The influence of thoracic epidural anesthesia on liver hemodynamics in patients under general anesthesia

Background and objective. Hepatic hypoperfusion is regarded as an important factor in the pathophysiology of perioperative liver injury. Although thoracic epidural anesthesia is a widely used technique, limited data are available about the effects on hepatic blood flow with blockade restricted to thoracic segments in humans. The main objective of the present study was to investigate the effects of thoracic epidural anesthesia on hepatic blood flow under general anesthesia in humans. Material and methods. In 40 patients under general anesthesia, we assessed hepatic blood flow using plasma disappearance rate of indocyanine green (PDRICG) as a simple noninvasive method before and after induction of thoracic epidural anesthesia. The epidural catheter was inserted at the Th7/8 or Th8/9, and 1% lidocaine at a mean (range) dose of 8 (6–10) mL was injected. Ephedrine bolus was given to patients who demonstrated a decrease in mean arterial blood pressure below 60 mm Hg after induction of thoracic epidural anesthesia (TEA-E group). Other patients did not receive any catecholamines during the study period (TEA group). Ten patients who did not undergo TEA served as controls (control group). Results. In 7 patients, administration of ephedrine was necessary to avoid a decrease in mean arterial blood pressure below 60 mm Hg. Thus, the TEA-E group consisted of 7 patients and TEA group of 33. In the TEA group, thoracic epidural anesthesia was associated with a mean 2.3% min–1 decrease in PDRICG (P<0.05). In the TEA-E group, all seven patients showed a 2.2% min–1decrease in PDRICG (P<0.05). Patients in the control group showed a mean 1.1% min–1 increase in PDRICG (P<0.05). In contrast to hepatic blood flow, cardiac output was not affected by thoracic epidural anesthesia. Conclusions. In humans, thoracic epidural anesthesia is associated with a decrease in hepatic blood flow. Thoracic epidural anesthesia combined with ephedrine bolus was found to result in further decrease in hepatic blood flow

An evaluation of the effectiveness and safety of midazolam in children undergoing dental surgery

Objective: The aim of this study was to evaluate the effectiveness and safety of oral midazolam in children undergoing dental surgery. Materials and methods: A prospective, randomized, controlled trial was conducted to assess the effectiveness and safety of midazolam in children. Patients aged 2–9 years who underwent dental surgery under general anesthesia were randomly allocated into one of the four groups: midazolam 0.2 mg/kg dose group (n = 30); midazolam 0.21–0.4 mg/kg dose group (n = 15); midazolam more than 0.41 mg/kg dose group (n = 15) or the placebo group (n = 31). The effectiveness of midazolam on sedation was assessed by the evaluation of vital signs, such as the respiratory and heart rate, oxygen saturation and the patients’ reactive behaviors, in comparison with the placebo. Results: The scores of the ratings for sleep, movement and crying, as well as patients’ reactions at the moment of separation from their parents and their collaboration with the staff were statistically significantly better among patients who received oral midazolam compared with the placebo. There were statistically significant direct correlations between the doses of midazolam and higher sleep, movement, crying and reaction scores 30 min after premedication as well as higher scores of patients upon separation from their parents. There were only a few clinically insignificant side effects. Conclusions: Oral midazolam, at a single dose from 0.2 to 0.6 mg/kg, is effective and safe, and provides the expected sedative effects in children required by premedication for dental surgery

Thrombosis Related ABO, F5, MTHFR, and FGG Gene Polymorphisms in Morbidly Obese Patients

Objective. Obesity is a well-known risk factor for thrombotic complications. The aim of the present study was to determine the frequency of thrombosis related ABO, F5, MTHFR, and FGG gene polymorphisms in morbidly obese patients and compare them with the group of nonobese individuals. Methods. Gene polymorphisms were analyzed in 320 morbidly obese patients (BMI > 40 kg/m2) and 303 control individuals (BMI T (rs505922), F5 C>G (rs6427196), MTHFR C>T (rs1801133), and FGG C>T (rs6536024) SNPs were genotyped by RT-PCR. Results. We observed a tendency for MTHFR rs1801133 TT genotype to be linked with morbid obesity when compared to CC genotype; however, the difference did not reach the significant P value (OR 1.84, 95% CI 0.83–4.05, P=0.129). Overall, the genotypes and alleles of rs505922, rs6427196, rs1801133, and rs6536024 SNPs had similar distribution between morbidly obese and nonobese control individuals. Distribution of height and weight means among individuals carrying different rs505922, rs6427196, rs1801133, and rs6536024 genotypes did not differ significantly. Conclusions. Gene polymorphisms ABO C>T (rs505922), F5 C>G (rs6427196), MTHFR C>T (rs1801133), and FGG C>T (rs6536024) were not associated with height, weight, or morbid obesity among European subjects

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

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

Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study

Background Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications. Methods We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients’ preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARRadj). This study is registered with ClinicalTrials.gov, number NCT01865513. Findings Between June 16, 2014, and April 29, 2015, data from 22803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21694); ORadj 1·86, 95% CI 1·53–2·26; ARRadj –4·4%, 95% CI –5·5 to –3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1·31, 95% CI 1·15–1·49; ARRadj –2·6%, 95% CI –3·9 to –1·4) and the administration of reversal agents (1·23, 1·07–1·41; –1·9%, –3·2 to –0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1·03, 95% CI 0·85–1·25; ARRadj –0·3%, 95% CI –2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82–1·31; –0·4%, –3·5 to 2·2) was associated with better pulmonary outcomes. Interpretation We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications