Sympathetic-parasympathetic cardiac autonomic tonus during induction of anesthesia with propofol and fentanyl

Valeriu Ghereg Department of Anesthesiology and Intensive Care No 1, Department of Pathophysiology and Clinical Pathophysiology, Nicolae Testemitsanu State University of Medicine and Pharmacy, Chisinau, the Republic of MoldovaBackground: Administration of propofol and fentanyl for induction of general anesthesia is often associated with cardiovascular instability. This effect can be caused by changes in the cardiac autonomic tonus induced by the drugs. In the literature there is no consensus regarding the effect of propofol and fentanyl on sympathetic or parasympathetic balance of the heart. Material and methods: There was performed a randomized prospective study which was approved by the Ethic Committee. Written informed consent was signed by all patients. The study group involved 47 patients scheduled for surgical intervention, anesthetic risk ASA I-II. The analysis of heart rate variability and the changes in cardiac autonomic tonus was performed with Holter ECG at rest, after premedication with fentanyl solution and after induction of general anesthesia with propofol and fentanyl. Results: After administration of fentanyl in doses of 1.0 mkg/kg for premedication there were not significant changes of heart rate variability and autonomic heart tonus. Administration of propofol 2.5 mg/kg combined with fentanyl 1.0 mkg/kg for induction of general anesthesia leads to significant changes in heart rate variability. There was a considerable reduction of heart rate variability. The LFun (marker of sympathetic heart tonus) has enhanced by 6.8% compared with previous stage (67.1 (95% CI 63.1-71.1) vs 72.0 (95% CI 67.9-76.1) (p=0.004). The HFun (marker of parasympathetic cardiac tonus) has reduced by 19.8% (32.9 (95% CI 28.9-36.8) vs 26.4 (95% CI 20.4-34.3) (p=0.007). After administration of propofol and fentanyl for induction of general anesthesia the LFun/HFun ratio has enhanced by 30.8% (2.7 (95%CI 2.1-3.4) vs 3.9 (95%CI9 2.9-4.8) (p=0.003), signaling an enhanced sympathetic heart tonus. Conclusions: Administration of fentanyl solution in doses 1.0 mkg/kg for premedication is not associated with significant changes of autonomic tonus of the heart. Administration of propofol 2.5 mg/kg in combination with fentanyl 1.0 mkg/kg for induction of general anesthesia leads to significant enhanced sympathetic cardiac tonus

Intraoperative transfusion practices in Europe

Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl and increased to 9.8 (1.8) g dl after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold

Intraoperative transfusion practices and perioperative outcome in the European elderly: A secondary analysis of the observational ETPOS study

The demographic development suggests a dramatic growth in the number of elderly patients undergoing surgery in Europe. Most red blood cell transfusions (RBCT) are administered to older people, but little is known about perioperative transfusion practices in this population. In this secondary analysis of the prospective observational multicentre European Transfusion Practice and Outcome Study (ETPOS), we specifically evaluated intraoperative transfusion practices and the related outcomes of 3149 patients aged 65 years and older. Enrolled patients underwent elective surgery in 123 European hospitals, received at least one RBCT intraoperatively and were followed up for 30 days maximum. The mean haemoglobin value at the beginning of surgery was 108 (21) g/l, 84 (15) g/l before transfusion and 101 (16) g/l at the end of surgery. A median of 2 [1–2] units of RBCT were administered. Mostly, more than one transfusion trigger was present, with physiological triggers being preeminent. We revealed a descriptive association between each intraoperatively administered RBCT and mortality and discharge respectively, within the first 10 postoperative days but not thereafter. In our unadjusted model the hazard ratio (HR) for mortality was 1.11 (95% CI: 1.08–1.15) and the HR for discharge was 0.78 (95% CI: 0.74–0.83). After adjustment for several variables, such as age, preoperative haemoglobin and blood loss, the HR for mortality was 1.10 (95% CI: 1.05–1.15) and HR for discharge was 0.82 (95% CI: 0.78–0.87). Preoperative anaemia in European elderly surgical patients is undertreated. Various triggers seem to support the decision for RBCT. A closer monitoring of elderly patients receiving intraoperative RBCT for the first 10 postoperative days might be justifiable. Further research on the causal relationship between RBCT and outcomes and on optimal transfusion strategies in the elderly population is warranted. A thorough analysis of different time periods within the first 30 postoperative days is recommended

Intraoperative transfusion practices in Europe

© 2016 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.Background: Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. Methods: We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. Results: The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl-1 and increased to 9.8 (1.8) g dl-1 after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). Conclusions: Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl-1), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold