroSCORE was associated with preoperative HRQoL, LOS and postoperative rate of complications. Hierarchical regression analysis was performed to explore the associations between EuroSCORE, postoperative events and postoperative HRQoL. RESULTS: EuroSCORE is associated with physical functioning before and after CABG and a higher EuroSCORE is a predictor of poor physical functioning and not a predictor of the mental domains of quality of life, while smoking predicted bodily pain after CABG. Furthermore, readmission within six weeks after discharge was a predictor of poor physical functioning, physical role and general health. Moreover, post hoc tests showed statistically significant and clinically relevant differences in physical functioning between low-risk and high-risk EuroSCORE classes, and between medium and high classes at baseline and six months after CABG. High-risk patients had more perioperative complications and longer lengths of stay, as compared to low-risk patients. CONCLUSION: EuroSCORE is a predictor of poor self-reported physical functioning six months after CABG and is not a predictor of mental functioning.

Continuous epidural infusion of morphine for pain relief after cardiac operations.

Postoperative pain relief and stress hormones were examined during the use of continuous epidural infusion of morphine at a rate of 0.1 mg/hr in 30 patients (Group B) after coronary artery bypass grafting. This was compared to our routine method of postoperative analgesia of intravenous morphine 2 mg/2 hr and as needed in another 30 patients (Group A). Continuous epidural morphine infusion required occasional supplementation with intravenous morphine and achieved effective analgesia in 80% of the patients. Pain relief was adequate in 50% of the patients in Group A. The mean dose of morphine used in Group B during the first 3 postoperative days was 5 mg per patient per day and was significantly lower than that used in Group A (mean 18 mg per patient per day). Serum morphine was undetectable (below 2.5 ng/ml) in Group B and was significantly lower than that in Group A (17 ng/ml). Epidural analgesia was associated with adequate postoperative pulmonary and cardiovascular functions; nausea and vomiting occurred in two patients. Levels of postoperative stress, serum cortisol, and beta-endorphin were significantly lower in Group B than in Group A. This study shows that continuous epidural infusion of morphine at a rate of 0.1 mg/hr provides selective and effective pain relief and reduces postoperative stress after cardiac operations. This method of analgesia was also associated with minimal side effects and provides an alternate approach for treatment of pain after cardiac operations.

High-frequency ventilation with an uncuffed endobronchial tube. A new technique for one-lung anesthesia.

Conventional one-lung intermittent positive-pressure ventilation (OL-IPPV) has been a valuable technique during anesthesia for intrathoracic operations. OL-IPPV has been associated with a high incidence of hypoxemia, as a result of the associated intrapulmonary shunt of 21% to 65% of cardiac output. The administration of OL-IPPV requires the use of a large cuffed endobronchial double-lumen tube. These tubes can be difficult to position properly and have been associated with malfunction, trauma, and tracheobronchial rupture. In an effort to avoid the problems associated with conventional OL-IPPV, we have developed a new technique of modified one-lung high-frequency ventilation (MOL-HFV). MOL-HFV is based on the administration of high-frequency ventilation (HFV) through a small uncuffed endobronchial tube. MOL-HFV was studied in 26 patients during a variety of intrathoracic surgical procedures, and it was compared to one-lung high-frequency ventilation (OL-HFV) and OL-IPPV in each patient. After the chest was opened, each patient received a sequence of OL-IPPV, OL-HFV, and MOL-HFV. Arterial PO2 was measured and intrapulmonary shunting was calculated after 30 minutes of each type of ventilation. This study showed that arterial PO2 was significantly higher during MOL-HFV (mean 379 mm Hg) than during OL-HFV (mean 235 mm HG) or OL-IPPV (mean 141 mm Hg). This was the result of a significantly lower intrapulmonary shunt during MOL-HFV (19%). We conclude that MOL-HFV through a small uncuffed endobronchial tube provides better oxygenation, optimal surgical access, and avoids the problems associated with the use of double-lumen tubes.

Survival in patients undergoing tracheal sleeve pneumonectomy for bronchogenic carcinoma.

Thirty-four patients underwent tracheal sleeve pneumonectomy during the years 1964 through 1981. In 30 patients, simultaneous resection of the right lung and carina was performed with an anastomosis established between the left main bronchus and trachea. In four patients a previous pneumonectomy had been performed (two right and two left) and, because of recurrence in the stump, resection of the stump and carina was carried out with either right or left bronchotracheal anastomosis. Preoperative irradiation was given in 28 of the patients in the group, and tumor sterilization occurred in six of those so treated. Four of 30 patients are long-term survivors: Two are still alive and free of cancer at 7 and more than 11 years postoperatively. One patient in the group of four with stump recurrence is alive more than 11 years postoperatively. All long-term survivors had epidermoid carcinoma and all received preoperative irradiation. The most frequent complications were fistula formation and pneumonia, resulting in 10 deaths in the perioperative period for a mortality of 29%. The 5 year survival rate of the entire group was 15%, and the survival rate by life-table analysis in the 30 patients with lung and carinal resection was 13.3% at 5 and 8.8% at 10 years.

One-lung high-frequency ventilation for tracheoplasty and bronchoplasty: a new technique.

Major airway surgery requires the maintenance of adequate ventilation and oxygenation during the period of resection and reconstruction, as well as an unobstructed surgical field and optimal access to the airway's circumference. High-frequency positive-pressure ventilation (HFPPV) at a frequency of 1 Hz (60 breaths/min) or more, along with a small tidal volume (50 to 250 cc), provides adequate ventilation and oxygenation with minimal impairment of pulmonic and systemic circulatory functions. We have used HFPPV of one lung through a 2 mm internal diameter catheter in six patients (three undergoing right sleeve pneumonectomies, two having carinal tumor resections, and one having tracheal resection). High-frequency positive-pressure ventilation of the left lung provided continuous and adequate ventilation and oxygenation during the period of resection and reconstruction of the airways, while the small catheter permitted unimpaired visualization and adequate access to the operative site.

High frequency ventilation through a small catheter for laser surgery of laryngotracheal and bronchial disorders.

One-lung and two-lung high frequency ventilation (HFV) through a 2-mm internal diameter catheter was evaluated in 22 patients during endoscopic laser excision of stenotic lesions of larynx, trachea, and bronchi. High frequency ventilation at 80 to 250 breaths per minute using air during two-lung HFV and using air-oxygen at an inspired oxygen concentration of 25% during one-lung HFV maintained adequate alveolar ventilation and oxygenation in all patients. The use of HFV through a catheter allowed continuous control of ventilation and provided maximal surgical exposure for endoscopic laser surgery. The continuous outflow of HFV gases through the endoscope also prevented lung contamination with blood and debris. The potential of HFV polyvinylchloride catheter ignition by laser was also evaluated in the laboratory during continuous flow of air-oxygen and oxygen-nitrous oxide. The laser ignited polyvinylchloride tubes in all the mixtures of oxygen and nitrous oxide within 3 to 7 seconds. Oxygen at 30% mixed with nitrogen 70% was safe and all such tubes were not ignited by the laser. The ability of HFV to provide adequate oxygenation during endoscopic laser surgery using air-oxygen at an FiO2 below 30% also avoids the hazard of catheter and airway fire.

Combined high-frequency ventilation for management of terminal respiratory failure: a new technique.

Seven patients with severe adult respiratory distress syndrome (ARDS) developed terminal respiratory failure and severe hypoxemia (PaO2 below 50 mm Hg) with death imminent despite maximal ventilatory support with intermittent positive-pressure ventilation (IPPV) and positive end-expiratory pressure (PEEP). High-frequency positive-pressure ventilation (HFPPV) was used in these patients for one day at a rate of 250 breaths/min, with slight improvement of PaO2 to a mean of 80 mm Hg. High-frequency oscillatory (HFO) ventilation was used during the second day at a rate of 2000 breaths/min; this provided adequate oxygenation with a mean PaO2 of 244 mm Hg. Nonetheless, during HFO there was progressive CO2 retention and respiratory acidosis (mean PCO2 67 mm Hg). On the third study day, all seven patients were ventilated with combined high-frequency ventilation (CHFV) for a period from 5-21 days. CHFV is based on the administration of HFPPV simultaneously with HFO and provided adequate oxygenation by accelerated gas diffusion and CO2 elimination by convection. PaO2 was maintained during CHFV at a mean of 280 mm Hg. CO2 elimination was adequate with a mean PaCO2 of 32 mm Hg. Cardiac output also was adequately maintained during CHFV. Moreover, CHFV was well tolerated in our patients, allowing them to communicate with their families and nurses. CHFV successfully treated the hypoxemia of respiratory failure in all the patients. However, five patients (71%) died of cardiac arrest as a result of multisystem failure despite adequate oxygenation (PaO2 above 80 mm Hg).

Continuous epidural infusion of morphine for treatment of pain after thoracic surgery: a new technique.

We evaluated postoperative pain relief and the incidence of side effects of three methods of thoracic epidural analgesia. Ninety patients, divided into three equal groups, received postoperative analgesia after thoracic surgery either as intermittent epidural injections of bupivacaine (25 mg/5 ml, 0.5% solution) as needed, or, intermittent epidural injections of morphine (5 mg/5 ml of normal saline, 0.1% solution) as needed, or continuous epidural infusion of morphine (0.1 mg, in 1 ml of normal saline) per hour supplemented with intravenous morphine (2 mg) upon request. Pain relief was evaluated by each patient on a pain scale visual analogue and by pain relief questionnaire for a period of 72 hr. Postoperative pain relief was achieved equally with these three methods of epidural analgesia in all patients with no significant difference between groups. Intermittent epidural injection of bupivacaine relieved pain for 4.9 +/- 1.9 (SD) hr/injection and was associated with urinary retention in all patients, with numbness and weakness of the hands in 12 patients, and with severe hypotension in 7 patients. Intermittent epidural injection of morphine relieved pain for 5.8 +/- 2.3 hr/injection and was associated with urinary retention in all patients, with pruritus in 12 patients, and with central narcosis and respiratory depression in 8 patients. Continuous epidural infusion of morphine with occasional intravenous morphine (2 mg) supplementation also effectively relieved postoperative pain and was associated with minimal systemic side effects. One patient complained of pruritus, and two patients developed urinary retention.(ABSTRACT TRUNCATED AT 250 WORDS)