Cataract surgery is one of the most frequent surgeries in the world. It is a very safe procedure mostly performed under topical anesthesia in outpatients centers. Due to the growing lack of ...anesthesiologists, cataract surgeries are more frequently performed without an anesthesiologist present in the operating room. Although extremely rare, life-threatening complications may occur.
We report two cases of cataract surgery complicated by severe hypotension that required emergency resuscitation in the immediate postoperative period and hospitalization in intensive care unit. Anaphylactic shock was confirmed in the first case and suspected in the second.
Even though cataract surgery is a very safe procedure, it is essential to ensure the presence of an anesthesiologist to manage potential, though extremely rare, life-threatening complications such as anaphylactic reactions.
Deliberate hypotension is one way to achieve a bloodless surgical field in endoscopic sinus surgery (ESS). We compared two anaesthesia regimens to induce deliberate hypotension and attempted to ...determine the most efficient one.
Fifty-nine patients undergoing ESS were minimized into two groups. In the CLO group, patients received I.V. sufentanil 0.15 µg/kg together with I.V. clonidine 2-3 µg/kg. In the REMI group, patients received remifentanil at a rate of up to 1 µg/kg/min. Fromme scores were collected 15 min after the incision and at the end of the procedure. Mean arterial pressure readings (MAP), heart rate readings, time to eyes opening, time to extubation, pain scores, analgesic requirements, and oxygen needs were collected and compared.
There were no significant differences in Fromme scores between the two groups. The averaged MAP from 15 min to the end of the procedure was significantly lower in the REMI group; these patients also received more ephedrine. Significantly fewer patients in the CLO group needed oxygen therapy to keep their Pulse Oximeter Oxygen Saturation within 3% of their preoperative values. Patients in this group also needed less piritramide in the recovery room, and their pain scores were lower at discharge from the recovery room.
Although both anaesthesia regimens offered a similar quality of surgical field, this study suggests that clonidine had a better average safety profile. Furthermore, patients who received this regimen required fewer painkillers immediately after surgery.
Chez les patients sévèrement dénutris, un support nutritionnel préopératoire permet de réduire l’impact péjoratif de la dénutrition sur l’évolution postopératoire. Un pré-requis indispensable est ...d’identifier cette dénutrition. Nous avons voulu savoir si la consultation pré-anesthésique (non obligatoire en Belgique) était un outil permettant d’atteindre ces objectifs de dépistage préopératoire chez des patients opérés d’une chirurgie abdominale.
Notre méthode de travail s’est articulée en trois étapes. Après avoir déterminé notre situation de départ, nous sommes intervenus en insérant le
Nutritionnal risk screening (NRS) 2002 dans notre protocole de consultation informatisé et en créant une procédure permettant de coupler notre consultation à celle de diététique le même jour. Nous avons ensuite analysé l’efficacité de nos interventions.
Nous avons reçu 87,8 % des patients opérés électivement d’une chirurgie abdominale à la consultation pré-anesthésique. Grâce à l’informatisation du NRS 2002, notre dépistage nutritionnel est passé de 60,8 % à 86,1 %. Tout patient à risque de dénutrition a été référé le jour même au service de diététique pour une évaluation nutritionnelle et un support nutritionnel si nécessaire. Cette procédure a réduit au maximum les retours des patients à l’hôpital. Le délai moyen de 13 à 15
jours entre la consultation pré-anesthésique et la chirurgie était suffisant pour mettre en place un support nutritionnel préopératoire.
La consultation pré-anesthésique est ainsi devenue un outil de dépistage pour la prise en charge nutritionnelle préopératoire.
In severely malnourished patients, preoperative nutritional support helps lessen the adverse impact of malnourishment on postoperative progress. An essential prerequisite is to identify this malnourishment. We wanted to find out whether pre-anaesthetic consultation (which is not compulsory in Belgium) was a tool that could be used to achieve these objectives of preoperative nutritional screening in patients undergoing abdominal surgery.
Our working method comprised of three phases. Having conducted a study to determine our situation, we integrated the NRS 2002 into our computerised consultation protocol and created a procedure used to link our consultation with the dietetics consultation on the same day. We then analysed the effectiveness of our actions.
We received 87.8% of patients undergoing elective abdominal surgery at the pre-anaesthetic consultation. Thanks to the computerisation of the NRS 2002, our nutritional screening rose from 60.8% to 86.1%. All patients at risk of malnutrition were referred to the dietetics service on the same day for a nutritional assessment and nutritional support if necessary. This procedure reduced the hospital re-admittance rate as much as possible. The average period of 13 to 15 days between the pre-anaesthetic consultation and the surgery was sufficient to put in place preoperative nutritional support.
Pre-anaesthetic consultation has therefore become a tool used for preoperative nutritional screening and care.
To determine the main causes for unplanned admission of children to the paediatric intensive care unit (PICU) following anaesthesia in our centre. To compare the results with previous publications ...and propose a data sheet for the prospective collection of such information.
Inclusion criteria were any patient under 16 years who had an unplanned post-anaesthetic admission to the PICU from 1999 to 2010 in our university hospital. Age, ASA score, type of procedure, origin and causes of the incident(s) that prompted admission and time of the admission decision were recorded.
Out of a total of 44,559 paediatric interventions performed under anaesthesia during the study period, 85 were followed with an unplanned admission to the PICU: 67% of patients were younger than 5 years old. Their ASA status distribution from I to IV was 13, 47, 39 and 1%, respectively. The cause of admission was anaesthetic, surgical or mixed in 50, 37 and 13% of cases, respectively. The main causes of anaesthesia-related admission were respiratory or airway management problems (44%) and cardiac catheterisation complications (29%). In 62%, the admission decision was taken in the operating room.
Unplanned admission to the PICU after general anaesthesia is a rare event. In our series, most cases were less than 5 years old and were associated with at least one comorbidity. The main cause of admission was respiratory distress and the main type of procedure associated with admission was cardiac catheterisation.
Coronary artery bypass grafting for the treatment of unstable angina is still associated with increased operative risk and postoperative morbidity. The impact of the extended use of arterial grafts ...on early results is incompletely defined. In a 7-year period (1986 to 1993), 474 patients (average age, 65 years; range, 34 to 85 years) underwent coronary artery bypass grafting for the treatment of unstable angina. Sixty-eight patients were operated on emergently and 406 urgently. They received an average of 3.0 distal anastomoses (range, 1 to 6). Seventy-nine patients had exclusively venous grafts, 316 had one internal thoracic artery graft, 79 had bilateral internal thoracic artery grafts, and 20 had inferior epigastric artery grafts. Sequential internal thoracic artery grafting was performed in 70 patients. Redo operations were performed in 26 patients. Thirty-four patients (7.2%) experienced a new myocardial infarction. Eighty-nine patients (18.8%) had an intraaortic balloon pump inserted preoperatively, intraoperatively, or postoperatively. Eight patients (1.7%) died intraoperatively and 24 patients (5.1%) died postoperatively. Seventy-seven patients (16.2%) had an adverse outcome, as shown by the need for an intraaortic balloon pump (intraoperatively or postoperatively) or hospital death, or by both. Forty variables were examined by multivariate analysis for their influence on the occurrence of an adverse outcome. Aortic cross-clamp time (
p = 0.0004), transfer from the intensive care unit (
p = 0.0023), female sex (
p = 0.0023), operation performed in early years (
p = 0.0041), left ventricular aneurysm (
p = 0.0068), the number of diseased coronary vessels (
p = 0.0312), and reoperation (
p = 0.0318) were all found to be significant independent predictors of increased risk. Thus, aortic cross-clamp duration remains the main determining factor of postoperative hospital outcome, which suggests the need for improved myocardial protection techniques. Outcome was not found to be adversely affected by the extended use of arterial grafts.
Objective: The objective of this study was to assess improved myocardial protection by performing coronary artery bypass grafting (CABG) on the beating heart. A case-matched study was conducted among ...patients who underwent CABG either on-pump (group 1), or off-pump (group 2). Methods: Forty-five pairs of patients, having a similar clinical profile, were selected on the basis of five variables: age, gender, body surface area, ejection fraction, extent of coronary disease. Operative risk predicted by the The Society of Thoracic Surgeons national database was 1.80±0.35% in group 1, and 1.89±0.37% in group 2 (NS). Cold blood cardioplegia and 28°C cardiopulmonary bypass were used in group 1. In group 2, beating heart coronary grafting was achieved with the Octopus™ 1 and 2 stabilizers. The average number of distal anastomoses was 2.8±0.1 in group 1 and 2.3±0.1 in group 2 (P=0.015). Results: There was no significant difference among the groups regarding the trend in cardiac index, left and right ventricular stroke work indexes, and systemic and pulmonary vascular resistance indexes. However, heart rate trend was slower in group 2 (P=0.05). Pharmacological support was required in 65% of the patients in group 1, and in 33% in group 2 (P<0.001). The total amount of Dobutamine and/or Dopamine administered during the first 48 h was 3914±1306 γ/kg in group 1 and 1645±697 γ/kg in group 2 (P=0.049). Release of creatine kinase MB mass isoenzyme (CK-MB mass) was markedly reduced in group 2 (P<10−4). Conclusions: Hemodynamic outcome following off-pump CABG is similar to on-pump CABG but the need for inotropic support is significantly reduced and CPK-MB mass release is markedly lower.
To assess the influence on myocardial protection of the rate of infusion (continuous vs intermittent) of cold blood cardioplegia administered retrogradely during prolonged aortic cross-clamping. The ...end-points were ventricular performance and biochemical markers of ischemia.
Seventy patients undergoing myocardial revascularization for three-vessel disease were prospectively randomized to receive intermittent or continuous retrograde cold blood cardioplegia. Hemodynamic measurements were obtained using a rapid-response thermodilution catheter and included right ventricular ejection fraction, cardiac output, left and right ventricular stroke work index, and systemic and pulmonary vascular resistance. Blood samples were obtained from the coronary sinus before cross-clamp application and immediately after cross-clamp removal for determinations of lactate and hypoxanthine.
The left ventricular stroke work index trend was significantly superior (
p = 0.038) by repeated-measures analysis in continuous cardioplegia. Other hemodynamic measurements revealed a similar trend. The need for postoperative inotropic drugs support was reduced in continuous cardioplegia. The release of lactate in the coronary sinus after unclamping was 2.30 ± 0.12 mmol/L after intermittent cardioplegia and 1.97 ± 0.09 mmol/L after continuous cardioplegia (
p = 0.036). The release of hypoxanthine was 20.47 ± 2.74 μmol/L in intermittent cardioplegia and 11.77 ± 0.69 μmol/L in continuous cardioplegia (
p = 0.002).
Continuous cold blood cardioplegia results in improved ventricular performance and reduced myocardial ischemia in comparison with intermittent administration.
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