naloxone and Aortic-Aneurysm--Abdominal

The purpose of this study was to review retrospectively recent results in 75 patients undergoing thoracoabdominal aortic operations using the technique of distal aortic perfusion with segmental aortic clamping. Between July 1997 and November 2003, 46 males (61%) and 29 females (39%) were treated. The patients ranged in age from 26 to 82 (mean 63 +/- 13) years. Indications for surgery included dissecting thoracoabdominal aortic aneurysm (n = 28), atherosclerotic thoracoabdominal aortic aneurysm (n = 46), and traumatic aneurysm (n = 1). Emergency operation was performed in 8 (11%). The extent of aneurysm was Crawford type I in 12 patients, type II in 19, type III in 34, and type IV in 10. Profound hypothermic circulatory arrest was used in 3 patients and retrograde segmental clamping technique in 5. Cerebrospinal fluid drainage and naloxone hydrochloride administration were performed as adjunctive methods since February 2000. There were 6 (8%) in-hospital deaths. The overall incidence of postoperative paraplegia or paraparesis was 8% (6/75). Although the survival rate has improved, the problem of a complete prevention of ischemic spinal cord injury on the thoracoabdominal aortic operations remains unsolved. The multimodality approach is needed to reduce the risk of this devastating complication.

Topics: Adult; Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Cerebrospinal Fluid; Drainage; Female; Heart Arrest, Induced; Humans; Hypothermia, Induced; Male; Middle Aged; Naloxone; Paraplegia; Perioperative Care; Postoperative Complications; Retrospective Studies; Spinal Cord Ischemia; Treatment Outcome

Our basic strategy for spinal cord protection during thoracoabdominal aortic surgery has been established since August 1994 such as: 1) distal aortic perfusion using partial cardiopulmonary bypass (32-34 degrees C), 2) multi-segmental sequential clamping, 3) deep hypothermic circulatory arrest when sequential clamping is impossible, 4) evoked spinal cord potential-guided reconstruction of the critical intercostal arteries (preoperative evaluation using multi-detector row computed tomography), 5) cerebrospinal fluid drainage, and 6) administration of naloxone hydrochloride and methylprednisolone. In this paper, we analyzed clinical outcome of thoracoabdominal aortic surgery according to this strategy.. We have performed thoracoabdominal aortic surgery for 84 patients (52 male, mean 62 +/- 12 years old) during 1991-2003. Their etiology was 34 dissection, 44 non-dissection degenerative disease, 3 pseudo-aneurysm, and 3 infection. Ten operations were performed urgently and 8 emergently. Crawford's classification (type I/II/III/IV/V) was 17/28/17/13/9 for each type. We used partial cardiopulmonary bypass for 67 cases and deep hypothermic circulatory arrest for 14.. For overall/elective cases (n = 84/66), we experienced 13.1/12.1% of incidence of spinal cord injury (paraplegia/paraparesis) and 8.3/4.5% of in-hospital mortality. Within 65 cases (55 elective) operated after August 1994, they decreased up to 7.7/5.5% (0% in type II) and 4.6/1.8%, respectively. Paraplegia was experienced in 2 patients before and 2 patients (emergent operations due to infective aneurysm) after August 1994 (4.8%). Thus, we have experienced no paraplegia in elective cases after establishment of our strategy.. Our strategy for spinal cord protection during thoracoabdominal aortic surgery could provide acceptable clinical outcome and seemed justified.

Topics: Adult; Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Cerebrospinal Fluid; Drainage; Evoked Potentials, Motor; Female; Humans; Hypothermia, Induced; Intraoperative Complications; Male; Middle Aged; Monitoring, Intraoperative; Naloxone; Paraplegia; Perioperative Care; Postoperative Complications; Retrospective Studies; Spinal Cord; Spinal Cord Ischemia; Treatment Outcome

A patient underwent repair of a thoracoabdominal aortic aneurysm. Epidural morphine, 4 mg, was given for pain relief. After anesthesia, the patient displayed lower extremity paraparesis. This effect was reversed by naloxone. The authors sought to confirm these observations using a rat spinal ischemia model to define the effects of intrathecal morphine administered at various times after reflow on behavior and spinal histopathology.. Spinal cord ischemia was induced for 6 min using an intraaortic balloon. Morphine or saline, 30 microg, was injected intrathecally at 0.5, 2, or 24 h after reflow. In a separate group, spinal cord temperature was decreased to 27 degrees C before ischemia. After ischemia, recovery of motor function was assessed periodically using the motor deficit index (0 = complete recovery; 6 = complete paraplegia).. After ischemia, all rats showed near-complete recovery of function by 4-6 h. Intrathecal injection of morphine at 0.5 or 2 h of reflow (but not at 24 h) but not saline caused a development of hind limb dysfunction and lasted for 4.5 h (motor deficit index score = 4-6). This effect was reversed by intrathecal naloxone (30 microg). Intrathecal morphine administered after hypothermic ischemia was without effect. Histopathological analysis in animals that received intrathecal morphine at 0.5 or 2 h after ischemia (but not at 24 h) revealed dark-staining alpha motoneurons and interneurons. Intrathecal saline or spinal hypothermia plus morphine was without effect.. These data indicate that during the immediate reflow following a noninjurious interval of spinal ischemia, intrathecal morphine potentiates motor dysfunction. Reversal by naloxone suggests that this effect results from an opioid receptor-mediated potentiation of a transient block of inhibitory neurons initiated by spinal ischemia.

Topics: Aged; Analgesics, Opioid; Animals; Aortic Aneurysm, Abdominal; Aortic Valve Stenosis; Constriction; Dyskinesia, Drug-Induced; Female; Humans; Hypothermia, Induced; Injections, Spinal; Male; Morphine; Naloxone; Narcotic Antagonists; Rats; Rats, Sprague-Dawley; Reperfusion Injury; Spinal Cord; Spinal Cord Ischemia; Tissue Fixation; Vascular Surgical Procedures

We studied factors that influence paralysis risk, renal function, and mortality in thoracoabdominal aortic replacement.. We prospectively collected preoperative demographic and intraoperative physiologic data and used univariate and multivariate analyses to correlate this data with risk factors for paralysis. A mathematical model of paraplegia risk was used to study the efficacy of paraplegia reduction strategies. We analyzed preoperative and operative factors for paralysis risk, renal function, and mortality for 217 consecutive patients surgically treated from 1984 through 1996 for 176 thoracoabdominal and 41 thoracic aneurysms at the University of Wisconsin Hospital and Clinics. No patient had intercostal reimplantation or assisted circulation. One hundred fifty patients (group A) received cerebrospinal fluid drainage (CSFD) and low-dose naloxone (1 microg/kg/hour) as adjuncts to reduce the risk of paralysis. Sixty-seven patients (group B) did not receive CSFD and naloxone.. Seventeen deficits occurred in 205 surviving patients: 5 of the 147 in group A (expected deficits = 31) and 12 of the 58 in group B (expected deficits = 13) (p < 0.001). In a multivariate logistic regression model, acute presentation, Crawford type 2 aneurysm, group B membership, and a decrease in cardiac index with aortic occlusion remained significant risk factors for deficit (p < 0.0001). By odds ratio analysis, group A patients had 1/40th the risk of paralysis of group B. The only significant predictor of postoperative renal function was the preoperative creatinine level (p < 0.0001); renal revascularization significantly improved renal function. The mortality rate was 1.6% (2) for patients undergoing elective treatment and 21% (19) for patients who had acute presentations. Acute presentation, age, and the preoperative creatinine level were found to be significant factors for operative mortality in a logistic regression model (p < 0.001) and defined a group at high risk for death.. CSFD and low-dose naloxone significantly reduce the paralysis risk associated with thoracoabdominal aortic replacement. A decrease in the cardiac index with aortic occlusion is a previously unreported variable that defines a subset of patients at higher risk for paralysis.

Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Analysis of Variance; Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Cardiac Output; Cerebrospinal Fluid; Creatinine; Demography; Drainage; Female; Heart; Humans; Kidney; Logistic Models; Male; Middle Aged; Monitoring, Intraoperative; Multivariate Analysis; Naloxone; Narcotic Antagonists; Odds Ratio; Paralysis; Paraplegia; Prospective Studies; Reperfusion; Risk Factors; Survival Rate

This report summarizes our experience with the use of cerebral spinal fluid drainage (CSFD) and naloxone for prevention of postoperative neurologic deficit (paraplegia or paraparesis).. We reviewed 110 consecutive patients with 86 thoracoabdominal aneurysms and 24 thoracic aneurysms. The status of 47 patients (43%) was acute (rupture or dissection), and the status of 52 (47%) was Crawford type I or II. None of the patients had intercostal artery reimplantation. There were two patient groups for analysis of neurologic deficit risk. Group A (61 patients) received naloxone and CSFD, and group B (49 patients) did not.. One deficit occurred in group A and 11 deficits occurred in group B (p = 0.001). By multiple logistic regression analysis, the variables acute status, Crawford type II, or group B classification were significant factors for deficit risk. Use of the same logistic regression analysis on the subgroup of 47 patients with acute aneurysms and 33 patients with Crawford type 2 aneurysms confirmed the protective effect of combined CSFD and naloxone (group A) and that clinical presentation and extent of aorta replaced are the primary risk factors for development of deficit. To test this conclusion we developed a highly predictive model (correlation coefficient 0.997 with 16 series of thoracoabdominal aneurysms) for neurologic deficit. We applied our data to this model. Group B had the predicted number of deficits, and group A had substantially fewer deficits than predicted.. We conclude that the combined use of CSFD and naloxone offers significant protection from neurologic deficits in patients undergoing thoracoabdominal and thoracic aortic replacement.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analysis of Variance; Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Cerebrospinal Fluid; Combined Modality Therapy; Drainage; Female; Follow-Up Studies; Humans; Infusions, Intravenous; Intraoperative Care; Logistic Models; Male; Middle Aged; Naloxone; Paraplegia; Postoperative Complications; Predictive Value of Tests; Risk Factors