Haemodynamic stability during anaesthesia induction with propofol – impact of phenylephrine. A double-blind, randomised clinical trial.

Background. We studied the efects of a parallel phenylephrine infusion during bispectral index guided anaesthesia induction with propofol on haemodynamic parameters. We hypothesised that mean arterial pressure and cardiac index would be better maintained in the group of patients receiving the phenylephrine infusion during induction. Methods. We studied ASA I-III patients scheduled for oncological abdominal surgery. Forty patients randomly received either a 0.9% NaCl or a phenylephrine (0.5 μg/kg/min) infusion during the induction of anaesthesia with propofol to a bispectral index value of 60. Mean arterial pressure, stroke volume index and systemic vascular resistance index were recorded, starting at one minute before induction for 20 minutes, at one-minute intervals. Results. Afer induction of anaesthesia before intubation mean arterial pressure and stroke volume index decreased signifcantly compared to baseline in both groups, while the systemic vascular resistance index increased slightly. At the end of measurements, mean arterial pressure (66 ± 11 vs. 94 ± 14 mmHg; 0.9% NaCl vs. phenylephrine group p<0.01) and stroke volume index (34.2 ± 9.1 vs. 44.0 ± 9.7 ml/ m2; 0.9% NaCl vs. phenylephrine group p<0.01) were lower in both groups in comparison to baseline values, but were better maintained in the phenylephrine group, whereas systemic vascular resistance index was higher than at baseline (2308 ± 656 vs. 3198 ± 825 dynes s/cm5/m2; 0.9% NaCl vs. phenylephrine group p<0.01) with signifcant diferences between groups. Conclusion. Our study shows that a continuous phenylephrine infusion can attenuate the drop in mean arterial pressure and stroke volume index during anaesthesia induction with propofol

Bispectral index guided induction of general anaesthesia in patients scheduled for major abdominal surgery: propofol versus etomidate

Izhodišče – Namen naše dvojno slepe randomizirane raziskave je bila primerjava hemodinamskih učinkov z bispektralnim indeksom (BIS) vodene infuzije etomidata in propofola pri bolnikih, predvidenih za veliko operacijo v trebušni votlini. Metode – 46 bolnikov, predvidenih za veliko operacijo v trebušni votlini zaradi raka, smo naključno razporedili v dve skupini. Skupina E je za uvod v anestezijo dobila infuzijo etomidata, skupina P pa infuzijo propofola. Oba anestetika smo odmerjali do vrednosti BIS 60. Hitrost infuzije je bila 0,5 mg/kg/min za propofol in 0,05 mg/kg/min za etomidat. Meritve srednjega arterijskega tlaka (SAT), indeksa minutnega volumna srca (MVSI), indeksa sistemskega žilnega upora (SŽUI) in srčne frekvence (SF) smo začeli eno minuto pred odmerjanjem fentanila in jih nato ponavljali vsako minuto v naslednjih 20 minutah. Prav tako smo merili čas od začetka infuzije anestetika do: izgube palpebralnega refleksa, vrednosti BIS 60 in vstavljanja dihalne cevke. Zapisali smo porabljen odmerek anestetika. Vrednost p < 0,05 smo obravnavali kot statistično značilno. Rezultati – V analizo je bilo vključenih 46 bolnikov. Pred in med vstavljanjem dihalne cevke glede SAT, MVSI, SŽUI, SF, BIS in saturacije ni bilo statistično značilnih razlik med skupinama, le vrednost SAT je bila v skupini E med vstavljanjem dihalne cevke statistično značilno večja glede na skupino P (p = 0,019). Po vstavitvi dihalne cevke je bila vrednost SAT v skupini E statistično značilno večja od vrednosti v skupini P 1 (p = 0,002), 2 (p = 0,000), 3 (p = 0,002), 4 (p = 0,002), 5 (p = 0,018), 6 (p = 0,012) in 7 (p = 0,004) minut po vstavitvi. V skupini E je bila vrednost MVSI statistično značilno večja 2 (p = 0,039), 6 (p = 0,038) in 7 (p = 0,024) minut po vstavitvi dihalne cevke, medtem ko so bile razlike v vrednosti MVSI med skupinama 3 (p = 0,093), 4 (p = 0,055) in 5 (p = 0,068) minut po vstavitvi dihalne cevke na meji statistične značilnosti. V skupini E so bile večje kot v skupini P. Vrednosti SŽUI in SF se celoten čas po vstavitvi dihalne cevke med skupinama niso statistično značilno razlikovale. Med vstavljanjem dihalne cevke sta se vrednosti SAT in SF v skupini E statistično neznačilno razlikovali od izhodne vrednosti, medtem ko je bila vrednost SAT v skupini P statistično značilno nižja od izhodne vrednosti, vrednost SF pa se od izhodišča ni statistično značilno razlikovala. V obeh skupinah je bila vrednost MVSI v času od 3. minute pred vstavljanjem dihalne cevke do konca meritev statistično značilno manjša od izhodne vrednosti. Pri 23 bolnikih so se pojavili zapleti, ki so zahtevali rešilne odmerke zdravil: pri 10 bolnikih v skupini P in pri 13 v skupini E. Glede na pojav zapletov se skupini v splošnem nista razlikovali (p = 0,376). V skupini P je bilo več hipotenzije (p = 0,08), v skupini E pa statistično značilno več hipertenzije (p = 0,007) Zaključek – Z raziskavo smo ugotovili, da je uporaba propofola za uvod v anestezijo povezana z manj hipertenzije in tahikardije med vstavljanjem dihalne cevke v primerjavi z uporabo etomidata. Kljub temu, da so bili potrebni odmerki propofola zaradi odmerjanja glede na ustrezno globino anestezije manjši od sicer priporočenih enkratnih odmerkov v literaturi, je bila uporaba propofola pogosto povezana s pojavom hipotenzije po vstavitvi dihalne cevke. Prav tako smo ugotovili, da uporaba etomidata ni bila povezana z večjo stabilnostjo obtočil, saj so se pri bolnikih pojavljale tako hipertenzija in tahikardija med vstavljanjem dihalne cevke kot tudi hipotenzija in bradikardija po vstavitvi dihalne cevke. Menimo, da bi bilo merjenje globine anestezije (npr. z monitorjem BIS) lahko primerno orodje za prilagajanje odmerka hipnotika med uvodom v anestezijo pri posameznem bolniku.Background – The purpose of this study was to compare bispectral index (BIS) guided infusion of etomidate and propofol at anaesthesia induction with special reference to hemodynamic effects in patients scheduled for major abdominal surgery due to cancer. Methods – Fourty-six patients scheduled for major abdominal surgery due to cancer were randomly assigned to two gropus based on the induction of anaesthesia, which was performed with either an infusion of etomidate (E group) or propofol (P group). Both anaesthetics were titrated to a BIS value of 60. The speed of infusion was 0.5 mg/kg/min for propofol and 0.05 mg/kg/min for etomidate. Mean arterial pressure, cardiac index, heart rate and systemic vascular resistance index measurements were started 1 minute before intravenous fentanyl administration and were recorded every minute for 20 minutes. The time from the start of the anesthetic infusion until: the loss of palpebral reflex, the decrease of BIS value to 60 and the orotracheal intubation were measured. The total amount of the anesthetic dose was recorded. P < 0.05 was considered statistically significant. Results – Fourty-six patients were included in the analysis. Before and at intubation, there were no significant differences among the two groups with respect to mean arterial pressure, cardiac index, systemic vascular resistance index, bispectral index and saturation. At intubation, only mean arterial pressure was significantly higher in the E group (p=0.019). After intubation, mean arterial pressure was significantly higher 1 (p = 0.002), 2 (p = 0.000), 3 (p=0.002), 4 (p=0.002), 5 (p=0.018), 6 (p=0.012), and 7 (p=0.004) minutes after intubation in the E group with respect to the P group. In the E group, cardiac index was significantly higher 2 (p=0.039), 6 (p=0.038) and 7 (p=0.024) minutes after intubation, whereas 3 (p=0.093), 4 (p=0.055) and 5 (p=0.068) minutes after intubation the difference between the groups was on the limit of statistical significance. After intubation, there were no significant differences among the two groups with respect to systemic vascular resistance index and heart rate. In the E group, mean arterial pressure and heart rate increased during intubation and reached aproximately the baseline value. In the P group mean arterial pressure did not change at intubation and remained significantly decreased with respect to baseline, whereas there was no significant difference in heart rate compared to baseline. In both groups, cardiac index was significantly decreased from 3 minutes before intubation until the end of the measurements compared to baseline. Twenty-three patients developed complicationsten in the propofol group and thirteen in the etomidate group. There were no significant differences among the groups with respect to complications overall (p=0.376). The incidence of hypotension was higher in the P group than in the E group (8 vs. 3p=0.08) and the incidence of hypertension was significantly higher in the E group than in the P group (10 vs. 2p=0.007). Conclusions – Our study showed that the use of propofol resulted in less hypertension and tachycardia at and after intubation than etomidate. But even with the reduced doses given with the BIS-guided protocol, it often caused significant hypotension. On the other side, the use of etomidate was not associated with a more stable haemodynamics. Etomidate was associated with more hypertension and tachycardia during intubation and in some cases also caused hypotension and bradycardia after intubation. In our opinion, measuring anaesthesia depth (e.g. with BIS monitor) might be a good option to customize the anesthesia for each patient

Epidemiology of surgery associated acute kidney injury (EPIS-AKI): a prospective international observational multi-center clinical study

Purpose: The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. Methods: We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (&gt; 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72&nbsp;h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. Results: We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1-3) days vs. 3 (Q1-Q3, 1-6) days) and hospital length of stay (median 14 (Q1-Q3, 9-24) days vs. 10 (Q1-Q3, 7-17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. Conclusion: In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide