piperidines and Postoperative-Complications

The present study aimed to assess the prevalence of symptoms of anxiety and depression among health professionals in the three most affected regions in Cameroon.. The study was a descriptive cross-sectional type. Participants were health care professionals working in the three chosen regions of Cameroon. The non_probability convinient sample technique and that of the snowball were valued via a web questionnaire. The non-exhaustive sample size was 292. The diagnosis of anxiety and depression was made by the HAD (Hospital Anxiety and Depression scale).. Les auteurs rapportent que le secteur médical est classé à un plus grand risque de contracter le COVID-19 et de le propager potentiellement à d’autres. Le nombre sans cesse croissant de cas confirmés et suspects, la pression dans les soins, l’épuisement des équipements de protection individuelle et le manque de médicaments spécifiques peuvent contribuer à un vécu anxio-dépressif significatif. La présente étude s’est donnée pour ambition d’évaluer la prévalence des symptômes de l’anxiété et de la dépression chez les professionnels de santé dans les trois Régions les plus concernées au Cameroun.. Le choix des trois Régions du Cameroun se justifie non seulement par le fait qu’elles totalisent 95,8 % des cas de coronavirus au pays depuis le début de la pandémie, mais aussi parce qu’elles disposent de plus de la moitié des personnels de santé (56 %). Il s’agit d’une étude transversale, descriptive et analytique. Les participants sont des professionnels de la santé en service dans les Régions du Centre, Littoral et de l’Ouest du Cameroun. La méthode d’échantillonnage non probabiliste de convenance couplée à celle de boule de neige via un web questionnaire a été adoptée. La collecte des données a duré du 5 au 19 avril 2020, intervalle de temps après lequel on n’avait plus eu de répondants. À la fin de cette période, la taille de l’échantillon non exhaustive était de 292 professionnels. Le diagnostic de l’état anxio-dépressive était posé via l’échelle de HAD (Hospital Anxiety and Depression scale). Dans le HAD, chaque réponse cotée évalue de manière semi-quantitative l’intensité du symptôme au cours de la semaine écoulée. Un score total est obtenu ainsi que des scores aux deux sous-échelles : le score maximal est de 42 pour l’échelle globale et de 21 pour chacune des sous-échelles. Le coefficient alpha de Cronbach est de 0,70 pour la dépression et de 0,74 pour l’anxiété. Certains auteurs après plusieurs travaux ont proposé qu’une note inférieure ou égale à 7 indique une absence d’anxiété ou de dépression ; celle comprise entre 8 et 10 suggère une anxiété ou une dépression faible à bénigne ; entre 11 et 14, pour une anxiété ou une dépression modérée ; enfin, une note comprise entre 15 et 21 est révélatrice d’une anxiété sévère. Le logiciel Excel 2013 et Epi Info version 7.2.2.6 ont été utilisés pour les traitements statistiques. Les liens entre les variables ont été considérées significatifs pour une valeur de. L’amélioration des conditions de travail et notamment la fourniture d’équipement de protection, la mise en place des cellules spéciales d’écoute pour le personnel de santé pourraient être proposées.. Taken together with satisfactory selectivity index (SI) values, the acetone and methanol extracts of. During a mean follow-up period of 25.6 ± 13.9 months, 38 (18.4%) VAs and 78 (37.7%) end-stage events occurred. Big ET-1 was positively correlated with NYHA class (. In primary prevention ICD indication patients, plasma big ET-1 levels can predict VAs and end-stage events and may facilitate ICD-implantation risk stratification.. Beyond age, cognitive impairment was associated with prior MI/stroke, higher hsCRP, statin use, less education, lower eGFR, BMI and LVEF.. These data demonstrate that even a short period of detraining is harmful for elderly women who regularly participate in a program of strength training, since it impairs physical performance, insulin sensitivity and cholesterol metabolism.. Exposure to PM. Respiratory sinus arrhythmia is reduced after PVI in patients with paroxysmal AF. Our findings suggest that this is related to a decrease in cardiac vagal tone. Whether and how this affects the clinical outcome including exercise capacity need to be determined.. BDNF and leptin were not associated with weight. We found that miR-214-5p exerted a protective role in I/R injured cardiac cells by direct targeting FASLG. The results indicated that the MGO injection reduced all CCl. The hepatoprotective effects of MGO might be due to histopathological suppression and inflammation inhibition in the liver.. OVEO showed moderate antifungal activity, whereas its main components carvacrol and thymol have great application potential as natural fungicides or lead compounds for commercial fungicides in preventing and controlling plant diseases caused by. PF trajectories were mainly related to income, pregestational BMI, birth weight, hospitalisation due to respiratory diseases in childhood, participant's BMI, report of wheezing, medical diagnosis and family history of asthma, gestational exposure to tobacco and current smoking status in adolescence and young adult age.. In chronic pain patients on opioids, administration of certain benzodiazepine sedatives induced a mild respiratory depression but paradoxically reduced sleep apnoea risk and severity by increasing the respiratory arousal threshold.. Quantitative measurements of sensory disturbances using the PainVision. The serum level of 20S-proteasome may be a useful marker for disease activity in AAV.. The electrophysiological data and MD simulations collectively suggest a crucial role of the interactions between the HA helix and S4-S5 linker in the apparent Ca. Invited for the cover of this issue are Vanesa Fernández-Moreira, Nils Metzler-Nolte, M. Concepción Gimeno and co-workers at Universidad de Zaragoza and Ruhr-Universität Bochum. The image depicts the reported bimetallic bioconjugates as planes directing the gold fragment towards the target (lysosomes). Read the full text of the article at 10.1002/chem.202002067.. The optimal CRT pacing configuration changes during dobutamine infusion while LV and RV activation timing does not. Further studies investigating the usefulness of automated dynamic changes to CRT pacing configuration according to physiologic condition may be warranted.

Topics: 3' Untranslated Regions; 5'-Nucleotidase; A549 Cells; Accidental Falls; Acetylcholinesterase; Acrylic Resins; Actinobacillus; Acute Disease; Acute Kidney Injury; Adaptor Proteins, Signal Transducing; Adenosine; Adenosine Triphosphate; Administration, Inhalation; Administration, Oral; Adolescent; Adult; Advance Care Planning; Africa, Northern; Age Factors; Aged; Aged, 80 and over; Air Pollutants; Air Pollution; Air Pollution, Indoor; Albendazole; Aluminum Oxide; Anastomosis, Surgical; Ancylostoma; Ancylostomiasis; Androstadienes; Angiogenesis Inhibitors; Angiotensin II; Animals; Anti-Bacterial Agents; Anti-Infective Agents; Antibodies, Bispecific; Antibodies, Viral; Anticoagulants; Antihypertensive Agents; Antinematodal Agents; Antineoplastic Agents; Antineoplastic Agents, Immunological; Antineoplastic Combined Chemotherapy Protocols; Antioxidants; Antiporters; Antiviral Agents; Apoptosis; Aptamers, Nucleotide; Aromatase Inhibitors; Asian People; Astrocytes; Atrial Fibrillation; Auditory Threshold; Aurora Kinase B; Australia; Autophagy; Autophagy-Related Protein 5; Autotrophic Processes; Bacillus cereus; Bacillus thuringiensis; Bacterial Proteins; Beclin-1; Belgium; Benzene; Benzene Derivatives; Benzhydryl Compounds; beta Catenin; beta-Arrestin 2; Biliary Tract Diseases; Biofilms; Biofuels; Biomarkers; Biomarkers, Tumor; Biomass; Biomechanical Phenomena; Bioreactors; Biosensing Techniques; Biosynthetic Pathways; Bismuth; Blood Platelets; Bone and Bones; Bone Regeneration; Bortezomib; Botulinum Toxins, Type A; Brain; Brain Injuries; Brain Ischemia; Brain Neoplasms; Breast Neoplasms; Breath Tests; Bronchodilator Agents; Calcium Phosphates; Cannabis; Carbon Dioxide; Carbon Isotopes; Carcinogenesis; Carcinoma, Hepatocellular; Carcinoma, Non-Small-Cell Lung; Carcinoma, Squamous Cell; Cardiac Resynchronization Therapy; Cardiac Resynchronization Therapy Devices; Cardiomyopathies; Cardiovascular Diseases; Cariostatic Agents; Case Managers; Case-Control Studies; Catalysis; Cation Transport Proteins; CD8-Positive T-Lymphocytes; Cecropia Plant; Cell Adhesion; Cell Count; Cell Differentiation; Cell Division; Cell Line; Cell Line, Tumor; Cell Membrane; Cell Movement; Cell Proliferation; Cell Self Renewal; Cell Survival; Cells, Cultured; Cellular Reprogramming; Cellulose; Charcoal; Chemical and Drug Induced Liver Injury; Chemical Phenomena; Chemokines; Chemoradiotherapy; Chemoreceptor Cells; Child; Child Abuse; Child, Preschool; China; Chlorogenic Acid; Chloroquine; Chromatography, Gas; Chronic Disease; Clinical Competence; Coated Materials, Biocompatible; Cochlea; Cohort Studies; Color; Comorbidity; Computer Simulation; Computer-Aided Design; Contraception; Contraceptive Agents, Female; Contrast Media; COP-Coated Vesicles; Coronavirus Infections; Cost of Illness; Coturnix; COVID-19; Creatinine; Cross-Over Studies; Cross-Sectional Studies; Culex; Curriculum; Cyclic N-Oxides; Cytokines; Cytoplasm; Cytotoxicity, Immunologic; Cytotoxins; Databases, Factual; Deep Learning; Delivery, Obstetric; Denitrification; Dental Caries; Denture, Complete; Dexamethasone; Diabetes Complications; Diabetes Mellitus; Diabetes Mellitus, Experimental; Diabetes Mellitus, Type 2; Dielectric Spectroscopy; Diet, High-Fat; Dietary Fiber; Disease Models, Animal; Disease Progression; DNA; DNA Copy Number Variations; DNA, Mitochondrial; Dog Diseases; Dogs; Dopaminergic Neurons; Double-Blind Method; Down-Regulation; Doxorubicin; Drug Carriers; Drug Design; Drug Interactions; Drug Resistance, Bacterial; Drug Resistance, Neoplasm; Drug-Related Side Effects and Adverse Reactions; Drugs, Chinese Herbal; Dry Powder Inhalers; Dust; E2F1 Transcription Factor; Ecosystem; Education, Nursing; Education, Nursing, Baccalaureate; Electric Impedance; Electricity; Electrocardiography; Electrochemical Techniques; Electrochemistry; Electrodes; Electrophoresis, Polyacrylamide Gel; Endoplasmic Reticulum; Endothelial Cells; Environmental Monitoring; Enzyme Inhibitors; Epithelial Cells; Epithelial-Mesenchymal Transition; Esophageal Neoplasms; Esophageal Squamous Cell Carcinoma; Estrogen Receptor Modulators; Europe; Evoked Potentials, Auditory, Brain Stem; Exosomes; Feasibility Studies; Female; Ferricyanides; Ferrocyanides; Fibrinogen; Finite Element Analysis; Fistula; Fluorescent Dyes; Fluorides, Topical; Fluorodeoxyglucose F18; Fluticasone; Follow-Up Studies; Food Contamination; Food Microbiology; Foods, Specialized; Forensic Medicine; Frail Elderly; France; Free Radicals; Fresh Water; Fungi; Fungicides, Industrial; Galactosamine; Gastrointestinal Neoplasms; Gene Expression Profiling; Gene Expression Regulation, Neoplastic; Gene Frequency; Genetic Predisposition to Disease; Genotype; Gingival Hemorrhage; Glioblastoma; Glioma; Glomerular Filtration Rate; Glomerulosclerosis, Focal Segmental; Glucose; Glucose Transport Proteins, Facilitative; Glucosides; Glutamine; Glycolysis; Gold; GPI-Linked Proteins; Gram-Negative Bacteria; Gram-Positive Bacteria; Graphite; Haplotypes; HCT116 Cells; Healthy Volunteers; Hearing Loss; Heart Failure; Hedgehog Proteins; HEK293 Cells; HeLa Cells; Hemodynamics; Hemorrhage; Hepatocytes; Hippo Signaling Pathway; Histone Deacetylases; Homeostasis; Hospital Mortality; Hospitalization; Humans; Hydantoins; Hydrazines; Hydrogen Peroxide; Hydrogen-Ion Concentration; Hydrophobic and Hydrophilic Interactions; Hydroxylamines; Hypoglycemic Agents; Immunity, Innate; Immunoglobulin G; Immunohistochemistry; Immunologic Factors; Immunomodulation; Immunophenotyping; Immunotherapy; Incidence; Indazoles; Indonesia; Infant; Infant, Newborn; Infarction, Middle Cerebral Artery; Inflammation; Injections, Intramuscular; Insecticides; Insulin-Like Growth Factor I; Insurance, Health; Intention to Treat Analysis; Interleukin-1 Receptor-Associated Kinases; Interleukin-6; Intrauterine Devices; Intrauterine Devices, Copper; Iron; Ischemia; Jordan; Keratinocytes; Kidney; Kidney Diseases; Kir5.1 Channel; Klebsiella Infections; Klebsiella pneumoniae; Lab-On-A-Chip Devices; Laparoscopy; Lasers; Lasers, Semiconductor; Lenalidomide; Leptin; Lethal Dose 50; Levonorgestrel; Limit of Detection; Lipid Metabolism; Lipid Metabolism Disorders; Lipogenesis; Lipopolysaccharides; Liquid Biopsy; Liver; Liver Abscess, Pyogenic; Liver Cirrhosis; Liver Diseases; Liver Neoplasms; Longevity; Lung Neoplasms; Luteolin; Lymph Nodes; Lymphocyte Activation; Macaca fascicularis; Macrophages; Mad2 Proteins; Magnetic Resonance Imaging; Male; Mammary Glands, Human; Manganese; Manganese Compounds; MAP Kinase Signaling System; Materials Testing; Maternal Health Services; MCF-7 Cells; Medicaid; Medicine, Chinese Traditional; Melanoma; Membrane Proteins; Mental Health; Mercury; Metal Nanoparticles; Metals, Heavy; Metformin; Methionine Adenosyltransferase; Mice; Mice, Inbred BALB C; Mice, Inbred C3H; Mice, Inbred C57BL; Mice, Inbred CBA; Mice, Knockout; Mice, Nude; Microalgae; Microbial Sensitivity Tests; Microglia; MicroRNAs; Microscopy, Atomic Force; Microscopy, Electron, Scanning; Middle Aged; Mitochondria; Mitochondrial Proteins; Mitral Valve; Mitral Valve Insufficiency; Models, Anatomic; Molecular Structure; Molybdenum; Monocarboxylic Acid Transporters; Moths; MPTP Poisoning; Multigene Family; Multiparametric Magnetic Resonance Imaging; Multiple Myeloma; Muscle, Skeletal; Mutagens; Mutation; Myeloid Cells; Nanocomposites; Nanofibers; Nanomedicine; Nanoparticles; Nanowires; Neoadjuvant Therapy; Neomycin; Neoplasm Grading; Neoplasm Recurrence, Local; Neoplasms; Neoplastic Stem Cells; Neostriatum; Neovascularization, Pathologic; Netherlands; Neuromuscular Agents; Neurons; NF-E2-Related Factor 2; NF-kappa B; Nickel; Nitrogen Oxides; Non-alcoholic Fatty Liver Disease; Nucleosides; Nucleotidyltransferases; Nutritional Status; Obesity, Morbid; Ofloxacin; Oils, Volatile; Oligopeptides; Oncogene Protein v-akt; Optical Imaging; Organic Cation Transport Proteins; Organophosphonates; Osteoarthritis; Osteoarthritis, Hip; Osteoarthritis, Knee; Osteoblasts; Osteogenesis; Oxidation-Reduction; Oxidative Stress; 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Skull Fractures; Social Determinants of Health; Sodium; Sodium Fluoride; Sodium Potassium Chloride Symporter Inhibitors; Sodium-Glucose Transporter 2 Inhibitors; Soil; Soil Pollutants; Spain; Spectrophotometry; Spectroscopy, Fourier Transform Infrared; Staphylococcal Protein A; Staphylococcus aureus; Stem Cells; Stereoisomerism; Stomach Neoplasms; Streptomyces; Strontium; Structure-Activity Relationship; Students, Nursing; Substance-Related Disorders; Succinic Acid; Sulfur; Surface Properties; Survival Rate; Survivin; Symporters; T-Lymphocytes; Temozolomide; Tensile Strength; Thiazoles; Thiobacillus; Thiohydantoins; Thiourea; Thrombectomy; Time Factors; Titanium; Tobacco Mosaic Virus; Tobacco Use Disorder; Toll-Like Receptor 4; Toluene; Tomography, X-Ray Computed; TOR Serine-Threonine Kinases; Toxicity Tests, Acute; Toxicity Tests, Subacute; Transcriptional Activation; Treatment Outcome; Troponin I; Tumor Cells, Cultured; Tumor Escape; Tumor Hypoxia; Tumor Microenvironment; Tumor Necrosis Factor Inhibitors; Tumor Necrosis Factor-alpha; Tyrosine; Ubiquitin-Protein Ligases; Ubiquitination; Ultrasonic Waves; United Kingdom; United States; United States Department of Veterans Affairs; Up-Regulation; Urea; Uric Acid; Urinary Bladder Neoplasms; Urinary Bladder, Neurogenic; Urine; Urodynamics; User-Computer Interface; Vemurafenib; Verbenaceae; Veterans; Veterans Health; Viral Load; Virtual Reality; Vitiligo; Water Pollutants, Chemical; Wildfires; Wnt Signaling Pathway; Wound Healing; X-Ray Diffraction; Xenograft Model Antitumor Assays; Xylenes; Young Adult; Zinc; Zinc Oxide; Zinc Sulfate; Zoonoses

Postoperative ileus is common and is a major clinical problem. It has been widely studied in patients and in experimental models in laboratory animals. A wide variety of treatments have been tested to prevent or modify the course of this disorder.. This review draws together information on animal studies of ileus with studies on human patients. It summarizes some of the conceptual advances made in understanding the mechanisms that underlie paralytic ileus. The treatments that have been tested in human subjects (both pharmacological and non-pharmacological) and their efficacy are summarized and graded consistent with current clinical guidelines. The review is not intended to provide a comprehensive overview of ileus, but rather a general understanding of the major clinical problems associated with it, how animal models have been useful to elucidate key mechanisms and, finally, some perspectives from both scientists and clinicians as to how we may move forward with this debilitating yet common condition.

Topics: Anesthesia, Epidural; Animals; Benzofurans; Chewing Gum; Cholinergic Agents; Contrast Media; Cyclooxygenase Inhibitors; Diatrizoate Meglumine; Digestive System Surgical Procedures; Enhanced Recovery After Surgery; Enteral Nutrition; Enteric Nervous System; Fluid Therapy; Gastrointestinal Agents; Gastrointestinal Motility; Ghrelin; Humans; Ileus; Inflammation; Intestinal Pseudo-Obstruction; Intubation, Gastrointestinal; Laparoscopy; Mast Cells; Piperidines; Postoperative Complications; Serotonin 5-HT4 Receptor Agonists; Sympathetic Nervous System; Sympatholytics

Alvimopan is a Food and Drug Administration-approved treatment to accelerate gastrointestinal recovery after abdominal surgery; however, benefits may vary across different procedures and contexts of care. The purpose of this study is to summarize the evidence regarding the effect of alvimopan on postoperative outcomes after abdominal surgery.. Major databases (Medline, Embase, Biosis, Cochrane, Web of Science, and Scopus) were searched for randomized controlled trials and nonrandomized studies comparing alvimopan versus control. Risk of bias was assessed using Cochrane's risk of bias tool 2.0 (for randomized controlled trials) and Risk of Bias in Nonrandomized Studies-of Intervention tool (for nonrandomized studies). Results were appraised descriptively as heterogeneity in reporting and risk of bias hindered meta-analysis. Quality of evidence across different surgical procedures and contexts of care (ie, open versus minimally invasive surgery, traditional care versus enhanced recovery pathway) was evaluated using Grading of Recommendations Assessment, Development, and Evaluation.. Nine randomized controlled trials and 35 nonrandomized studies were identified. Evidence of low to moderate certainty supports that alvimopan reduces length of stay and improves gastrointestinal recovery after open bowel resection and open radical cystectomy. Limited evidence supports alvimopan for surgeries not listed in Food and Drug Administration labels (ie, total abdominal hysterectomy and retroperitoneal lymph node dissection). Similar effects were observed in traditional and enhanced recovery pathway settings, but enhanced recovery pathway elements varied across studies. There is very low certainty of evidence supporting alvimopan for patients undergoing minimally invasive surgery.. Evidence supports that alvimopan improves outcomes after open bowel resection and open radical cystectomy. Benefits for patients undergoing minimally invasive surgery and treated in contemporary enhanced recovery pathway settings remain uncertain. These findings contribute important new knowledge to inform evidence-based alvimopan prescribing.

Topics: Abdomen; Clinical Trials as Topic; Databases, Factual; Digestive System Surgical Procedures; Gastrointestinal Agents; Humans; Perioperative Care; Piperidines; Postoperative Complications; Publication Bias; Treatment Outcome

Post-operative ileus (POI) and delayed return of gastrointestinal (GI) function are common complications after colorectal surgery. There is a lack of uniformity in enhanced recovery protocols (ERPs) with regards to interventions used to target these complications. This systematic review aims to categorize and summarize management recommendations available from published ERPs.. A systematic search of Ovid MEDLINE, Embase, Cochrane Library and PubMed databases was performed from January 1990 to May 2018. All studies publishing enhanced recovery or fast-track or multimodal pathway protocols for colorectal surgery in their full-text were included. Data on interventions aimed at reducing the duration of POI were extracted, as well as references quoted to support specific interventions.. Of 481 manuscripts screened, 37 published ERPs were identified from 37 studies (18 cohort, seven historical-control, five guidelines, four randomized controlled trials, one randomized controlled trial protocol, one case series and one narrative review). The most commonly recommended interventions were magnesium-based laxatives (18 of 37, 48.6%), chewing gum (13 of 37, 35.1%), Alvimopan (6 of 37, 16.2%), lactulose (4 of 37, 10.8%), neostigmine (2 of 37, 5.4%) and bisacodyl (2 of 37, 5.4%). Geographical trends were noted for the various interventions, but high-quality evidence was only referenced to support the use of Alvimopan.. ERP recommendations specific to interventions targeting POI and return of GI function are varied. While laxatives are the most commonly recommended intervention, there is only weak evidence reported to support this practice.

Topics: Bisacodyl; Chewing Gum; Colonic Diseases; Humans; Ileus; Lactulose; Neostigmine; Piperidines; Postoperative Complications; Recovery of Function; Rectal Diseases

Topics: Cystectomy; Defecation; Eating; Gastrointestinal Agents; Gastrointestinal Tract; Humans; Length of Stay; Piperidines; Postoperative Complications; Recovery of Function; Urinary Bladder

Alvimopan is used in abdominal surgery to reduce postoperative ileus in patients undergoing small bowel resections with primary anastomosis. The role and efficacy of alvimopan in patients undergoing radical cystectomy with urinary diversion is not well understood.. To assess the effects of alvimopan in the context of enhanced recovery pathways compared to enhanced recovery pathways alone for perioperative bowel dysfunction in patients undergoing radical cystectomy.. The terms alvimopan and cystectomy were used to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. We also reviewed abstracts from the past four years (2013 to 2016) of the American Urologic Association, Society of Urologic Oncology, and American Society of Clinical Oncology Genitourinary Cancers.. We searched for randomized controlled trials that compared alvimopan to placebo.. This study was based on a published protocol. We performed a comprehensive search of multiple databases including CENTRAL in the Cochrane Library, MEDLINE, Embase, LILACS, Web of Science, Scopus and Biosis, which we last updated on 6 February 2017. We also searched abstract proceedings for major relevant meetings (2013 to 2016), databases of the grey literature, trial registries, citations of relevant reviews and contacted clinical experts and the drug manufacturer.Two independent reviewers screened the literature in two stages (title and abstract, full-text) using Covidence software. Two independent reviewers assessed the risk of bias on a 'per outcome' basis using the Cochrane 'Risk of bias; tool and rated the quality of evidence according to GRADE. Results of the single eligible trial were reported in a 'Summary of findings' table based on an intention-to-treat analysis.. Based on a single trial and moderate-quality evidence, alvimopan reduced the time to reach a composite endpoint of tolerance of solid food and documented bowel movements (hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.41 to 2.23). This represents 165 more patients (109 more to 207 more) per 1000 meeting this endpoint within 10 days of surgery. Based on moderate-quality evidence, alvimopan reduced the time to hospital discharge (HR 1.67, 95% CI 1.38 to 2.01). This represents 138 more patients (82 more to 198 more) per 1000 being discharged within 10 days of surgery. Also based on moderate-quality evidence, alvimopan was associated with a reduced risk of major adverse events (risk ratio (RR) 0.28, 95% CI 0.18 to 0.44) representing 355 fewer patients (404 fewer to 276 fewer) with major adverse events per 1000. We downgraded this outcome for indirectness as it included adverse events that we did not consider major.In terms of secondary outcomes, alvimopan did not appear to alter the rate of readmission (RR 0.89, 95% CI 0.59 to 1.33), change the rate of any cardiovascular event (RR 0.54, 95% CI 0.27 to 1.05) or alter the mean narcotic pain medication use (mean difference 0, 95% CI 14.08 fewer to 14.08 more morphine equivalents). The quality of evidence was moderate for all three outcomes. Based on high-quality evidence, alvimopan reduced the rate of nasogastric tube replacement (RR 0.31, 95% CI 0.16 to 0.59). We did not find evidence for the drug's impact on rates of parenteral nutrition. All outcomes were short term and limited to a 30-day time horizon.Based on the existence of only one trial, we were unable to perform any subgroup or sensitivity analyses.. In patients undergoing radical cystectomy and urinary diversion, the use of alvimopan administered as part of an enhanced recovery pathway for a limited duration (up to 15 doses for up to seven days) probably reduces the time to tolerance of solid food, time to hospital discharge and rates of major adverse events. Readmission rates, rates of cardiovascular events and narcotic pain requirements are probably similar. The need for reinsertion of nasogastric tubes is reduced. We found no evidence for the impact on rates of parenteral nutrition within 30 postoperative days.

Topics: Cardiovascular Diseases; Cystectomy; Defecation; Eating; Gastrointestinal Agents; Humans; Ileus; Patient Discharge; Patient Readmission; Piperidines; Postoperative Complications; Randomized Controlled Trials as Topic; Recovery of Function; Time Factors; Urinary Diversion

To determine whether the administration of remifentanil increases the incidence of postoperative shivering in comparison with the administration of alfentanil, fentanyl, or sufentanil.. Meta-analysis.. Operating room and postanesthesia care unit.. We performed a computerized search of articles on PubMed, MEDLINE, and Scopus. Meta-analysis was performed using Review Manager and the DerSimonian and Laird random-effects model. The pooled effect estimates for binary variables were calculated as relative risk (RR) values with 95% confidence intervals (CIs).. Eighteen randomized controlled trials met our inclusion criteria. Remifentanil was associated with a significantly increased incidence of postoperative shivering compared with other opioids (RR=2.17; CI, 1.76-2.68; P<.00001; I(2)=0.00%). A subgroup analysis of remifentanil compared with alfentanil, fentanyl, or sufentanil showed that only sufentanil had a similar rate of postoperative shivering incidence (RR=2.13; CI, 0.67-6.74; P=.20; I(2)=0.00%). Remifentanil administration was associated with a significant increase in the incidence of postoperative shivering compared with the administration of other opioids when both propofol (RR=2.44; CI, 1.52-3.92; P=.0002; I(2)=0.00%) and inhalation anesthesia drugs (RR=2.45; CI, 1.46-4.11; P=.0007; I(2)=0.00%) were used for anesthesia maintenance. In addition, the administration of remifentanil at both low (RR=2.06; CI, 1.63-2.60; P<.00001; I(2)=0.00%) and high dosages (RR=2.77; CI, 1.67-4.57; P<.0001; I(2)=0.00%) was associated with a significant increase in the incidence of postoperative shivering compared with the administration of other opioids.. Our meta-analysis showed that remifentanil was associated with an increased incidence of postoperative shivering compared with alfentanil or fentanyl, but no significant difference was seen when compared with sufentanil.

Topics: Alfentanil; Analgesics, Opioid; Fentanyl; Humans; Incidence; Piperidines; Postoperative Complications; Remifentanil; Shivering; Sufentanil

The aim of the study was to evaluate the efficacy of alvimopan on accelerates gastrointestinal recovery after radical cystectomy.. We searched for all studies investigating alvimopan for bladder cancer patients undergoing radical cystectomy in Pubmed, Web of Knowledge, and the Cochrane Central Search Library. A systematic review and meta-analysis were performed. All studies that compared alvimopan with control group for patients undergoing radical cystectomy were included. Studies with overlapping or insufficient data were excluded. No language restrictions were made. Efficacy was assessed by the time to first toleration of clear liquids, first toleration of solid food, first bowel movement and length of stay.. Our searches identified 5 studies, including 613 patients. A total of 294 (47%) patients took alvimopan. On meta-analysis, alvimopan reduced time to first toleration of clear liquids (HR 1.34, 95% CI 1.19 to 1.51, p < 0.001), first toleration of solid food (HR 1.22, 95% CI 1.11 to 1.34, p < 0.001), first bowel movement (HR 1.27, 95% CI 1.12 to 1.43, p < 0.001) and length of stay (HR 1.17, 95% CI 1.10 to 1.25, p < 0.001).. This meta-analysis has shown that alvimopan significantly accelerates recovery of gastrointestinal function and reduces the length of stay in patients performed radical cystectomy. More large scale, multicenter randomized controlled studies are needed before final clinical recommendations can be made.

Topics: Cystectomy; Gastrointestinal Agents; Gastrointestinal Tract; Humans; Length of Stay; Piperidines; Postoperative Complications

Prolonged ileus is a common complication following gastrointestinal surgery, with an incidence of up to 40 %. Investigations examining pharmacological treatment of ileus have proved largely disappointing; however, recently, several compounds have been shown to have benefited when used as prophylaxis to prevent ileus.. This review aimed to evaluate the safety and efficacy of compounds which have been recently developed or repurposed to reduce bowel recovery time, thereby preventing ileus.. Data were taken from a systematic review of the MEDLINE, EMBASE and Cochrane Library Databases, in addition to manual searching of reference lists up to April 2015. No limits were applied.. Only randomized trials were eligible for inclusion.. Opioid receptor antagonists, ghrelin receptor agonists and serotonin receptor agonists used for the prevention of postoperative ileus in gastrointestinal surgery.. Outcomes of time to first defecation, first flatus and composite bowel recovery endpoints (GI2 and GI3) were used to determine efficacy. Pooled treatment effects were presented as the standard mean difference or as hazard ratios alongside the corresponding 95 % confidence intervals. Risk of bias was assessed using the Cochrane risk of bias framework.. A total of 17 studies were included in the final analysis. The μ-opioid receptor antagonist alvimopan and serotonin receptor agonists appeared to significantly shorten the duration of ileus. The use of Ghrelin receptor agonists did not appear to have any effect in five trials. No publication bias was detected.. Most of the trials were poorly reported and of mixed quality. Future studies must focus on the development of a set of core outcomes.. There is evidence to make a strong recommendation for the use of alvimopan in major gastrointestinal surgery to reduce postoperative ileus. Further randomized trials are required to establish whether serotonin receptor agonists are of use. Identifying a low-cost compound to promote bowel recovery following surgery could reduce complications and shorten duration of hospital admissions.

Topics: Abdomen; Digestive System Surgical Procedures; Gastrointestinal Agents; Humans; Ileus; Narcotic Antagonists; Piperidines; Postoperative Complications; Receptors, Ghrelin; Serotonin Receptor Agonists; Treatment Outcome

To assess the efficacy and safety of alvimopan in conjunction with enhanced recovery strategy, compared with this strategy alone, in management of postoperative ileus in patients undergoing open abdominal surgery.. Electronic databases were comprehensively searched for relevant randomized controlled trials. We were interested in doses of 6 and 12 mg. The efficacy end points included the time to recovery of full gastrointestinal (GI) function (a composite end point measured by the time to first toleration of solid food [SF] and the time to first passage of stool, GI-2), the recovery of upper (SF) or the lower (the time to first bowel movement, BM) GI function, and the length of hospital stay (the time to discharge order written). Safety end points included GI-related, non-GI-related, and serious adverse events. These parameters were all analyzed by RevMan 5.3 software.. Nine randomized controlled trials involving 4075 patients were enrolled in this study. The pooled results showed that alvimopan significantly decreased the time to GI-2 recovery (6 mg, hazard ratio [HR] = 1.45, P < 0.00001; 12 mg, HR = 1.59, P < 0.00001), BM (6 mg, HR = 1.54, P < 0.00001; 12 mg, HR = 1.74, P = 0.0002), and the time to discharge order written (6 mg, HR = 1.37, P < 0.00001; 12 mg, HR = 1.34, P < 0.00001) compared with the placebo group. However, SF was significantly reduced in 6 mg group (HR = 1.23, P = 0.008) rather than 12 mg group (HR = 1.14, 95% confidence interval 1.00, 1.30, P = 0.04). The incidence of some GI-related and serious adverse events were significantly lower in the alvimopan group than the placebo group, and the dose of 12 mg was superior to 6 mg in this regard.. Alvimopan can accelerate recovery of GI function (especially for the lower GI tract), shorten the length of hospital stay, and reduce postoperative ileus-related morbidity without compromising opioid analgesia in an enhanced recovery setting.

Topics: Abdomen; Combined Modality Therapy; Dose-Response Relationship, Drug; Drug Administration Schedule; Gastrointestinal Agents; Humans; Ileus; Length of Stay; Models, Statistical; Piperidines; Postoperative Care; Postoperative Complications; Treatment Outcome

Fungal mesh infections are a rare complication of hernia repairs with mesh. The first case of Coccidioides spp. mesh infection is described, and a systematic literature review of all known fungal mesh infections was performed. Nine cases of fungal mesh infection are reviewed. Female and male patients are equally represented, median age is 49.5 years, and critical illness and preinfection antibiotic use were common. Fungal mesh infections are rare, but potentially fatal, complications of hernias repaired with mesh.

Topics: Adenine; Aged; Antifungal Agents; Coccidioides; Coccidioidomycosis; Female; Fluconazole; Herniorrhaphy; Humans; Hyphae; Male; Middle Aged; Piperidines; Postoperative Complications; Pyrazoles; Pyrimidines; Surgical Mesh

Prolonged postoperative ileus (POI) is the predominant cause of extended hospitalization after bowel resection surgery. Alvimopan accelerates gastrointestinal recovery, potentially reducing health care costs. We examined the value of alvimopan in reducing prolonged POI and length of stay for patients undergoing abdominal surgery using different definitions of POI.. We developed a decision analytic model to examine costs and outcomes associated with postoperative treatment with either an accelerated care pathway (ACP) only or alvimopan+ACP. To represent an overall perspective for alvimopan, data from four phase 3 bowel resection trials and one phase 4 radical cystectomy trial were used to populate the model with 3 different definitions of POI. The period analyzed included start of surgery to 7 days post discharge. Costs were obtained from standard US costing sources and are reported in 2015 US dollars. Due to variations in published definitions of POI, alternative definitions based on adverse event reports, NG tube insertion, and time to food toleration were examined.. The combined clinical trial data included 1,003 ACP and 1,013 alvimopan+ACP patients. When POI was reported as an adverse event, the incidence of POI was significantly lower with alvimopan+ACP (n = 70 [7%]) vs ACP alone (n = 148 [15%]; p < 0.0001). Time to discharge order written was shorter for patients with POI who were treated with alvimopan+ACP than with ACP (202 ± 115 hours vs 266 ± 138 hours; p < 0.0001). As a result, costs were $731 lower with alvimopan+ACP ($17,835) vs ACP ($18,566). Alternative definitions of POI produced similar results.. The addition of alvimopan to existing treatment pathways for patients undergoing abdominal surgery can reduce overall hospital costs.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Combined Modality Therapy; Cystectomy; Decision Trees; Digestive System Surgical Procedures; Female; Gastrointestinal Agents; Hospital Costs; Humans; Ileus; Length of Stay; Male; Middle Aged; Models, Statistical; Piperidines; Postoperative Care; Postoperative Complications; United States; Young Adult

Tissue injury secondary to surgical lesion produces profound changes in endocrine-metabolic function and defence mechanisms in the patient (inflammatory, immunological), leading to an increase in catabolism, immunosuppression and postoperative morbidity. The best anaesthetic and surgical technique should be capable of modulating this response, especially in major surgery, where it can be most harmful and increase patient morbidity. Many of the changes that maintain homeostasis are controlled by the hypothalamicpituitary- adrenal axis. The autonomic-adrenal response is usually immediate, compared to the hypothalamus-pituitary gland, which is slower and longer lasting. Cytokine synthesis and release are the earliest stages in the response to tissue lesion. The most frequently studied cytokines in surgical stress response are IL-6 and TNF-α. Inflammatory mediator concentrations are direct indicators of perioperative stress, while haemodynamic changes are considered the indirect indicators of this response. Multiple anaesthetic techniques have been described to modify the stress response in patients undergoing elective surgery. The aim of this review is to present clinical evidence on perioperative stress modulation with different anesthetics. We also describe a different point of view in immunomodulation with the intraoperative management of haemodynamic responses with inhalational bolus of sevoflurane or with remifentanil intravenous bolus. The effects of sevoflurane used as an inhalational bolus to counteract patients' intraoperative haemodynamic responses modulates the immune response the same than opioid remifentanil.

Topics: Anesthetics, Inhalation; Anesthetics, Intravenous; Animals; Humans; Methyl Ethers; Oxidative Stress; Piperidines; Postoperative Complications; Remifentanil; Sevoflurane; Treatment Outcome

For radical cystectomy, historical practice trends have favored the use of preoperative bowel preparations to reduce complications, including surgical site infections, ileus, and anastomotic leaks. However, emerging data has questioned this practice. Postoperative cystectomy care also remains in flux, as new pharmacologic agents that may potentiate earlier return of bowel function are studied. We review the current literature with regards to preoperative and postoperative cystectomy bowel management.

Topics: Anti-Bacterial Agents; Cathartics; Chemoprevention; Cystectomy; Gastrointestinal Agents; Humans; Ileus; Piperidines; Postoperative Care; Postoperative Complications; Preoperative Care; Surgical Wound Infection; Urinary Diversion

Topics: Airway Management; Androstanols; Anesthesia; Anesthetics; Animals; Brain; Child; Child, Preschool; Humans; Hyperglycemia; Hyponatremia; Infant; Infant, Newborn; Intraoperative Care; Intraoperative Complications; Mice; Pediatrics; Piperidines; Postoperative Complications; Remifentanil; Rocuronium

Topics: Anesthesia, General; Anesthesia, Inhalation; Anesthetics; Cardiac Catheterization; Cardiac Surgical Procedures; Child; Child, Preschool; Fentanyl; Heart Defects, Congenital; Humans; Hypertension, Pulmonary; Infant; Infant, Newborn; Methyl Ethers; Perioperative Care; Piperidines; Postoperative Complications; Remifentanil; Sevoflurane; Vascular Resistance

Peripherally acting mu-opioid receptor antagonists methylnaltrexone and alvimopan are a new class of drugs designed to reverse opioid-induced side-effects on the gastrointestinal system without compromising pain relief. This article gives an overview of the pharmacology, the efficacy, and adverse effects of these drugs. Both compounds seem to be generally well tolerated and effective for the treatment of opioid-related bowel dysfunction and postoperative ileus. Methylnaltrexone recently received approval by the US Food and Drug Administration (FDA) and the European Medicines Agency for treatment of opioid-related bowel dysfunction in patients with advanced illness. Alvimopan was recently approved by the FDA for treatment of postoperative ileus, but the use of the drug is restricted to inpatients because it has been associated with an increased rate of myocardial infarction. Further research should assess the effectiveness and safety of these drugs in clinical practice.

Topics: Analgesics, Opioid; Blood-Brain Barrier; Drug Approval; Europe; Humans; Ileus; Myocardial Infarction; Naltrexone; Narcotic Antagonists; Patient Selection; Piperidines; Postoperative Complications; Quaternary Ammonium Compounds; Research Design; Safety; United States; United States Food and Drug Administration

The duration of postoperative ileus following abdominal surgery is quite variable, and prolonged postoperative ileus is an iatrogenic phenomenon with important influence on patient morbidity, hospital costs and length of stay in hospital. Adequate treatment for prolonged postoperative ileus is important to improve patient morbidity and clinical efficiency. Both clinical and pharmacological management strategies have improved rapidly over the last decade, and appropriate and timely management using multimodal techniques should be used for optimal care. In this review, we define postoperative ileus, describe the pathogenesis and briefly discuss clinical management before detailing potential pharmacologic management options.

Topics: Adrenergic alpha-Antagonists; Adrenergic beta-Antagonists; Anti-Inflammatory Agents, Non-Steroidal; Bisacodyl; Cathartics; Cisapride; Dihydroergotamine; Humans; Ileus; Inflammation; Naltrexone; Neostigmine; Parasympathomimetics; Piperidines; Postoperative Complications; Propranolol; Quaternary Ammonium Compounds; Receptors, Opioid, mu; Serotonin Receptor Agonists

Topics: Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Child; Halothane; Humans; Methyl Ethers; Pediatrics; Piperidines; Postoperative Complications; Propofol; Remifentanil; Sevoflurane

The efficacy, safety, pharmacology, pharmacokinetics, drug-drug interactions, and administration of alvimopan for postoperative ileus are reviewed.. Alvimopan is a selective mu-opioid receptor antagonist with no central nervous system activity. When orally administered after partial small- or large-bowel resection in patients with primary anastomosis, alvimopan shortened the return of bowel function and time to discharge by approximately one day without compromising analgesia. Alvimopan was not shown to be beneficial on these same outcomes after hysterectomy and has not been studied in other surgical populations. Alvimopan is generally well tolerated, with the frequency of adverse events being similar to placebo when used postoperatively for one week or less. Long-term studies of alvimopan in opioid-induced bowel dysfunction have shown an association with adverse cardiovascular outcomes, neoplasms, and fractures. Because of these concerns, the Entereg Access Support and Education program was developed. The recommended dosage of alvimopan is 12 mg administered with a sip of water 30 minutes to five hours before surgery, followed by 12 mg twice daily beginning the day after surgery for a maximum of seven days, 15 total doses, or until discharge. There is a limited amount of pharmacoeconomic analysis concerning alvimopan.. Alvimopan, a peripherally acting mu-opioid receptor antagonist, is a novel agent for the treatment of postoperative ileus. It appears to decrease the duration of postoperative ileus and hospitalization by approximately one day, theoretically offsetting its acquisition costs. Unresolved long-term safety issues, a limited indication, and its restricted-access program are likely to hinder its widespread use in the surgical population.

Topics: Animals; Humans; Ileus; Piperidines; Postoperative Complications; Receptors, Opioid, mu

To summarize the evidence on pharmacologic options in preventing postoperative ileus (POI).. The Cochrane Database of Reviews and OVID databases and Food and Drug Administration (FDA) Web site were searched (1950-April 2009) using the term postoperative ileus.. Meta-analyses and randomized controlled trials were included for review. The FDA Web site was searched for clinical reviews and label information for drugs indicated for the prevention of POI.. Three meta-analyses, 2 on gum-chewing and 1 on alvimopan, and 18 clinical trials were identified. Only gum chewing and alvimopan were effective in preventing POI. Gum chewing reduced the time to first flatus and bowel movement (weighted mean difference 21h; p = 0.0006 and 33h; p = 0.0002, respectively). In one meta-analysis, gum chewing significantly reduced length of stay (LOS) by 2.4 days (p < 0.00001) but this was not replicated in the second meta-analysis. Alvimopan shortened the time to reach a composite endpoint of solid food intake, plus/minus flatus, and bowel movement (93 vs 105 h; p < 0.001). A higher incidence of myocardial infarction was observed in a 12-month study of alvimopan for the treatment of opioid-induced bowel dysfunction, but not in studies in patients undergoing bowel resection. Alvimopan decreased the time to written hospital discharge order (hazard ratio 1.35; p < 0.01), while the significance of a reduction in LOS (0.2-1.3 days) was not reported.. Gum chewing and alvimopan are effective in preventing POI, but given safety concerns and higher cost with alvimopan, gum chewing may be preferred.

Topics: Chewing Gum; Clinical Trials as Topic; Drug Costs; Gastrointestinal Agents; Humans; Ileus; Piperidines; Postoperative Care; Postoperative Complications

Topics: Animals; Humans; Ileus; Piperidines; Postoperative Complications; Randomized Controlled Trials as Topic

Alvimopan is a selective, competitive mu-opioid receptor antagonist with limited oral bioavailability which may be used to reduce length of post-operative ileus.. The study compared alvimopan with placebo following bowel resection or total abdominal hysterectomy.. A meta-analysis of randomized-controlled trials published between 2001 and 2006 of alvimopan vs. placebo was performed. The primary efficacy end-points were composite measures of passage of flatus, stool, and tolerance of solid food (GI-3) and passage of stool and tolerance of solid food (GI-2). The incidence of treatment emergent adverse events was assessed.. Five trials matched the selection criteria, reporting on 2195 patients. A total of 1521 (69.3%) had alvimopan and 674 (30.7%) placebo. GI-3 significantly improved (hazard ratio 1.30; 95% confidence intervals 1.16, 1.45, P < 0.001), as did GI-2 (hazard ratio 1.61; 95% confidence intervals 1.26, 2.05, P < 0.001) on alvimopan 12 mg. Time to discharge (hazard ratio 1.26; 95% confidence intervals 1.13, 1.40, P < 0.001), time to bowel motion (hazard ratio 1.74; 95% confidence intervals 1.29, 2.35, P < 0.001), and time to solid food (hazard ratio 1.14; 95% confidence intervals 1.01, 1.30, P < 0.04) also improved significantly. No difference was noted in the incidence of treatment emergent adverse events.. Alvimopan showed significant advantages over placebo in restoring gastro-intestinal function, and reduced time to discharge following major abdominal surgery, with acceptable side effects.

Topics: Adolescent; Adult; Digestive System Surgical Procedures; Female; Gastrointestinal Motility; Humans; Hysterectomy; Ileus; Middle Aged; Piperidines; Postoperative Complications; Randomized Controlled Trials as Topic; Receptors, Opioid, mu; Recovery of Function; Treatment Outcome

To obtain further analysis regarding specific outcomes and alvimopan doses in bowel resection (BR) patients.. Although postoperative ileus (POI) is common after BR, there is currently no recognized treatment or prevention available. Alvimopan, a novel, peripherally active mu-opioid receptor antagonist, accelerated GI recovery after BR or hysterectomy in 3 phase III trials.. A pooled retrospective subset analysis of BR patients in alvimopan phase III trials was performed. Randomized BR patients received alvimopan 6 mg (n = 397), 12 mg (n = 413), or placebo (n = 402) >or=2 hours before surgery and twice daily until hospital discharge for

Topics: Clinical Trials, Phase III as Topic; Digestive System Surgical Procedures; Gastrointestinal Agents; Humans; Ileus; Intestine, Large; Intestine, Small; Piperidines; Postoperative Complications; Proportional Hazards Models; Randomized Controlled Trials as Topic; Receptors, Opioid, mu

Methylnaltrexone and alvimopan are two new and potentially useful agents in the management of opioid-induced bowel dysfunction and prevention of postoperative ileus. Both agents have promising prokinetic properties and appear to be capable of reversing the effects of opioids on delayed gastrointestinal transit. This article reviews currently available published literature to provide an overview of the clinical trials and to provide insight for the potential use of these agents for patients requiring opioid based analgesia. These compounds represent a new class of compounds that may impact the therapeutics for opioid induced bowel dysfunction as well as postoperative ileus.

Topics: Analgesics, Opioid; Gastrointestinal Transit; Humans; Ileus; Intestinal Diseases; Naltrexone; Narcotic Antagonists; Piperidines; Postoperative Complications; Quaternary Ammonium Compounds

Postoperative ileus (POI), a transient cessation of coordinated bowel motility after surgery, is an important factor in extending the length of hospital stay. The etiology of POI is multifactorial, and related to both the surgical and anesthetic pathways chosen. Additionally, opioids used to manage non-cancer-related and cancer-related chronic pain may also decrease gastrointestinal (GI) motility resulting in opioid-induced bowel dysfunction (OBD). Postoperative ileus has been associated with prolonged hospital stay and readmission, and thus may increase the overall hospital costs per patient with POI. Alvimopan, a peripherally acting mu-opioid receptor antagonist, accelerated time to GI recovery and reduced postoperative hospital length of stay in phase III POI clinical trials and improved symptoms of OBD compared with placebo in phase II/III clinical trials. The U.S. Food and Drug Administration is currently evaluating alvimopan for the management of POI after bowel resection. Alvimopan may provide clinically meaningful benefits to patients and may lower the economic burden of POI to the healthcare system.

Topics: Analgesics, Opioid; Clinical Trials as Topic; Gastrointestinal Agents; Gastrointestinal Diseases; Humans; Piperidines; Postoperative Complications; Receptors, Opioid, mu

Postoperative ileus is a transient cessation of bowel motility that occurs after bowel resection (BR). Alvimopan, a peripherally acting mu-opioid receptor antagonist accelerated gastrointestinal (GI) recovery in 5 randomized, double-blind, phase III postoperative ileus trials.. Individual covariates (age, gender, race) were assessed separately using Cox proportional hazards models that included the main effects of treatment and covariate factor. Time-to-GI recovery (GI-3 [first toleration of solid food and first bowel movement or flatus]; GI-2 [first toleration of solid food and first bowel movement]) for patients who underwent open laparotomy for BR in the absence of epidural anesthesia and received alvimopan (12 mg) or placebo was analyzed within subgroups (age, gender, race, concomitant medication use) using Cox proportional hazards models to generate hazard ratios (HRs). P values were calculated with the Wald chi2 test.. Elderly (>or=65 years), male, and nonwhite patients achieved GI-3 recovery later than younger (<65 years), female, and white patients (HR > 1 and P < .05 for all). Overall, alvimopan (12 mg) accelerated GI-3 recovery by 12 hours and GI-2 recovery by 17 hours compared with placebo. Within subgroups, regardless of covariate effect, patients who received alvimopan (12 mg) achieved GI-2 and GI-3 recovery sooner than patients who received placebo (HR > 1 and P < .05 for all).. These post hoc analyses support that alvimopan (12 mg) accelerates GI recovery across various patient populations.

Topics: Age Distribution; Clinical Trials, Phase III as Topic; Gastrointestinal Agents; Gastrointestinal Diseases; Humans; Multicenter Studies as Topic; Piperidines; Postoperative Complications; Racial Groups; Randomized Controlled Trials as Topic; Recovery of Function; Sex Distribution

We performed a quantitative systematic review of randomised, controlled trials that compared remifentanil to short-acting opioids (fentanyl, alfentanil, or sufentanil) for general anaesthesia. Eighty-five trials were identified and these included a total of 13 057 patients. Intra-operatively, remifentanil was associated with clinical signs of deeper analgesia and anaesthesia, such as fewer responses to noxious stimuli (relative risk 0.65, 95% CI 0.48-0.87), more frequent episodes of bradycardia (1.46, 1.04-2.05), more hypotension (1.68, 1.36-2.07) and less hypertension (0.60, 0.46-0.78). Postoperatively, remifentanil was associated with faster recovery (difference in extubation time of -2.03, 9.5% CI, -2.92 to -1.14 min), more frequent postoperative analgesic requirements (1.36, 1.21-1.53) and fewer respiratory events requiring naloxone (0.25, 0.14-0.47). Remifentanil had no overall impact on postoperative nausea (1.03, 0.97-1.09) or vomiting (1.06, 0.96-1.17), but was associated with twice as much shivering (2.15, 1.73-2.69). Remifentanil does not seem to offer any advantage for lengthy, major interventions, but may be useful for selected patients, e.g. when postoperative respiratory depression is a concern.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, General; Evidence-Based Medicine; Humans; Intraoperative Complications; Piperidines; Postoperative Complications; Randomized Controlled Trials as Topic; Remifentanil

The adverse effects of opioids are well documented. Because opioid receptors have a wide-ranging anatomic distribution, the effects subsequent to opioid binding, both good and bad, occur centrally and in the periphery. Postoperative strategies to reduce opioid burden, therefore, are in the patient's best interest. Multimodal analgesia is the key towards balancing the need for opioids while simultaneously reducing their burden. Alternative anesthesia and analgesia options such as regional anesthesia, nonsteroidal anti-inflammatory drugs, or cyclooxygenase-2 enzyme inhibitors should be considered part of multimodal protocols. Familiarity of where these drugs are active in the body and how they can be employed is imperative for all surgical team members. Optimal implementation of multimodal approaches can reduce hospital stay and improve clinical outcomes, including patient satisfaction. Finally, strategies that may help reduce rates of hospital readmission also contribute to overall improved outcome. New peripherally acting mu-opioid-receptor antagonists represent significant progress in the ability of perianesthesia nurses to play an even greater role in achieving these goals. In contrast to older opioid-receptor antagonists, these agents specifically target an important aspect of the multifactorial etiology of postoperative ileus (POI), mu-opioid-receptor-mediated activity in the GI tract. In addition, they do not pass the blood-brain barrier or diminish opioid-mediated analgesia. Advanced clinical trials have already demonstrated the ability of one of these agents, alvimopan, to reduce POI and improve other postoperative outcomes while maintaining adequate analgesia. Combined with other options aimed at reducing opioid burden, alvimopan and similar drugs in development hold promise as part of multimodal protocols to optimize pain management while minimizing postoperative morbidities.

Topics: Analgesia; Analgesics, Opioid; Anesthesia; Anesthesiology; Anti-Inflammatory Agents, Non-Steroidal; Attitude of Health Personnel; Blood-Brain Barrier; Clinical Trials, Phase III as Topic; Humans; Ileus; Length of Stay; Naltrexone; Narcotic Antagonists; Nurse's Role; Outcome Assessment, Health Care; Pain, Postoperative; Patient Satisfaction; Piperidines; Postanesthesia Nursing; Postoperative Care; Postoperative Complications; Quaternary Ammonium Compounds; Receptors, Opioid, mu; Risk Factors

Postoperative ileus (POI) is defined as the impairment of bowel motility that occurs almost universally after major open abdominal procedures, as well as other abdominal and nonabdominal procedures. For the majority of affected patients, POI generally lasts approximately three to five days, but longer duration is not uncommon. The causes of POI are multifactorial, but can be broadly categorized into two groups: those related to the surgical procedure and those related to pharmacologic interventions (opioids). The fact that POI is generally transient and therefore self-limited should not deter the surgical team from seeking improved ways to mitigate its associated adverse effects, which can be substantial and immensely uncomfortable for the patient, and can have far-reaching implications regarding overall hospitalization costs for many types of surgeries. Optimization of POI management and prevention efforts is a responsibility of all members of the surgical team and can drastically affect the overall clinical outcome of major abdominal surgery. Depending on the individual team member's role, different perspectives and strategies may be used to achieve improved outcomes, including but not limited to hospitalization costs related to care and length of stay, resource utilization, and, perhaps most critically, patient quality of life not only immediately after surgery but also after discharge. The ability to reliably and significantly decrease the duration of POI should be readily recognized as an important objective in the management of this condition. Opioids will continue to be a mainstay of postoperative care regimens, but new agents such as peripherally acting mu-opioid-receptor antagonists may offer a unique clinical advantage by helping to reduce the adverse gastrointestinal effects of opioids while preserving their desired benefits for postoperative analgesia.

Topics: Analgesics, Opioid; Causality; Cost of Illness; Hospital Costs; Humans; Ileus; Incidence; Laparotomy; Length of Stay; Naltrexone; Narcotic Antagonists; Nurse's Role; Outcome Assessment, Health Care; Pain, Postoperative; Patient Care Team; Patient Satisfaction; Piperidines; Postanesthesia Nursing; Postoperative Care; Postoperative Complications; Professional Role; Quaternary Ammonium Compounds; Time Factors; Total Quality Management

Postoperative ileus (POI) is frequently experienced by many patients undergoing abdominal operations and other surgical procedures. Postoperative ileus causes physical discomfort and may increase risk for prolonged hospital length of stay. Despite its prevalence, there is currently no accepted standard definition of POI and, consequently, no standardized mode of prevention or treatment; it is no wonder that a variety of management approaches for POI have been developed. Some of these include alternative surgical techniques such as laparoscopic or endoscopic procedures to minimize trauma and help lessen the release of endogenous mediators of POI. Others have evaluated alternate analgesic regimens such as thoracic epidural anesthetics to avoid stimulating opioid receptors in the gut. These approaches have had varying results. Other pharmacologic attempts to reduce POI have focused on the blockade of opioid receptors to prevent opioid-induced GI-related adverse effects. A new class of agents, peripherally acting mu-opioid-receptor antagonists such as methylnaltrexone and alvimopan, may improve the pharmacologic management of POI and reshape the current paradigm of multimodal management of POI. Protocols that incorporate these agents may offer yet another avenue to mitigate the adverse effects of POI, and thus help improve surgical outcomes. To date, alvimopan has been shown in phase 3 clinical trials to significantly reduce the duration of POI while maintaining satisfactory analgesia and reducing length of hospital stay. Combinations of strategies with demonstrated effectiveness such as early feeding, epidural analgesia, laparoscopic surgery, and peripherally acting mu-opioid-receptor antagonists may help transform the management of POI into an effective multimodal paradigm that targets the diverse etiologic factors leading to this common clinical problem. Clearly, all surgical team members are crucial in the optimal implementation of such multimodal approaches.

Topics: Analgesia, Epidural; Analgesics, Opioid; Attitude of Health Personnel; Choice Behavior; Enteral Nutrition; Evidence-Based Medicine; General Surgery; Humans; Ileus; Intubation, Gastrointestinal; Laparoscopy; Laparotomy; Length of Stay; Naltrexone; Narcotic Antagonists; Outcome Assessment, Health Care; Patient Care Team; Patient Selection; Piperidines; Postoperative Care; Postoperative Complications; Practice Guidelines as Topic; Quaternary Ammonium Compounds; Risk Factors

Alvimopan is a novel, peripherally acting mu-opioid antagonist that is being developed for the management of acute postoperative ileus and for the reversal of the delayed gastrointestinal and colonic transit that result in symptoms such as constipation, nausea and motility disorders in patients treated with opiate analgesics. There is a clinical need for effective medications for the treatment of postoperative ileus and opiate-induced constipation and other motility disorders. This review addresses the basic and applied pharmacology and current evidence for the use of the medication, alvimopan, in clinical gastroenterology.

Topics: Animals; Constipation; Gastrointestinal Motility; Humans; Ileus; Narcotic Antagonists; Piperidines; Postoperative Complications; Receptors, Opioid, mu

Alvimopan is a synthetic peripherally restricted mu-receptor opioid antagonist. Alvimopan has a greater affinity for the mu-receptor than the kappa- or sigma-opioid receptors (Ki = 0.77 nM). The polarity of the molecule limits gastrointestinal absorption and central nervous system penetration. It has limited systemic bioavailability and higher affinity for the mu-opioid receptor than naloxone (Ki = 3.7 nM). Completed Phase III trials suggest efficacy in accelerating the recovery of gastrointestinal function after abdominal surgery. Adverse events with all doses have been similar to placebo groups. Further efficacy in alleviating opioid-induced bowel dysfunction in patients with chronic opioid usage has also been demonstrated. This evidence-based review assesses this new drug and discusses its potential role in clinical practice.

Topics: Abdomen; Administration, Oral; Adult; Analgesics, Opioid; Constipation; Gastrointestinal Agents; Gastrointestinal Motility; Humans; Ileus; Male; Middle Aged; Narcotic Antagonists; Piperidines; Postoperative Complications; Randomized Controlled Trials as Topic; Receptors, Opioid, mu

To review the pharmacology, pharmacokinetics, clinical efficacy, safety, dosage, and administration of alvimopan, a peripherally acting mu-opioid receptor antagonist, in the management of postoperative ileus (POI).. A literature search (1980-October 2004) applying the terms alvimopan, ADL 8-2698, and LY246736 was conducted using MEDLINE. Information was also obtained from scientific congress abstracts and data on file with the manufacturer.. Studies and abstracts investigating alvimopan and POI were considered for inclusion; however, they were restricted to English-language articles.. Alvimopan is a novel, peripherally acting mu-opioid receptor antagonist that is currently under evaluation for the management of POI. POI presents significant clinical challenges that can delay patient recovery and contribute to increased morbidity and prolonged hospitalization after surgery. Clinical trials have demonstrated that alvimopan, at oral doses of 6 and 12 mg, can accelerate time to recovery of gastrointestinal (GI) function and time to hospital discharge following abdominal surgery. The incidence of adverse events with alvimopan therapy was shown to be similar to that of placebo.. Alvimopan is well tolerated and effective at accelerating GI recovery and time to discharge in patients who have undergone bowel resection or hysterectomy when administered prior to surgery and twice daily thereafter until discharge or for up to 7 days. Alvimopan potentially offers significant benefits for patients with POI over currently available treatments.

Topics: Clinical Trials as Topic; Costs and Cost Analysis; Drug Interactions; Humans; Ileus; Piperidines; Postoperative Complications

To demonstrate that alvimopan (6 or 12 mg) accelerates recovery of gastrointestinal (GI) function in patients undergoing laparotomy for bowel resection or radical hysterectomy.. Postoperative ileus (POI) following laparotomy may increase morbidity and extend hospitalization. Opioids can contribute to the duration of POI. Alvimopan is a novel opioid receptor antagonist in development for the management of POI.. A total of 510 patients scheduled for bowel resection or radical hysterectomy were randomized (1:1:1) to receive alvimopan 6 mg, alvimopan 12 mg, or placebo orally > or =2 hours before surgery, then twice a day (b.i.d.) until hospital discharge or for up to 7 days. The primary efficacy end point was a composite of time to recovery of upper and lower GI function. An associated secondary end point was time to hospital discharge order written.. The modified intent-to-treat population included 469 patients (451 bowel resection and 18 radical hysterectomy patients). Time to recovery of GI function was accelerated for the alvimopan 6 mg (hazard ratio [HR] = 1.28; P < 0.05) and 12 mg (HR = 1.54; P < 0.001) groups with a mean difference of 15 and 22 hours, respectively, compared with placebo. The time to hospital discharge order written was also accelerated in the alvimopan 12 mg group (HR = 1.42; P = 0.003) with a mean difference of 20 hours compared with placebo. The incidence of adverse events was similar among treatment groups.. Alvimopan accelerated GI recovery and time to hospital discharge order written compared with placebo in patients undergoing laparotomy and was well tolerated.

Topics: Adult; Aged; Aged, 80 and over; Defecation; Double-Blind Method; Female; Gastrointestinal Agents; Humans; Hysterectomy; Ileus; Intestine, Large; Intestine, Small; Laparotomy; Male; Middle Aged; Patient Discharge; Piperidines; Placebos; Postoperative Complications; Premedication; Receptors, Opioid, mu; Recovery of Function; Time Factors

This article will review the pathophysiology of postoperative ileus, with emphasis on potential therapeutic targets, and examine the efficacy of pharmacologic and nonpharmacologic interventions. Proposed mechanisms include actuation of spinal and local sympathetic neural reflexes, inflammatory mediation, and exacerbation by anesthetic or surgical procedures. Some procedures or agents have shown clinical benefit, and these include use of laparoscopic surgery, thoracic epidurals, nonsteroidal anti-inflammatory drugs, and opiate antagonists. Other procedures may be helpful with low risk of adverse effects. These include early feeding and ambulation, laxatives, and possibly neostigmine.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Decompression, Surgical; Early Ambulation; Gastrointestinal Motility; Humans; Ileus; Laparoscopy; Naloxone; Narcotic Antagonists; Neostigmine; Piperidines; Postoperative Complications

Ileus is a common postoperative complication after major abdominal surgery. Surgical manipulation of the bowel and stimulation of opiod receptor are the main causes of ileus. An investigational drug (ADL 8-2698, Alvinopam) a selective opioid antagonist with a very low oral absorption was recently introduced to clinical medicine. Unlike other opioid antagonist its activity is restricted to GI tract, it is potent, has a long duration of action, is orally effective, does not readily cross the blood-brain barrier even after intravenous administration in animals. Two randomized controlled clinical studies tested its effects in humans. Liu et al.'s study confirmed peripheral restriction of ADL 8-2698 by its lack of central effect on morphine analgesia and pupil miosis. They also showed that ADL 8-2698 prevents increases in gastrointestinal transit time. Taguchi et al. concluded that high dose (6 mg) of ADL 8-2698 archived fast recovery of gastrointestinal function, without antagonising analgesic efficacy of systemic opioid. In summary, selective inhibition of gastrointestinal opioid receptor by a peripherally restricted oral antagonist speeds recovery of bowel function, shortens times of hospitalization and preserves the analgesic effects of opiods.

Topics: Adolescent; Adult; Aged; Humans; Intestinal Obstruction; Middle Aged; Narcotic Antagonists; Piperidines; Postoperative Complications; Postoperative Nausea and Vomiting; Randomized Controlled Trials as Topic

Alvimopan (ADL 8-2698; Adolor Corporation, Exton, PA, USA) is a novel, peripherally restricted opioid antagonist. After oral administration, it has activity specific to the gastrointestinal (GI) tract. ADL 8-2698 has low systemic absorption and a high affinity for mu-opioid receptors. In healthy subjects, ADL 8-2698 antagonized loperamide-induced changes in GI transit and prevented morphine-induced delays in oral-cecal transit time without antagonizing centrally mediated opioid effects, such as analgesia or pupillary constriction. In the treatment of opioid naive patients who underwent surgery and received opioids for acute pain, oral ADL 8-2698 (6.0 mg) improved the management of postoperative ileus (POI) by shortening the time to achieve normal bowel function and, ultimately, hospital stay. Postoperative nausea and vomiting and the overall incidence of all GI side effects were reduced in patients treated with ADL 8-2698 for POI. Analgesia was not compromised, because there were no changes in median opioid consumption or Visual Analog Scale (VAS) pain scores in patients treated with ADL 8-2698 versus patients treated with placebo. No drug-related side effects were observed in acute pain postsurgical patients in the initial POI study. In patients treated with opioids for chronic pain or opioid addiction, lower doses of oral ADL 8-2698 (0.5 to 3.0 mg) reversed opioid bowel dysfunction (OBD) and normalized GI activity. These effects were evident without compromising opioid analgesia or inducing central nervous system symptoms of withdrawal. Some chronic opioid patients receiving apparently supramaximal doses of ADL 8-2698 (> or = 3.0 mg) reported localized GI side effects, possibly indicative of a localized GI withdrawal response. The most common side effects of ADL 8-2698 in chronic pain patients with OBD were abdominal pain, flatulence, and diarrhea. These effects were not observed in most OBD patients receiving lower doses of ADL 8-2698. Overall, ADL 8-2698 was well tolerated in clinical trials. Further studies to evaluate the efficacy and safety of ADL 8-2698 in clinical practice are in progress.

Topics: Analgesia; Analgesics, Opioid; Animals; Gastrointestinal Transit; Humans; Intestinal Pseudo-Obstruction; Intestines; Narcotic Antagonists; Pain Measurement; Piperidines; Postoperative Complications

The contributions of remifentanil to anesthesia for heart surgery is described. The pharmacokinetic properties are described along with our clinical experience with the various modes and doses of perfusion for induction as well as during and after surgery.

Topics: Analgesics; Anesthesia, Conduction; Anesthesia, General; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Cardiac Surgical Procedures; Extracorporeal Circulation; Half-Life; Hemodynamics; Humans; Methyl Ethers; Myocardial Infarction; Myocardium; Neuromuscular Nondepolarizing Agents; Oxygen Consumption; Pain, Postoperative; Piperidines; Postoperative Complications; Propofol; Remifentanil; Sevoflurane; Stress, Physiological; Sympathetic Nervous System

1. Fibrosis is characterized by extracellular matrix deposition, of which collagen type I is the major constituent. The progressive accumulation of connective tissue resulted in destruction of normal tissue architecture and function. 2. Fibrosis is a common response to various insults or injuries and can be the outcome of any perturbation in the cellular function of any tissue. 3. Halofuginone was found to inhibit collagen alpha 1(I) gene expression and collagen synthesis in a variety of cell cultures including human fibroblasts derived from patients with excessive skin collagen type I synthesis. 4. Halofuginone was found to inhibit collagen alpha 1(I) gene expression and collagen synthesis in animal models characterized by excessive deposition of collagen. In these models, fibrosis was induced in various tissues such as skin, liver, lung, etc. Halofuginone was injected intraperitoneally, added to the foodstuff or applied locally. 5. Halofuginone decreased skin collagen in a chronic graft-versus-host disease patient. 6. The ability of extremely low concentrations of halofuginone to inhibit collagen alpha 1(I) synthesis specifically and transiently at the transcriptional level suggests that this material fulfills the criteria for a successful and effective anti-fibrotic therapy.

Topics: Animals; Collagen; Fibrosis; Humans; Liver Cirrhosis; Piperidines; Postoperative Complications; Protein Synthesis Inhibitors; Pulmonary Fibrosis; Quinazolines; Quinazolinones; Skin; Tissue Adhesions

All horses undergoing coeliotomy for an acute abdominal crisis are at risk of developing ileus and should receive therapy aimed at promoting gastrointestinal function by restoring fluid and electrolyte balance. Adequate analgesia and prevention against peritonitis, bacteraemia and endotoxaemia should be provided. Horses that at the time of surgery have a strangulating or non-strangulating small intestinal obstruction should be considered to be at greater risk of developing a persistent ileus that is refractory to treatment than those horses with lesions involving the large intestine. In horses considered to be at greater risk of developing a persistent ileus, the use of prokinetic agents should be considered. Agents that may be used to improve gastrointestinal motility include adrenergic receptor antagonists, cholinergic agonists, benzamides, dopamine antagonists, macrolide antimicrobials, opiate receptor agonists and antagonists, somatostatin analogues and local anaesthetics. There are limited studies into the use of these agents in the horse. Until further research provides more information on motility disorders following intestinal surgery and the efficacy of prokinetic agents in this species, only selective use of some of these drugs can be recommended.

Topics: Adrenergic Antagonists; Anesthetics, Local; Animals; Anti-Bacterial Agents; Cholinergic Agonists; Cisapride; Dopamine Antagonists; Electric Stimulation; Gastrointestinal Agents; Gastrointestinal Motility; Horse Diseases; Horses; Intestinal Obstruction; Macrolides; Metoclopramide; Narcotic Antagonists; Narcotics; Octreotide; Piperidines; Postoperative Complications

Topics: Abdomen; Cisapride; Dopamine Antagonists; Erythromycin; Gastric Emptying; Gastrointestinal Agents; Humans; Intestinal Obstruction; Intubation, Gastrointestinal; Metoclopramide; Parasympathomimetics; Piperidines; Postoperative Complications; Protein Synthesis Inhibitors

In the treatment of gastrointestinal motility disorders 3 prokinetic agents are principally available. They are differentiated from their pharmacological mode of action, their clinical efficacy and tolerability. Metroclopramide is an antidopaminergic benzamide with mainly antiemetic effects and minor prokinetic efficacy in the GI-Tract. Domperidon is a pure dopaminantagonist. It accelerates gastric emptying but has less effect on bowel motility. Cisapride stimulates indirect the secretion of acetylcholine and acts via 5 HT-receptors selective at the plexus myentericus. These pharmacological differences have clinical relevance: metoclopramide and domperidon could not consistently prove efficacy in functional dyspepsia and GORD. In addition the data in other indications are rare. Only cisapride has shown significant responder rates in controlled studies in the treatment of gastrointestinal motility disorders particularly in long term treatment. As concerns tolerability cisapride presents a progress by its selective mode of action in contrast to the agents crossing the blood-brain-barrier.

Topics: Adult; Antiemetics; Child; Cisapride; Clinical Trials as Topic; Domperidone; Dopamine Antagonists; Dyspepsia; Gastric Emptying; Gastroesophageal Reflux; Gastrointestinal Motility; Humans; Metoclopramide; Piperidines; Postoperative Complications; Serotonin Receptor Agonists; Treatment Outcome

Disorders of gastric emptying are observed in many clinical situations. Their symptoms are diverse and correlate poorly with the objective abnormalities of gastric emptying. The underlying mechanism consists of abnormalities of basal electrical rhythm, fundic compliance, post-prandial antral motricity and, above all, antro-pyloro-duodenal co-ordination, associated to varying degrees. Among possible causes 3 clinical situations predominate: diabetes mellitus, functional gastrointestinal disorders (idiopathic dyspepsia) and sequelae of gastric surgery where retention of solids and accelerated evacuation of liquids may coexist in the same patient. Treatment of gastric incontinence rests, almost exclusively, on dietary measures, but several drugs, such as metoclopramide, domperidone and cisapride, are available to treat gastric stasis. Other compounds, notably motilin agonists (erythromycin and its derivatives) are currently being evaluated and will reinforce this therapeutic armentarium in a not too distant future.

Topics: Cisapride; Diabetes Complications; Domperidone; Dyspepsia; Gastric Emptying; Gastroesophageal Reflux; Humans; Metoclopramide; Piperidines; Postoperative Complications; Serotonin Antagonists; Stomach Diseases; Stomach Ulcer

Five studies have shown that cisapride increased the antral motility index in the interdigestive and digestive states and three of these studies showed a stimulation of duodenal motility index and increased antroduodenal coordination. In normal volunteers and in patients with dyspepsia (223 subjects), both solid and liquid emptying is speeded by cisapride compared with placebo, and cisapride was as good as, or better than, metoclopramide at the same dosage. In studies in 37 diabetics with gastroparesis, both solid and liquid emptying were speeded and returned to normal, and cisapride was superior to metoclopramide. Solid emptying was speeded in patients with anorexia nervosa, chronic pseudo-obstruction and systemic sclerosis and the delay in gastric emptying induced by both morphine and dopamine was reversed. The effect of cisapride on bile reflux is still uncertain. Eight different methods of measuring gastric emptying were employed in these studies and they all gave similar results; the doses ranged from 2.5-10 mg i.v., and up to 20 mg orally.

Topics: Cisapride; Dyspepsia; Gastric Emptying; Gastrointestinal Motility; Humans; Piperidines; Postoperative Complications; Serotonin Antagonists

The present study aimed to assess the prevalence of symptoms of anxiety and depression among health professionals in the three most affected regions in Cameroon.. The study was a descriptive cross-sectional type. Participants were health care professionals working in the three chosen regions of Cameroon. The non_probability convinient sample technique and that of the snowball were valued via a web questionnaire. The non-exhaustive sample size was 292. The diagnosis of anxiety and depression was made by the HAD (Hospital Anxiety and Depression scale).. Les auteurs rapportent que le secteur médical est classé à un plus grand risque de contracter le COVID-19 et de le propager potentiellement à d’autres. Le nombre sans cesse croissant de cas confirmés et suspects, la pression dans les soins, l’épuisement des équipements de protection individuelle et le manque de médicaments spécifiques peuvent contribuer à un vécu anxio-dépressif significatif. La présente étude s’est donnée pour ambition d’évaluer la prévalence des symptômes de l’anxiété et de la dépression chez les professionnels de santé dans les trois Régions les plus concernées au Cameroun.. Le choix des trois Régions du Cameroun se justifie non seulement par le fait qu’elles totalisent 95,8 % des cas de coronavirus au pays depuis le début de la pandémie, mais aussi parce qu’elles disposent de plus de la moitié des personnels de santé (56 %). Il s’agit d’une étude transversale, descriptive et analytique. Les participants sont des professionnels de la santé en service dans les Régions du Centre, Littoral et de l’Ouest du Cameroun. La méthode d’échantillonnage non probabiliste de convenance couplée à celle de boule de neige via un web questionnaire a été adoptée. La collecte des données a duré du 5 au 19 avril 2020, intervalle de temps après lequel on n’avait plus eu de répondants. À la fin de cette période, la taille de l’échantillon non exhaustive était de 292 professionnels. Le diagnostic de l’état anxio-dépressive était posé via l’échelle de HAD (Hospital Anxiety and Depression scale). Dans le HAD, chaque réponse cotée évalue de manière semi-quantitative l’intensité du symptôme au cours de la semaine écoulée. Un score total est obtenu ainsi que des scores aux deux sous-échelles : le score maximal est de 42 pour l’échelle globale et de 21 pour chacune des sous-échelles. Le coefficient alpha de Cronbach est de 0,70 pour la dépression et de 0,74 pour l’anxiété. Certains auteurs après plusieurs travaux ont proposé qu’une note inférieure ou égale à 7 indique une absence d’anxiété ou de dépression ; celle comprise entre 8 et 10 suggère une anxiété ou une dépression faible à bénigne ; entre 11 et 14, pour une anxiété ou une dépression modérée ; enfin, une note comprise entre 15 et 21 est révélatrice d’une anxiété sévère. Le logiciel Excel 2013 et Epi Info version 7.2.2.6 ont été utilisés pour les traitements statistiques. Les liens entre les variables ont été considérées significatifs pour une valeur de. L’amélioration des conditions de travail et notamment la fourniture d’équipement de protection, la mise en place des cellules spéciales d’écoute pour le personnel de santé pourraient être proposées.. Taken together with satisfactory selectivity index (SI) values, the acetone and methanol extracts of. During a mean follow-up period of 25.6 ± 13.9 months, 38 (18.4%) VAs and 78 (37.7%) end-stage events occurred. Big ET-1 was positively correlated with NYHA class (. In primary prevention ICD indication patients, plasma big ET-1 levels can predict VAs and end-stage events and may facilitate ICD-implantation risk stratification.. Beyond age, cognitive impairment was associated with prior MI/stroke, higher hsCRP, statin use, less education, lower eGFR, BMI and LVEF.. These data demonstrate that even a short period of detraining is harmful for elderly women who regularly participate in a program of strength training, since it impairs physical performance, insulin sensitivity and cholesterol metabolism.. Exposure to PM. Respiratory sinus arrhythmia is reduced after PVI in patients with paroxysmal AF. Our findings suggest that this is related to a decrease in cardiac vagal tone. Whether and how this affects the clinical outcome including exercise capacity need to be determined.. BDNF and leptin were not associated with weight. We found that miR-214-5p exerted a protective role in I/R injured cardiac cells by direct targeting FASLG. The results indicated that the MGO injection reduced all CCl. The hepatoprotective effects of MGO might be due to histopathological suppression and inflammation inhibition in the liver.. OVEO showed moderate antifungal activity, whereas its main components carvacrol and thymol have great application potential as natural fungicides or lead compounds for commercial fungicides in preventing and controlling plant diseases caused by. PF trajectories were mainly related to income, pregestational BMI, birth weight, hospitalisation due to respiratory diseases in childhood, participant's BMI, report of wheezing, medical diagnosis and family history of asthma, gestational exposure to tobacco and current smoking status in adolescence and young adult age.. In chronic pain patients on opioids, administration of certain benzodiazepine sedatives induced a mild respiratory depression but paradoxically reduced sleep apnoea risk and severity by increasing the respiratory arousal threshold.. Quantitative measurements of sensory disturbances using the PainVision. The serum level of 20S-proteasome may be a useful marker for disease activity in AAV.. The electrophysiological data and MD simulations collectively suggest a crucial role of the interactions between the HA helix and S4-S5 linker in the apparent Ca. Invited for the cover of this issue are Vanesa Fernández-Moreira, Nils Metzler-Nolte, M. Concepción Gimeno and co-workers at Universidad de Zaragoza and Ruhr-Universität Bochum. The image depicts the reported bimetallic bioconjugates as planes directing the gold fragment towards the target (lysosomes). Read the full text of the article at 10.1002/chem.202002067.. The optimal CRT pacing configuration changes during dobutamine infusion while LV and RV activation timing does not. Further studies investigating the usefulness of automated dynamic changes to CRT pacing configuration according to physiologic condition may be warranted.

Topics: 3' Untranslated Regions; 5'-Nucleotidase; A549 Cells; Accidental Falls; Acetylcholinesterase; Acrylic Resins; Actinobacillus; Acute Disease; Acute Kidney Injury; Adaptor Proteins, Signal Transducing; Adenosine; Adenosine Triphosphate; Administration, Inhalation; Administration, Oral; Adolescent; Adult; Advance Care Planning; Africa, Northern; Age Factors; Aged; Aged, 80 and over; Air Pollutants; Air Pollution; Air Pollution, Indoor; Albendazole; Aluminum Oxide; Anastomosis, Surgical; Ancylostoma; Ancylostomiasis; Androstadienes; Angiogenesis Inhibitors; Angiotensin II; Animals; Anti-Bacterial Agents; Anti-Infective Agents; Antibodies, Bispecific; Antibodies, Viral; Anticoagulants; Antihypertensive Agents; Antinematodal Agents; Antineoplastic Agents; Antineoplastic Agents, Immunological; Antineoplastic Combined Chemotherapy Protocols; Antioxidants; Antiporters; Antiviral Agents; Apoptosis; Aptamers, Nucleotide; Aromatase Inhibitors; Asian People; Astrocytes; Atrial Fibrillation; Auditory Threshold; Aurora Kinase B; Australia; Autophagy; Autophagy-Related Protein 5; Autotrophic Processes; Bacillus cereus; Bacillus thuringiensis; Bacterial Proteins; Beclin-1; Belgium; Benzene; Benzene Derivatives; Benzhydryl Compounds; beta Catenin; beta-Arrestin 2; Biliary Tract Diseases; Biofilms; Biofuels; Biomarkers; Biomarkers, Tumor; Biomass; Biomechanical Phenomena; Bioreactors; Biosensing Techniques; Biosynthetic Pathways; Bismuth; Blood Platelets; Bone and Bones; Bone Regeneration; Bortezomib; Botulinum Toxins, Type A; Brain; Brain Injuries; Brain Ischemia; Brain Neoplasms; Breast Neoplasms; Breath Tests; Bronchodilator Agents; Calcium Phosphates; Cannabis; Carbon Dioxide; Carbon Isotopes; Carcinogenesis; Carcinoma, Hepatocellular; Carcinoma, Non-Small-Cell Lung; Carcinoma, Squamous Cell; Cardiac Resynchronization Therapy; Cardiac Resynchronization Therapy Devices; Cardiomyopathies; Cardiovascular Diseases; Cariostatic Agents; Case Managers; Case-Control Studies; Catalysis; Cation Transport Proteins; CD8-Positive T-Lymphocytes; Cecropia Plant; Cell Adhesion; Cell Count; Cell Differentiation; Cell Division; Cell Line; Cell Line, Tumor; Cell Membrane; Cell Movement; Cell Proliferation; Cell Self Renewal; Cell Survival; Cells, Cultured; Cellular Reprogramming; Cellulose; Charcoal; Chemical and Drug Induced Liver Injury; Chemical Phenomena; Chemokines; Chemoradiotherapy; Chemoreceptor Cells; Child; Child Abuse; Child, Preschool; China; Chlorogenic Acid; Chloroquine; Chromatography, Gas; Chronic Disease; Clinical Competence; Coated Materials, Biocompatible; Cochlea; Cohort Studies; Color; Comorbidity; Computer Simulation; Computer-Aided Design; Contraception; Contraceptive Agents, Female; Contrast Media; COP-Coated Vesicles; Coronavirus Infections; Cost of Illness; Coturnix; COVID-19; Creatinine; Cross-Over Studies; Cross-Sectional Studies; Culex; Curriculum; Cyclic N-Oxides; Cytokines; Cytoplasm; Cytotoxicity, Immunologic; Cytotoxins; Databases, Factual; Deep Learning; Delivery, Obstetric; Denitrification; Dental Caries; Denture, Complete; Dexamethasone; Diabetes Complications; Diabetes Mellitus; Diabetes Mellitus, Experimental; Diabetes Mellitus, Type 2; Dielectric Spectroscopy; Diet, High-Fat; Dietary Fiber; Disease Models, Animal; Disease Progression; DNA; DNA Copy Number Variations; DNA, Mitochondrial; Dog Diseases; Dogs; Dopaminergic Neurons; Double-Blind Method; Down-Regulation; Doxorubicin; Drug Carriers; Drug Design; Drug Interactions; Drug Resistance, Bacterial; Drug Resistance, Neoplasm; Drug-Related Side Effects and Adverse Reactions; Drugs, Chinese Herbal; Dry Powder Inhalers; Dust; E2F1 Transcription Factor; Ecosystem; Education, Nursing; Education, Nursing, Baccalaureate; Electric Impedance; Electricity; Electrocardiography; Electrochemical Techniques; Electrochemistry; Electrodes; Electrophoresis, Polyacrylamide Gel; Endoplasmic Reticulum; Endothelial Cells; Environmental Monitoring; Enzyme Inhibitors; Epithelial Cells; Epithelial-Mesenchymal Transition; Esophageal Neoplasms; Esophageal Squamous Cell Carcinoma; Estrogen Receptor Modulators; Europe; Evoked Potentials, Auditory, Brain Stem; Exosomes; Feasibility Studies; Female; Ferricyanides; Ferrocyanides; Fibrinogen; Finite Element Analysis; Fistula; Fluorescent Dyes; Fluorides, Topical; Fluorodeoxyglucose F18; Fluticasone; Follow-Up Studies; Food Contamination; Food Microbiology; Foods, Specialized; Forensic Medicine; Frail Elderly; France; Free Radicals; Fresh Water; Fungi; Fungicides, Industrial; Galactosamine; Gastrointestinal Neoplasms; Gene Expression Profiling; Gene Expression Regulation, Neoplastic; Gene Frequency; Genetic Predisposition to Disease; Genotype; Gingival Hemorrhage; Glioblastoma; Glioma; Glomerular Filtration Rate; Glomerulosclerosis, Focal Segmental; Glucose; Glucose Transport Proteins, Facilitative; Glucosides; Glutamine; Glycolysis; Gold; GPI-Linked Proteins; Gram-Negative Bacteria; Gram-Positive Bacteria; Graphite; Haplotypes; HCT116 Cells; Healthy Volunteers; Hearing Loss; Heart Failure; Hedgehog Proteins; HEK293 Cells; HeLa Cells; Hemodynamics; Hemorrhage; Hepatocytes; Hippo Signaling Pathway; Histone Deacetylases; Homeostasis; Hospital Mortality; Hospitalization; Humans; Hydantoins; Hydrazines; Hydrogen Peroxide; Hydrogen-Ion Concentration; Hydrophobic and Hydrophilic Interactions; Hydroxylamines; Hypoglycemic Agents; Immunity, Innate; Immunoglobulin G; Immunohistochemistry; Immunologic Factors; Immunomodulation; Immunophenotyping; Immunotherapy; Incidence; Indazoles; Indonesia; Infant; Infant, Newborn; Infarction, Middle Cerebral Artery; Inflammation; Injections, Intramuscular; Insecticides; Insulin-Like Growth Factor I; Insurance, Health; Intention to Treat Analysis; Interleukin-1 Receptor-Associated Kinases; Interleukin-6; Intrauterine Devices; Intrauterine Devices, Copper; Iron; Ischemia; Jordan; Keratinocytes; Kidney; Kidney Diseases; Kir5.1 Channel; Klebsiella Infections; Klebsiella pneumoniae; Lab-On-A-Chip Devices; Laparoscopy; Lasers; Lasers, Semiconductor; Lenalidomide; Leptin; Lethal Dose 50; Levonorgestrel; Limit of Detection; Lipid Metabolism; Lipid Metabolism Disorders; Lipogenesis; Lipopolysaccharides; Liquid Biopsy; Liver; Liver Abscess, Pyogenic; Liver Cirrhosis; Liver Diseases; Liver Neoplasms; Longevity; Lung Neoplasms; Luteolin; Lymph Nodes; Lymphocyte Activation; Macaca fascicularis; Macrophages; Mad2 Proteins; Magnetic Resonance Imaging; Male; Mammary Glands, Human; Manganese; Manganese Compounds; MAP Kinase Signaling System; Materials Testing; Maternal Health Services; MCF-7 Cells; Medicaid; Medicine, Chinese Traditional; Melanoma; Membrane Proteins; Mental Health; Mercury; Metal Nanoparticles; Metals, Heavy; Metformin; Methionine Adenosyltransferase; Mice; Mice, Inbred BALB C; Mice, Inbred C3H; Mice, Inbred C57BL; Mice, Inbred CBA; Mice, Knockout; Mice, Nude; Microalgae; Microbial Sensitivity Tests; Microglia; MicroRNAs; Microscopy, Atomic Force; Microscopy, Electron, Scanning; Middle Aged; Mitochondria; Mitochondrial Proteins; Mitral Valve; Mitral Valve Insufficiency; Models, Anatomic; Molecular Structure; Molybdenum; Monocarboxylic Acid Transporters; Moths; MPTP Poisoning; Multigene Family; Multiparametric Magnetic Resonance Imaging; Multiple Myeloma; Muscle, Skeletal; Mutagens; Mutation; Myeloid Cells; Nanocomposites; Nanofibers; Nanomedicine; Nanoparticles; Nanowires; Neoadjuvant Therapy; Neomycin; Neoplasm Grading; Neoplasm Recurrence, Local; Neoplasms; Neoplastic Stem Cells; Neostriatum; Neovascularization, Pathologic; Netherlands; Neuromuscular Agents; Neurons; NF-E2-Related Factor 2; NF-kappa B; Nickel; Nitrogen Oxides; Non-alcoholic Fatty Liver Disease; Nucleosides; Nucleotidyltransferases; Nutritional Status; Obesity, Morbid; Ofloxacin; Oils, Volatile; Oligopeptides; Oncogene Protein v-akt; Optical Imaging; Organic Cation Transport Proteins; Organophosphonates; Osteoarthritis; Osteoarthritis, Hip; Osteoarthritis, Knee; Osteoblasts; Osteogenesis; Oxidation-Reduction; Oxidative Stress; Oxides; Oxygen Isotopes; Pancreas; Pancreaticoduodenectomy; Pandemics; Particle Size; Particulate Matter; Patient Acceptance of Health Care; Patient Compliance; PC-3 Cells; Peptide Fragments; Peptides; Periodontal Attachment Loss; Periodontal Index; Periodontal Pocket; Periodontitis; Peroxides; Peru; Pest Control, Biological; Phosphatidylinositol 3-Kinase; Phosphatidylinositol 3-Kinases; Phylogeny; Pilot Projects; Piperidines; Plant Bark; Plant Extracts; Plant Leaves; Plasmids; Platelet Function Tests; Pneumonia, Viral; Podocytes; Poly (ADP-Ribose) Polymerase-1; Poly(ADP-ribose) Polymerase Inhibitors; Polyethylene Terephthalates; Polymers; Polymorphism, Single Nucleotide; Porosity; Portugal; Positron-Emission Tomography; Postoperative Complications; Postural Balance; Potassium Channels, Inwardly Rectifying; Povidone; Powders; Precancerous Conditions; Precision Medicine; Predictive Value of Tests; Pregnancy; Prenatal Care; Prognosis; Promoter Regions, Genetic; Prospective Studies; Prostatectomy; Prostatic Neoplasms; Proteasome Inhibitors; Protective Agents; Protein Binding; Protein Kinase Inhibitors; Protein Serine-Threonine Kinases; Protein Transport; Proto-Oncogene Proteins B-raf; Proto-Oncogene Proteins c-akt; Psychiatric Nursing; PTEN Phosphohydrolase; Pulmonary Embolism; Pyrimethamine; Radiopharmaceuticals; Rats; Rats, Sprague-Dawley; Rats, Wistar; Reactive Oxygen Species; Receptor, ErbB-2; Receptor, IGF Type 1; Receptors, Estrogen; Receptors, G-Protein-Coupled; Recombinational DNA Repair; Recovery of Function; Regional Blood Flow; Renal Dialysis; Renin; Renin-Angiotensin System; Reperfusion Injury; Reproducibility of Results; Republic of Korea; Respiratory Distress Syndrome; Retrospective Studies; Rhodamines; Risk Assessment; Risk Factors; RNA, Long Noncoding; RNA, Messenger; Running; Saccharomyces cerevisiae; Saccharomyces cerevisiae Proteins; Salinity; Salmeterol Xinafoate; Sarcoma; Seasons; Shoulder Injuries; Signal Transduction; Silicon Dioxide; Silver; Sirtuin 1; Sirtuins; Skull Fractures; Social Determinants of Health; Sodium; Sodium Fluoride; Sodium Potassium Chloride Symporter Inhibitors; Sodium-Glucose Transporter 2 Inhibitors; Soil; Soil Pollutants; Spain; Spectrophotometry; Spectroscopy, Fourier Transform Infrared; Staphylococcal Protein A; Staphylococcus aureus; Stem Cells; Stereoisomerism; Stomach Neoplasms; Streptomyces; Strontium; Structure-Activity Relationship; Students, Nursing; Substance-Related Disorders; Succinic Acid; Sulfur; Surface Properties; Survival Rate; Survivin; Symporters; T-Lymphocytes; Temozolomide; Tensile Strength; Thiazoles; Thiobacillus; Thiohydantoins; Thiourea; Thrombectomy; Time Factors; Titanium; Tobacco Mosaic Virus; Tobacco Use Disorder; Toll-Like Receptor 4; Toluene; Tomography, X-Ray Computed; TOR Serine-Threonine Kinases; Toxicity Tests, Acute; Toxicity Tests, Subacute; Transcriptional Activation; Treatment Outcome; Troponin I; Tumor Cells, Cultured; Tumor Escape; Tumor Hypoxia; Tumor Microenvironment; Tumor Necrosis Factor Inhibitors; Tumor Necrosis Factor-alpha; Tyrosine; Ubiquitin-Protein Ligases; Ubiquitination; Ultrasonic Waves; United Kingdom; United States; United States Department of Veterans Affairs; Up-Regulation; Urea; Uric Acid; Urinary Bladder Neoplasms; Urinary Bladder, Neurogenic; Urine; Urodynamics; User-Computer Interface; Vemurafenib; Verbenaceae; Veterans; Veterans Health; Viral Load; Virtual Reality; Vitiligo; Water Pollutants, Chemical; Wildfires; Wnt Signaling Pathway; Wound Healing; X-Ray Diffraction; Xenograft Model Antitumor Assays; Xylenes; Young Adult; Zinc; Zinc Oxide; Zinc Sulfate; Zoonoses

The number of published papers that compare the incidence of sufentanil- and remifentanil-related postoperative \ shivering is insufficient. We investigated the incidence of postoperative shivering after total intravenous anesthesia with either sufentanil \ or remifentanil in patients who underwent elective surgery.. Eighty-three patients, with a physical status classified as American Society of Anesthesiologists I or II, were \ randomly allocated to either the remifentanil–propofol (RP group, n = 40) or sufentanil–propofol (SP group, n = 43) group. The primary \ endpoint was the incidence of postoperative shivering 1 h after entering the recovery room. The secondary endpoints were intraoperative \ core temperatures of the esophagus and tympanic membrane at 30 min after the induction of anesthesia and at the end of surgery.. The overall postoperative shivering incidence was not significantly different between the RP (15%) and SP (11.6%) groups \ (P = 0.651). The intraoperative temperatures and their changes (the temperature 30 min after induction minus that after surgery) as \ measured at the distal esophagus and tympanic membrane were not significantly different between the RP and SP groups.. The incidence of postoperative shivering related to sufentanil was less than that related to remifentanil, with no significant \ differences in the intraoperative core temperatures.

Topics: Aged; Analgesics, Opioid; Anesthesia, General; Anesthetics, Intravenous; Body Temperature; Double-Blind Method; Esophagus; Female; Humans; Male; Middle Aged; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Republic of Korea; Shivering; Sufentanil; Tympanic Membrane

Post-operative cognitive dysfunction (POCD) is frequent in patients older than 60 years undergoing major non-cardiac surgery, and increases both morbidity and mortality. Anesthetic drugs may exert neurotoxic effects and contribute to the genesis of POCD. The hypothesis of the POCD-ELA trial was that closed-loop target-controlled infusion of propofol and remifentanil could reduce the occurrence of POCD by decreasing the risk of excessive depth of anesthesia and the dose of anesthetic drugs.. We designed a single-center, single-blind, randomized, controlled, parallel trial and aim to include 204 patients aged >60 years undergoing elective major non-cardiac surgery. Patients will be randomized to receive closed-loop versus manual target-controlled infusion of propofol and remifentanil guided by bispectral index monitoring. Cognitive assessment will be performed the day before surgery (baseline) and within 72 hours after surgery, using a battery of validated neuropsychological tests. The primary outcome is the incidence of POCD within 72 hours after surgery. POCD is defined as a Z-score value > 1.96 for at least 2 different tests or a Z-score composite value >1.96. The calculation of the Z-score is based on data from an age-matched control population who did not undergo surgery or general anesthesia.. This study was approved by the Ethics Committee (Comité de Protection des Personnes Est-II) and authorized by the French Health Products Agency (Agence Nationale de Sécurité des Médicaments, Saint-Denis, France). The University Hospital of Besancon is the trial sponsor and the holder of all data and publication rights. Results of the study will be submitted for publication in a peer-review international medical journal and for presentation in abstract (oral or poster) in international peer-reviewed congresses.. The trial is registered with ClinicalTrials.gov (Identifier: NCT02841423, principal investigator: Prof Emmanuel Samain, date of registration: July 22, 2016). Last amendment of protocol: version 8.0 April 2018.

Topics: Aged; Aged, 80 and over; Anesthesia, Closed-Circuit; Anesthetics, Intravenous; Cognitive Dysfunction; Elective Surgical Procedures; Female; Humans; Male; Middle Aged; Neuropsychological Tests; Piperidines; Postoperative Complications; Propofol; Remifentanil; Research Design; Single-Blind Method

Electro-acupuncture is a burgeoning treatment using the needle inserting into the body acupoints and the low-frequency pulse current being electrified by an electric acupuncture machine. This study was designed to evaluate the effects of preconditioning of electro-acupuncture on postoperative cognitive dysfunction in elderly.Ninety patients scheduled spine surgery were randomly assigned into 2 groups using a random number table: control group (group C) and electro-acupuncture group (group EA). In group EA, electro-acupuncture was applied on Baihui, Dazhui, and Zusanli acupoints 30 minutes before anesthesia. At 0 minute before treatment of electro-acupuncture, 1 hour after skin incision and surgery completed (T1-3), blood samples were taken for detection of interleukin (IL)-6, IL-10, and S100β by enzyme-linked immunosorbent assay. The total dose of remifentanil and propofol during surgery were recorded. Mini-Mental State Examination was applied to evaluate the cognitive function of patients at 1 day before surgery and 7th and 30th day after surgery.The results showed that compared with group C, score of MMSE increased after surgery, the serum concentration of IL-6, IL-10, and S100β decreased at 1 hour after skin incision, and surgery completed in group EA. Moreover, the total dose of remifentanil and propofol reduced during surgery in group EA.The present study suggests that preconditioning of electro-acupuncture could improve the postoperative cognitive function, and the reduction of inflammatory reaction and brain injury may be involved in the mechanism.

Topics: Aged; Anesthetics, Intravenous; Biomarkers; Cognitive Dysfunction; Electroacupuncture; Female; Humans; Interleukin-10; Interleukin-6; Male; Mental Status Schedule; Operative Time; Orthopedic Procedures; Piperidines; Postoperative Complications; Preoperative Care; Propofol; Remifentanil; S100 Calcium Binding Protein beta Subunit; Spine; Treatment Outcome

Topics: Aconitine; Aged; Analgesics, Opioid; Anesthesia, General; Female; Humans; Hyperalgesia; Male; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Complications; Remifentanil

To determine the end-tidal desflurane concentration required for tracheal extubation in anaesthetised adults.. After hospital Ethics Committee approval, eighteen ASA I-II adult patients (19-65 years of age), who had been scheduled for elective ambulatory surgery were included in the study. Anaesthesia was induced with propofol 2.5mg.kg. It was found that the end-tidal concentration of desflurane was 3.17±0.18% (95% CI: 3%-3.35%) for successful extubation in 50% of adults.. Extubation in patients receiving desflurane may be feasible at 0.62 minimum alveolar concentration.

Topics: Adult; Aged; Airway Extubation; Ambulatory Surgical Procedures; Anesthetics, Inhalation; Breath Tests; Cough; Cross-Over Studies; Desflurane; Female; Hemodynamics; Humans; Isoflurane; Laryngismus; Male; Middle Aged; Neuromuscular Monitoring; Piperidines; Postoperative Complications; Remifentanil; Young Adult

Anesthesia for craniotomies should blunt responses to noxious stimuli, whereas subsequently leaving patients sufficiently alert for early neurological evaluation. The aim was to compare postoperative blood pressure control, pain, and opioid requirement after anesthesia with dexmedetomidine versus remifentanil. We therefore tested 2 primary hypotheses: (1) intraoperative administration of dexmedetomidine provides better control of postoperative blood pressure than remifentanil; and (2) patients given dexmedetomidine have less postoperative pain and use less opioid.. Adults having elective brain tumor excisions under balanced general anesthesia with endotracheal intubation were randomized to an infusion of remifentanil (0.08 to 0.15 μg/kg/min, n=71) or dexmedetomidine (0.2 to 0.7 μg/kg/h, n=68). Patients also received propofol, rocuronium, fentanyl, and sevoflurane. The mean arterial pressure (MAP) and pain were recorded at 15, 30, 45, 60, and 90 postoperative minutes. Outcomes were assessed with joint hypothesis testing, evaluating noninferiority and superiority.. Compared with remifentanil, the use of dexmedetomidine was associated with reduced postoperative MAP (88±12 vs. 98±11 mm Hg), with estimated mean difference (97.5% confidence interval) of -10 (-13, -4) mm Hg, P<0.001, and mean visual analog pain score (2.9±2.6 vs. 5.1±2.4 points), with estimated mean difference of -5 (-10, -3) points, P<0.001, and required less median opioid consumption (5 [0, 10] vs. 10 [7, 15] mg morphine equivalents), with estimated median difference of -5 (-10, -3) mg, P<0.001. Dexmedetomidine was both noninferior and superior to remifentanil in maintaining postoperative hemodynamics and providing improved pain control.. Intraoperative dexmedetomidine better controlled postoperative MAP and provided superior analgesia in patients undergoing craniotomy.

Topics: Analgesia; Craniotomy; Dexmedetomidine; Female; Hemodynamics; Humans; Hypnotics and Sedatives; Male; Middle Aged; Piperidines; Postoperative Complications; Remifentanil

To examine the severity of cough and straining at the time of emergence from anesthesia.. Double-blind randomized, placebo-controlled study.. University-affiliated hospital.. Sixty-two American Society of Anesthesiologists 2 patients undergoing craniotomy and excision of supratentorial cerebral tumors.. Intravenous infusion of remifentanil (REM) at 0.05 μg/kg/min or normal saline (NS) upon termination of the surgical procedure.. Heart rate (HR) and mean arterial pressure (MAP) along with the frequency and severity of cough response (Modified Minogue Scale) to the endotracheal tube were recorded at different time points. The frequency of cough and straining was analyzed with χ(2) tests. HRs and MAP were analyzed by repeated-measures analysis of variance between REM and NS groups.. There was no case of significant cough in the REM group, and all of the patients in the NS group developed some extent of cough varying from mild retching to severe coughing episodes (P < .001). Both the HR and MAPs were consistently lower in the REM group compared to the NS group.. Infusion of REM at the end of craniotomy procedures results in significant reduction of the frequency and severity of coughing and straining. Compared to placebo, REM moderates increases in MAP upon emergence from general anesthesia until the time of extubation.

Topics: Adult; Aged; Analgesics, Opioid; Anesthesia Recovery Period; Arterial Pressure; Cough; Craniotomy; Double-Blind Method; Female; Heart Rate; Hemodynamics; Humans; Infusions, Intravenous; Intubation, Intratracheal; Male; Middle Aged; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil

To compare recovery times and respiratory complications during emergence after deep extubation using either desflurane alone or a lower concentration of desflurane with remifentanil.. Prospective randomized double-blind clinical trial.. Intraoperative.. A total of 62 patients between the ages of 20 and 60 years with American Society of Anesthesiologists class I or II and who underwent low- to intermediate-risk surgery of 2- to 4-hour duration were enrolled.. Randomly assigned either 1.5 minimum alveolar concentration desflurane (group D; n = 31) or 1.0 minimum alveolar concentration of desflurane and 1.0 ng/mL effect-site concentration of remifentanil (group DR; n = 31).. Recovery times, from the time of extubation to the time when the patients could breathe without assistance, were awake enough to maintain the airway independently, and exited the recovery room, as well as respiratory complications were compared between the groups.. Recovery times were significantly reduced in the group DR (P < .001). The incidence of respiratory complications was also lower in group DR than in group D (48% vs 3.8%; P < .001).. The combined use of remifentanil while lowering the concentration of desflurane improves recovery profiles during emergence after deep extubation.

Topics: Adult; Airway Extubation; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Desflurane; Double-Blind Method; Female; Humans; Isoflurane; Male; Middle Aged; Piperidines; Postoperative Complications; Prospective Studies; Pulmonary Alveoli; Remifentanil; Respiration Disorders; Young Adult

A harmful effect of stress hormone secretion during surgery is lipolysis and proteolysis to maintain normal blood glucose levels. A well-titrated general anesthetic improves blood glucose control by suppressing secretion of these stress hormones. The aim of this study was to explore the effect of intraoperative glucose infusion on lipolysis and proteolysis in patients undergoing a general anesthetic consisting of sevoflurane and remifentanil during long (>6 hours) major surgery.. In this prospective, single-blinded, randomized, multicenter trial, 80 patients with an expected duration of anesthesia of >6 hours were allocated to either the glucose group, consisting of 40 patients who were infused with acetated Ringer's solution with glucose (2 mg/kg/min), or the no glucose group, consisting of 40 patients who were infused with the same solution, but without glucose. After oxygenation, general anesthesia was induced with propofol, fentanyl, and rocuronium and was maintained with sevoflurane, oxygen, rocuronium, and remifentanil infusions. The rates of remifentanil infusion were titrated based on systolic arterial blood pressure, maintaining this parameter within 10% of its postanesthesia values. Seventy-four patients completed the study. Urinary 3-methylhistidine/creatinine (3-MH/Cre) ratio, acetoacetic acid, 3-hydroxybutyric acid, blood glucose, insulin, and cortisol were measured 3 times: at anesthesia induction (0 hour) and at 3 and 6 hours after anesthesia induction. Urinary 3-MH/Cre ratio was the primary study outcome.. In the no glucose group, the urinary 3-MH/Cre ratio at 6 hours was increased compared with that at 0 hour (213 [range, 42-1903] vs 124 [18-672] nmol/μmol; the difference in medians, 89; the 95% confidence interval [CI] of the difference, 82-252; P = .0002). Acetoacetic acid and 3-hydroxybutyric acid levels in the no glucose group were greater than those in the glucose group at 6 hours (110 [8-1036] vs 11 [2-238] μmol/L; the difference in medians, 99; the 95% CI of the difference, 92-196; P < .0001 and 481 [15-2783] vs 19 [4-555] μmol/L; the difference in medians, 462; the 95% CI of the difference, 367-675; P < 0.0001, respectively). Blood glucose and insulin levels in the glucose group were greater than those in the no glucose group at 3 hours (146 [103-190] vs 93 [72-124] mg/dL; the difference in medians, 53; the 95% CI of the difference, 47-55; P < .0001 and 9.8 [1.2-25.4] vs 3.2 [0.4-15.0] μU/mL; the difference in medians, 6.5; the 95% CI of the difference, 4.8-6.8; P < .0001) and 6 hours (139 [92-189] vs 87 [68-126] mg/dL; the difference in medians, 52; the 95% CI of the difference, 44-58; P < .0001 and 8.1 [1.2-22.3] vs 3.2 [0.4-10.1] μU/mL; the difference in medians, 4.9; the 95% CI of the difference, 4.0-5.9; P < .0001). Cortisol levels in both groups were similarly within normal levels at 0, 3, and 6 hours.. The study showed that intraoperative glucose infusion suppressed lipolysis and proteolysis in patients anesthetized with remifentanil in combination with sevoflurane during surgery of >6 hours in length.

Topics: Adipose Tissue; Aged; Aged, 80 and over; Anesthetics, General; Blood Glucose; Drug Therapy, Combination; Female; Glucose; Humans; Infusions, Intravenous; Intraoperative Care; Lipolysis; Male; Methyl Ethers; Middle Aged; Muscle Proteins; Piperidines; Postoperative Complications; Prospective Studies; Proteolysis; Remifentanil; Sevoflurane; Single-Blind Method

This study aimed to determine whether muscle relaxants facilitates insertion efficacy of the i-gel supraglottic device (i-gel) by novice doctors in anesthetized patients.. Randomized clinical trial.. Operating room.. Seventy adult patients scheduled for elective surgery under general anesthesia.. Seventy adult patients were assigned to the rocuronium (MR group; 35 patients) or control group (C group; 35 patients). Anesthesia was induced with propofol and remifentanil, and 0.9mgkg(-1) rocuronium was administered in the MR group.. The number of attempts to successful insertion, sealing pressure, and subjective difficulty of insertion were compared between the groups.. The total number of insertion attempts were as follows: one (MR group, 17 cases; C group, 4 cases), two (MR group, 13 cases; C group, 14 cases), three (MR group, 4 cases; C group, 14 cases), and failure (MR group, 1 case; C group, 3 cases), which was significantly different (P<.001). Sealing pressure was significantly higher in the MR group than in the C group (MR group, 22.1±5.4 cmH2O; C group, 18.7±3.2 cmH2O, P<.001). Subjective difficulty of insertion was significantly lower in the MR group than in the C group (C group, 72.4±19.0mm; MR group, 29.4±18.3mm; P<.001).. Our randomized clinical trial suggests that muscle relaxation facilitates i-gel insertion efficacy in anesthetized patients, as assessed by successful insertion rate, sealing pressure, and subjective difficulty of insertion.

Topics: Adult; Aged; Aged, 80 and over; Airway Management; Androstanols; Anesthesia, Intravenous; Anesthesiologists; Anesthetics, Intravenous; Clinical Competence; Female; Hoarseness; Humans; Intubation, Intratracheal; Male; Middle Aged; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Respiration, Artificial; Rocuronium; Young Adult

Postoperative cognitive dysfunction is a frequent complication occurring in geriatric patients. Type of anesthesia and the patient's inflammatory response may contribute to postoperative cognitive dysfunction (POCD). In this prospective randomized double-blinded controlled study we hypothesized that intraoperative remifentanil may reduce immediate and early POCD compared to fentanyl and evaluated if there is a correlation between cognitive status and postoperative inflammatory cytokines level.. Six hundred twenty-two patients older than 60 years undergoing major abdominal surgery were randomly assigned to two groups and treated with different opioids during surgery: continuous infusion of remifentanil or fentanyl boluses. Twenty-five patients per group were randomly selected for the quantitative determination of serum interleukin (IL)-1β, IL-6, and IL-10 to return to the ward and to the seventh postoperative day.. Cognitive status and its correlation with cytokines levels were assessed. The groups were comparable regarding to POCD incidence; however, IL-6 levels were lower the seventh day after surgery for remifentanil group (P= .04). No correlation was found between POCD and cytokine levels.. The use of remifentanil does not reduce POCD.

Topics: Abdomen; Aged; Analgesia; Analgesics, Opioid; Cognition; Female; Fentanyl; Humans; Infusions, Intravenous; Interleukin-10; Interleukin-1beta; Interleukin-6; Male; Middle Aged; Piperidines; Postoperative Complications; Postoperative Period; Prospective Studies; Remifentanil

The choice of anaesthetic technique for patients undergoing joint arthroplasty is debatable. The hypothesis of this study was that general anaesthesia would generate a more favourable recovery profile than spinal anaesthesia.. We randomly allocated 120 patients to either intrathecal bupivacaine or general anaesthesia with target-controlled infusion of remifentanil and propofol. Length of hospital stay assessed as meeting discharge criteria was the primary outcome parameter. Other outcome parameters were actual time of discharge, pain, use of rescue pain medication, blood loss, length of stay in the post-operative care unit, dizziness, post-operative nausea, need of urinary catheterisation and patient satisfaction.. General anaesthesia resulted in slightly reduced length of hospital stay (26 vs. 30 h, P = 0.004), less nausea (P = 0.043) and dizziness (P < 0.001). General anaesthesia patients had higher pain scores during the first two post-operative hours (P < 0.001) but lower after 6 h compared with the spinal anaesthesia group (P < 0.01 and P < 0.05). General anaesthesia patients had better orthostatic function compared with spinal anaesthesia patients (P = 0.008). Patients in the spinal anaesthesia group fulfilled the discharge criteria from the post-operative care unit earlier compared with the general anaesthesia patients (P = 0.004). General anaesthesia patients requested a change in the method of anaesthesia for a subsequent operation less often than the spinal anaesthesia patients (5 vs. 13, P = 0.022).. General anaesthesia resulted in a more favourable recovery profile compared with spinal anaesthesia.

Topics: Aged; Anesthesia, General; Anesthesia, Intravenous; Anesthesia, Spinal; Anesthetics, Intravenous; Anesthetics, Local; Arthroplasty, Replacement, Hip; Bupivacaine; Female; Humans; Length of Stay; Male; Patient Satisfaction; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil

This randomized, controlled, double-blind study was designed to determine the optimal dose of remifentanil for preventing complications associated with the removal of a laryngeal mask airway (LMA) without delaying emergence.. This study randomly assigned 128 patients to remifentanil effect-site concentrations (Ce) of 0 ng/mL (group R0), 0.5 ng/mL (group R0.5), 1.0 ng/mL (group R1.0), and 1.5 ng/mL (group R1.5) during emergence. The emergence and recovery profiles were recorded. Adverse events such as coughing, airway obstruction, breath-holding, agitation, desaturation, nausea, and vomiting were also evaluated.. The number of patients with respiratory complications such as coughing and breath-holding was significantly lower in the R1.0 and R1.5 groups than in the R0 group (p<0.05). Emergence agitation also decreased in the R1.0 and R1.5 groups (p<0.0083). The time to LMA removal was significantly longer in the R1.5 group than in the other groups (p<0.05).. Maintaining a remifentanil Ce of 1.0 ng/mL during emergence may suppress adverse events such as coughing, breath-holding, and agitation following the removal of LMA without delayed awakening.

Topics: Adult; Airway Management; Anesthesia Recovery Period; Anesthetics, Intravenous; Cough; Device Removal; Dose-Response Relationship, Drug; Double-Blind Method; Female; Humans; Infusions, Intravenous; Laryngeal Masks; Male; Middle Aged; Piperidines; Postoperative Complications; Psychomotor Agitation; Remifentanil; Vomiting

We have investigated the effects of ketamine-based and remifentanil-based anesthetic protocol on perioperative serum cystatin-C levels, and creatinine and/or cystatin-C-based eGFR equations in terms of acute kidney injury in coronary artery bypass graft (CABG) surgery. Using a simple randomization method (coin tossing), patients were divided into the two groups and not-blinded to the anesthetist. Remifentanil-midazolam-propofol or ketamine-midazolam-propofol-based anesthetic regimen was chosen. Different eGFR formulas using creatinine (MDRD, CKD-EPI, Cockrauft Gault); cystatin-C (eGFR1, eGFR2) or a combination of creatinine and cystatin-C (eGFR 3) were used to calculate estimated glomerular filtration rates (eGFRs). High-sensitive troponin T was used to determine if ketamine use in coronary surgery contributed to myocardial cell damage. Thirty-seven patients were included in the study (remifentanil group = 19, ketamine Group = 18). Urea, creatinine, cystatin-C levels were comparable between the groups in all the measurement times and also postoperative day 2 samples showed statistically higher results compared to baseline (p < 0.001). Effects of ketamine and remifentanil on renal functions were found similar. Creatinine and cystatin-C-based eGFR equations resulted similar in our study. Reversible stage 1 acute kidney injury (AKI) was observed on postoperative day 2 in seven patients from the remifentanil group and six patients from the ketamine group. Hs-troponin T was found to be higher in postoperative day 1 samples; there were no significant difference between the groups. Our results indicated that patients who have normal renal functions undergoing on-pump coronary bypass surgery, effects of ketamine and remifentanil on renal functions in terms of AKI were found to be similar.

Topics: Acute Kidney Injury; Aged; Anesthetics; Coronary Artery Bypass; Creatinine; Cystatin C; Female; Glomerular Filtration Rate; Humans; Ketamine; Male; Middle Aged; Piperidines; Postoperative Complications; Remifentanil; Troponin T

Postoperative cognitive dysfunction (POCD) is caused by many factors. This work was conducted to investigate the effect of different depths of anesthesia during combined intravenous-inhalational anesthesia on postoperative cognitive function in young and middle-aged laparoscopic patients.. A total of 192 patients scheduled for gynecologic laparoscopic operations were randomly divided into three groups. Anesthesia was maintained with inhalation of sevoflurane and infusion of remifentanil, which was adjusted to maintain bispectral index (BIS) at 30 < BIS ≤ 40 in Group I, 40 < BIS ≤ 50 in Group II and 50 < BIS ≤ 60 in Group III. The Mini-Mental State Examination (MMSE) and Trail-Making Test (TMT) were used to assess cognitive function on the day before anesthesia and the day after surgery.. There were no significant differences in age, body mass index, educational level and surgery time. On the day before anesthesia, the average MMSE scores and TMT completion times in the three groups were not significantly different. On the day after surgery, Group II had a significantly higher average MMSE score (29.00 ± 0.89) than Group I (28.36 ± 1.42, p = 0.010) and Group III (28.45 ± 1.27, p = 0.035) and lower TMT completion time (33.68 ± 10.34) than Group I (39.45 ± 13.99, p = 0.027) and Group III (39.50 ± 12.50, p = 0.026).. These results indicated that the depth of anesthesia, 40 < BIS ≤ 50, under combined intravenous-inhalational anesthesia yielded milder influence on postoperative cognitive function in young and middle-aged laparoscopic patients.

Topics: Adult; Anesthesia; Anesthetics, Inhalation; Cognition; Double-Blind Method; Female; Gynecologic Surgical Procedures; Humans; Laparoscopy; Methyl Ethers; Middle Aged; Neuropsychological Tests; Piperidines; Postoperative Complications; Postoperative Period; Remifentanil; Sevoflurane; Young Adult

Extracorporeal Shock Wave Lithotripsy is usually performed in day surgery setting, consequently people who undergo to this procedure need a safe and fast recovery. Conscious sedation with remifentanil can relieve from pain and keep patients in touch with anaesthesiologists. Few publications tell about infusion rates administered to perform this procedure7. The aim of this study is to assess which is the most appropriate infusion rate.. Patients were randomly assigned to two groups. Two different infusion rates were compared: 0,05 mcg/kg/min, GROUP A (N.=114), vs. 0.1 µg/kg/min, GROUP B (N.=114). Patients' vital signs, additional analgesic requests, PONV (postoperative nausea and vomiting) and other side effects were registered. The deepness of sedation and patient's satisfaction were evaluated referring to Obsever's Assessment of Alertness and Sedation scale (O/ASS) and using a Likert's scale respectively. Pain intensity was assessed with a 11-points VAS (visual analogue scale). Differences between groups were analyzed using Student t test for independent variables. The χ2 test was used to analyze categorical variables.. The study enrolled 228 patients and assigned them to two groups (N.=114). No significant differences were found regarding Likert's scale values (P=0.20), additional analgesic request (P=0.30) and mean VAS values (P>0.05) between the two groups. The difference between the two groups about PONV, hypotension, oxygen desaturation and respiratory depression was statistically significant (P<0.05), as a matter of fact in group A these side effects occurred less frequently. The fifth degree of O/ASS was estimated in about 1.61±0.19 min and 2.987±0.20 min in group A and in group B respectively (P<0.05).. According with previous results remifentanil at the infusion rate of 0.05 µg/kg/min provides an effective analgesia, causing a lower incidence of side effect than 0.1 µg/kg/min, granting a fast and safe recovery.

Topics: Analgesia; Anesthesia, Intravenous; Anesthetics, Intravenous; Conscious Sedation; Dose-Response Relationship, Drug; Double-Blind Method; Female; Hemodynamics; Humans; Hypotension; Hypoxia; Incidence; Infusions, Intravenous; Lithotripsy; Male; Middle Aged; Pain, Postoperative; Patient Satisfaction; Piperidines; Postoperative Complications; Postoperative Nausea and Vomiting; Remifentanil; Urolithiasis

Postoperative sore throat (POST) is a frequent complication caused by mucosal trauma to the pharyngeal, laryngeal, and tracheal airway after endotracheal intubation. We compared the effectiveness of Siccoral, Strefen, and Stomatovis treatments in alleviating POST.. This prospective, randomized, single-blinded, controlled trial compares the incidence of POST with Strefen lozenges, Siccoral spray, or Stomatovis gargle. Three hundred and twenty American Society of Anesthesiologists class I-III patients undergoing elective genitourinary surgery under general orotracheal anesthesia were randomly allocated to four groups of 80 patients each. In the postoperative awakening unit and during related services, POST was evaluated by a blinded anesthesiologist at 0, 1, 6, and 24 h post extubation.. The highest incidence of POST occured at 0 and 1 h post extubation in all groups (P = 0.002 × 10(-7), P = 0.004 × 10(-6), respectively). A significantly lower incidence of POST was observed in Strefen and Siccoral groups at 0 and 1 h compared to Control group (Strefen: P = 0.004 × 10(-2), P = 0.007 × 10(-4); Siccoral: P = 0.003 × 10(-8), P = 0.007 × 10(-5), respectively). A significantly lower incidence of POST was observed with Siccoral treatment at 0 h post extubation (P = 0.002 vs. Strefen treatment). Although POST incidence was not significantly different between the Stomatovis and Control groups, it was lower in the Stomatovis group at 0 and 1 h (P = 0.026 and 0.013, respectively). The incidence of POST was similar in all groups at 6 and 24 h post extubation (P = 0.141 and 0.426, respectively).. Siccoral and Strefen can be effective in relieving POST in the early hours after extubation.

Topics: Acetylcysteine; Adolescent; Adult; Aerosols; Aged; Aged, 80 and over; Analgesics, Opioid; Female; Flurbiprofen; Humans; Male; Middle Aged; Mouthwashes; Pharmaceutical Solutions; Pharyngitis; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Tablets; Treatment Outcome; Young Adult

We evaluated the effect of alvimopan treatment vs placebo on health care utilization and costs related to gastrointestinal recovery in patients treated with radical cystectomy in a randomized, phase 4 clinical trial.. Resource utilization data were prospectively collected and evaluated by cost consequence analysis. Hospital costs were estimated from 2012 Medicare reimbursement rates and medication wholesale acquisition costs. Differences in base case mean costs between the study cohorts for total postoperative ileus related costs (hospital days, study drug, nasogastric tubes, postoperative ileus related concomitant medication and postoperative ileus related readmissions) and total combined costs (postoperative ileus related, laboratory, electrocardiograms, nonpostoperative ileus related concomitant medication and nonpostoperative ileus related readmission) were evaluated by probabilistic sensitivity analysis using a bootstrap approach.. Mean hospital stay was 2.63 days shorter for alvimopan than placebo (mean±SD 8.44±3.05 vs 11.07±8.23 days, p=0.005). Use of medications or interventions likely intended to diagnose or manage postoperative ileus was lower for alvimopan than for placebo, eg total parenteral nutrition 10% vs 25% (p=0.001). Postoperative ileus related health care costs were $2,340 lower for alvimopan and mean total combined costs were decreased by $2,640 per patient for alvimopan vs placebo. Analysis using a 10,000-iteration bootstrap approach showed that the mean difference in postoperative ileus related costs (p=0.04) but not total combined costs (p=0.068) was significantly lower for alvimopan than for placebo.. In patients treated with radical cystectomy alvimopan decreased hospitalization cost by reducing the health care services associated with postoperative ileus and decreasing the hospital stay.

Topics: Administration, Oral; Costs and Cost Analysis; Cystectomy; Double-Blind Method; Follow-Up Studies; Gastrointestinal Agents; Hospital Costs; Humans; Ileus; Incidence; Patient Acceptance of Health Care; Piperidines; Postoperative Complications; Prospective Studies; Receptors, Opioid, mu; United States

This randomized, double-blind study was designed to assess the effect of perioperative remifentanil with controlled hypotension on intraoperative bleeding, postoperative edema, and ecchymosis.. Fifty-two patients undergoing rhinoplasty were divided into 2 groups. The remifentanil group received 1 µg · kg(-1) intravenously as a bolus before induction of anesthesia, 0.5 to 1 µg · kg(-1) · h(-1) by continuous intravenous infusion during the operation. After anesthesia induction with propofol (2-3 mg · kg(-1)) and fentanyl (1-15 µg · kg(-1)), muscle relaxation was achieved with rocuronium (0.45-0.90 mg · kg(-1)). Mean arterial pressure was maintained at 50 to 60 mm Hg in controlled hypotensive anesthesia achieved using remifentanil infusion. Perioperative hemodynamics and bleeding; early postoperative pain and agitation scale; postoperative first, third, and seventh day edema; and ecchymosis were evaluated. Edema and ecchymosis were evaluated using graded scale from 0 to 4.. Remifentanil reduced mean arterial pressure during the entire operative period and the first 30 minutes postoperatively (P < 0.05 for these comparisons). Intraoperative bleeding also decreased (P < 0.001). There was a significant decrease in edema in both upper and lower eyelid edema on the first and third days in the remifentanil group, although this difference was not detected on the seventh day (P(1upper) = 0.000, P(1lower) = 0.000, P(3upper) = 0.008, and P(3lower) = 0.002). Ecchymosis decreased significantly in both upper and lower eyelids on the first, third, and seventh days in the remifentanil group (P(1upper) = 0.000, P(3upper) = 0.000, P(3upper) = 0.002, P(3lower) = 0.002, P(7upper) = 0.049, and P(7lower) = 0.038). There were no differences in postoperative pain and agitation between 2 groups.. Remifentanil with controlled hypotension may reduce edema and ecchymosis of the upper and lower eyelids, by reducing mean arterial pressure and amount of bleeding in rhinoplasty.

Topics: Adult; Anesthetics, Intravenous; Antihypertensive Agents; Blood Loss, Surgical; Blood Pressure; Double-Blind Method; Ecchymosis; Edema; Eyelid Diseases; Female; Humans; Hypotension, Controlled; Male; Piperidines; Postoperative Complications; Remifentanil; Rhinoplasty; Young Adult

Although opioids are widely used as analgesics in general anaesthesia, they have unpleasant side-effects and can delay postoperative recovery. Acupuncture and related techniques are effective for acute and chronic pain, and reduces some side-effects. We assessed the effect of transcutaneous electric acupoint stimulation (TEAS) on intra-operative remifentanil consumption and the incidences of anaesthesia-related side-effects.. Sixty patients undergoing sinusotomy were randomly assigned to TEAS or control group. TEAS consisted of 30 min of stimulation (6-9 mA, 2/10 Hz) on the Hegu (LI4), Neiguan (PC6), and Zusanli (ST36) before anaesthesia. The patients in the control group had the electrodes applied, but received no stimulation. Bispectral index was used to monitor the depth of anaesthesia. Perioperative haemodynamics were recorded, and peripheral blood samples were collected to measure the levels of mediators of surgical stress. The primary end point was intraoperative remifentanil consumption and the secondary endpoints were recovery quality and anaesthesia-related side-effects.. Patients in the TEAS group required 39% less remifentanil during surgery than controls [0.0907 (SD 0.026) μg kg(-1) min(-1) vs 0.051 (0.018) μg kg(-1) min(-1)]. There were no differences in intra-operative haemodynamics or surgical stress between groups. However, the time to extubation and recall in the control group was 16.8 (6.8) min and 23.0 (5.0) min, respectively, significantly longer than that in the TEAS group (P<0.01). TEAS also decreased the incidence of dizziness and pruritus within the first 24 h after surgery (P<0.01).. The use of TEAS significantly reduced intra-operative remifentanil consumption and alleviated postoperative side-effects in patients undergoing sinusotomy.. The trial was registered at clinicaltrials.gov (NCT01700855).

Topics: Acupuncture Points; Adult; Analgesics, Opioid; Anesthesia Recovery Period; Double-Blind Method; Electroencephalography; Female; Humans; Intraoperative Care; Male; Monitoring, Intraoperative; Paranasal Sinuses; Piperidines; Postoperative Complications; Postoperative Nausea and Vomiting; Prospective Studies; Remifentanil; Stress, Physiological; Time Factors; Transcutaneous Electric Nerve Stimulation

Remifentanil, an ultra-short-acting opioid, is widely used for pain control during surgery. However, regular dose (RD) remifentanil exacerbates postoperative pain in a dose-dependent manner. Recent studies suggest that high-dose (HD) remifentanil offers sustained analgesia in experimental studies. We thus hypothesized that intraoperative administration of high-dose remifentanil may attenuate postoperative pain.. In this prospective, randomized, double blind, controlled clinical study, sixty patients undergoing thyroidectomy (18-60 years-of-age) received an intraoperative infusion of 0.2 (RD group) or 1.2 μg kg(-1) min(-1) (HD group) remifentanil during thyroidectomy. A visual analogue scale (VAS) was used to measure pain intensity. Mechanical pain threshold on the forearm was assessed using von Frey filaments before surgery (baseline), 2 h postoperatively and 18-24 h postoperatively. The primary outcome was to compare the difference of VAS score at different time points after operation and morphine consumption 24 h postoperatively between RD and HD groups. The second outcome was to compare the difference of mechanical pain thresholds in the forearm postoperatively between RD and the HD groups.. VAS scores were lower 30 min postoperatively in the HD group (1.29 ± 1.67, 95% CI 0.64-1.94) compared with the RD group (2.21 ± 1.67, 95% CI 1.57-2.84) (t = 3.427, p = 0.0043, RD group vs. HD group). Postoperative morphine consumption was much lower in the HD group compared with the RD group (1.27 ± 1.88 mg vs. 0.35 ± 1.25 mg, p = 0.033). In both groups, mechanical pain threshold was decreased 18-24 h postoperatively (2.93 ± 0.209 Ln(g) vs. 3.454 ± 2.072 Ln(g), p = 0.032 in RD group; 2.910 ± 0.196 Ln(g) vs. 3.621 ± 0.198 Ln(g), p = 0.006 in HD group, 18-24 h postoperatively vs baseline).. Intraoperative administration of high-dose remifentanil decreased VAS scores and morphine consumption postoperatively. Thus, modulation of intraoperative opiates may be a simple and effective method of postoperative pain management.. This trial is registered in ClinicalTrials.gov, with the Name: Effect of Higher Doses of Remifentanil on Postoperative Pain in Patients Undergoing Thyroidectomy, and ID number: NCT01761149.

Topics: Adolescent; Adult; Analgesics, Opioid; Dose-Response Relationship, Drug; Double-Blind Method; Female; Follow-Up Studies; Humans; Intraoperative Care; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Complications; Prognosis; Prospective Studies; Remifentanil; Thyroid Diseases; Thyroidectomy; Young Adult

Female sex and age more than 65 years are common risk factors for the development of torsades de pointes in association with heart rate-corrected QT (QTc) interval prolongation, which can be induced by tracheal intubation during general anaesthesia. However, the administration of remifentanil can prevent intubation-induced QTc interval prolongation. We compared sex-related differences in the effect-site concentration (Ce) of remifentanil for preventing QTc interval prolongation among elderly patients.. Twenty-two female and 22 male patients older than 65 years were enrolled. Anaesthesia was induced with remifentanil and propofol using a target-controlled infusion. The Ce of remifentanil for maintaining a QTc interval prolongation <15 ms following intubation was determined for each sex using the isotonic regression method and a bootstrapping approach following Dixon's up-and-down method.. The Ce of remifentanil for preventing QTc interval prolongation following intubation in 50 % of the population (EC50) and 95 % of the population (EC95) were significantly lower in females than in males. Isotonic regression revealed that the EC50 (83 % confidence interval) of remifentanil was 3.50 (2.95-4.08) ng/mL in females and 4.38 (4.08-4.63) ng/mL in males. The EC95 (95 % confidence interval) of remifentanil was 4.43 (4.25-4.48) ng/mL in females and 4.94 (4.78-4.98) ng/mL in males.. Target-controlled infusion of remifentanil is effective in attenuating QTc interval prolongation after intubation among elderly patients and the Ce of remifentanil is lower in females than in males.

Topics: Aged; Aged, 80 and over; Anesthesia, General; Anesthetics, Intravenous; Arrhythmias, Cardiac; Drug Administration Schedule; Female; Health Services for the Aged; Heart Conduction System; Humans; Inhibitory Concentration 50; Intubation, Intratracheal; Male; Piperidines; Postoperative Complications; Propofol; Remifentanil; Sex Factors

Fast-track treatment in cardiac surgery has become the global standard of care. We compared the efficacy and safety of a specialised post-anaesthetic care unit (PACU) to a conventional intensive care unit (ICU) in achieving defined fast-track end-points in adult patients after elective cardiac surgery.. In a prospective, single blinded, randomized study, 200 adult patients undergoing elective cardiac surgery (coronary artery bypass graft (CABG), valve surgery or combined CABG and valve surgery), were selected to receive their postoperative treatment either in the ICU (n = 100), or in the PACU (n = 100). Patients who, at the time of surgery, were in cardiogenic shock, required renal dialysis, or had an additive EuroSCORE of more than 10 were excluded from the study. The primary end points were: time to extubation (ET), and length of stay in the PACU or ICU (PACU/ICU LOS respectively). Secondary end points analysed were the incidences of: surgical re-exploration, development of haemothorax, new onset cardiac arrhythmia, low cardiac output syndrome, need for cardio-pulmonary resuscitation, stroke, acute renal failure, and death.. Median time to extubation was 90 [50; 140] min in the PACU vs. 478 [305; 643] min in the ICU group (P < 0.001). Median length of stay in PACU was 3.3 [2.7; 4.0] hours vs. 17.9 [10.3; 24.9] hours in the ICU (P < 0.001). Of the adverse events examined, only the incidence of new onset cardiac arrhythmia (25 in PACU vs. 41 in ICU, P = 0.02) was statistically different between groups.. Treatment in a specialised PACU rather than an ICU, after elective cardiac surgery leads to earlier extubation and quicker discharge to a step down unit, without compromising patient safety.. ISRCTN71768341. Registered 11 March 2014.

Topics: Adult; Analgesics, Opioid; Cardiac Surgical Procedures; Continuous Positive Airway Pressure; Cost Control; Elective Surgical Procedures; Humans; Intensive Care Units; Intubation, Intratracheal; Length of Stay; Outcome Assessment, Health Care; Patient Safety; Piperidines; Pirinitramide; Postoperative Care; Postoperative Complications; Prospective Studies; Remifentanil; Time Factors

To investigate whether the type of anesthetic agent administered affects the antitussive effect of remifentanil.. Prospective randomized study.. Operating room of a university hospital.. 78 ASA physical status 1 and 2 women, aged 20 to 65 years, who were scheduled to undergo a thyroidectomy.. Patients were randomly assigned to three groups to receive anesthesia with propofol (Group P), sevoflurane (Group S), or desflurane (Group D). The main anesthetics were titrated to maintain a target Bispectral Index for hypnosis of 40 to 60. Remifentanil was administered via effect-site target-controlled infusion (TCI). To determine the effective remifentanil effect-site concentration (Ce) to suppress coughing in each group, the up-and-down sequential allocation design was used.. The half maximal effective concentration (EC50) values of remifentanil for preventing coughing in the groups were estimated using isotonic regression and compared among the groups.. The EC50 of remifentanil for cough suppression in Group P [1.60 ng/mL (98.3% CI, 0.92-1.75 ng/mL)] was statistically lower than in Group D [1.96 ng/mL (98.3% CI, 1.81-2.50 ng/mL)]. The EC50 in Group S was 1.75 ng/mL (98.3% CI, 1.39-2.13 ng/mL), which was higher than in Group P and lower than in Group D, but did not differ significantly from either group.. Remifentanil administration for cough suppression during emergence should be customized to the anesthetic agent.

Topics: Adult; Aged; Anesthesia Recovery Period; Anesthetics, General; Antitussive Agents; Cough; Desflurane; Female; Humans; Intubation, Intratracheal; Isoflurane; Methyl Ethers; Middle Aged; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Sevoflurane; Thyroid Neoplasms; Thyroidectomy; Young Adult

This study was undertaken to compare the effects of general anaesthesia (GA) and spinal anaesthesia (SA) on the need for postoperative hospitalization and early postoperative comfort in patients undergoing fast-track total knee arthroplasty (TKA).. One hundred and twenty subjects were randomly allocated to receive either intrathecal bupivacaine (SA group) or GA with target controlled infusion of propofol and remifentanil (GA group). Primary outcome was length of hospital stay (LOS) defined as time from end of surgery until the subject met the hospital discharge criteria. Secondary outcome parameters included actual time of discharge, postoperative pain, intraoperative blood loss, length of stay in the Post Anaesthesia Care Unit, dizziness, postoperative nausea and vomiting, need for urinary catheterization and subject satisfaction.. GA resulted in shorter LOS (46 vs 52 h, P<0.001), and less nausea and vomiting (4 vs 15, P<0.05) and dizziness (VAS 0 mm vs 20 mm, P<0.05) compared with SA. During the first 2 postoperative hours, GA patients had higher pain scores (P<0.001), but after 6 h the SA group had significantly higher pain scores (P<0.001). Subjects in the GA group used fewer patient-controlled analgesia doses and less morphine (P<0.01), and were able to walk earlier compared with the SA group (P<0.001). Subjects receiving SA would request a change in the method of anaesthesia in the event of a subsequent operation more often than the GA subjects (P<0.05).. GA had more favourable recovery effects after TKA compared with SA.

Topics: Aged; Anesthesia Recovery Period; Anesthesia, General; Anesthesia, Intravenous; Anesthesia, Local; Anesthesia, Spinal; Arthroplasty, Replacement, Knee; Bupivacaine; Female; Humans; Length of Stay; Male; Patient Satisfaction; Piperidines; Postoperative Complications; Propofol; Remifentanil; Sweden

The aim of this study was to discover the optimal effect-site concentration of remifentanil for cough prevention that does not delay awakening or cause respiratory depression during emergence from anesthesia with propofol and remifentanil in laryngomicrosurgery patients.. Prospective, randomized, controlled trial.. One hundred five patients were randomly assigned to maintain an effect-site concentration (Ce) of remifentanil at a predetermined value of 1 (R1), 1.5 (R1.5), and 2 (R2) ng/mL during emergence. The incidence and grade (0, no coughing; 1, single cough; 2, more than one episode of nonsustained coughing; 3, sustained and repetitive coughing with head lift) of cough, emergence time, blood pressure (MAP), heart rate (HR), spontaneous respiratory rate, oxygen saturation, and postoperative nausea and vomiting (PONV) were recorded during emergence and recovery.. The total number of patients with coughing during emergence was lower in groups R1.5 and R2 than in group R1. The cough grade during tracheal extubation was lower in groups R1.5 and R2 than in group R1. In group R2, emergence time was longer and postanesthesia care unit score was lower than in groups R1 and R1.5. Also in group R2, transient hypoventilation and PONV were more frequent compared to group R1. There were no differences in MAP and HR among the three groups during emergence and recovery.. Maintenance of remifentanil at Ce 1.5 and 2 ng/mL suppressed coughing without serious adverse events during emergence from anesthesia with propofol and remifentanil in patients undergoing laryngomicrosurgery.

Topics: Adult; Aged; Cough; Dose-Response Relationship, Drug; Female; Follow-Up Studies; Humans; Hypnotics and Sedatives; Injections, Intravenous; Laryngeal Diseases; Larynx; Male; Microsurgery; Middle Aged; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Treatment Outcome; Young Adult

On the basis of data indicating that volatile anesthetics induce cardioprotection in cardiac surgery, current guidelines recommend volatile anesthetics for maintenance of general anesthesia during noncardiac surgery in hemodynamic stable patients at risk for perioperative myocardial ischemia. The aim of the current study was to compare increased troponin T (TnT) values in patients receiving sevoflurane-based anesthesia or total intravenous anesthesia in elective abdominal aortic surgery.. A prospective, randomized, open, parallel-group trial comparing sevoflurane-based anesthesia (group S) and total intravenous anesthesia (group T) with regard to cardioprotection in 193 patients scheduled for elective abdominal aortic surgery. Increased TnT level on the first postoperative day was the primary endpoint. Secondary endpoints were postoperative complications, nonfatal coronary events and mortality.. On the first postoperative day increased TnT values (>13 ng/l) were found in 43 (44%) patients in group S versus 41 (43%) in group T (P = 0.999), with no significant differences in TnT levels between the groups at any time point. Although underpowered, the authors found no differences in postoperative complications, nonfatal coronary events or mortality between the groups.. In elective abdominal aortic surgery sevoflurane-based anesthesia did not reduce myocardial injury, evaluated by TnT release, compared with total intravenous anesthesia. These data indicate that potential cardioprotective effects of volatile anesthetics found in cardiac surgery are less obvious in major vascular surgery.

Topics: Adult; Aged; Aged, 80 and over; Anesthesia, General; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Aorta, Abdominal; Cardiotonic Agents; Elective Surgical Procedures; Female; Fentanyl; Humans; Male; Methyl Ethers; Middle Aged; Norway; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Sevoflurane; Troponin T

Low-dose ketamine infusion (blood concentration around 100 ng/mL) during surgery reduces the incidence of postoperative shivering after remifentanil-based anesthesia. We hypothesized that perioperative infusion of very low-dose ketamine (blood concentration around 40 ng/mL) during remifentanil-based anesthesia may also prevent the development of remifentanil-induced shivering during the 2-hour period after the end of anesthesia.. Fifty female patients scheduled to undergo laparoscopic cystectomy or oophorectomy were assigned to one of two groups: (1) ketamine group, in which the patients received ketamine infusion (0.1 mg/kg/hour) from induction of anesthesia to emergence from anesthesia; and (2) control group, in which the patients received saline infusion from induction up till emergence from anesthesia. Anesthesia was induced and maintained by target-controlled infusion of propofol (estimated blood concentration: 2-4 μg/mL) and infusion of remifentanil, at 0.2-0.3 μg/kg/minute. Patients were observed for shivering from the end of anesthesia to 120 minutes after anesthesia. The time point at which the patient began to shiver was recorded and assigned to one of four time periods: at emergence, from emergence to 30 minutes after anesthesia, from 30 minutes to 60 minutes after anesthesia, and >60 minutes after anesthesia.. During the 120-minute observation period, the number of patients who shivered was higher in the ketamine group than the in control group (18 vs. 8, ketamine group vs. control group, p = 0.01). The time period during which patients began to shiver was different between the two groups (1 patient, 4 patients, and 13 patients vs. 3 patients, 2 patients, and 3 patients at emergence, from emergence to 30 minutes, and from 30 minutes to 60 minutes after anesthesia, respectively; ketamine group vs. control group, p = 0.007).. Intraoperative infusion of very low-dose ketamine during remifentanil-based anesthesia may increase the incidence of postoperative shivering.

Topics: Adult; Anesthetics, Intravenous; Double-Blind Method; Excitatory Amino Acid Antagonists; Female; Humans; Incidence; Ketamine; Piperidines; Postoperative Complications; Receptors, N-Methyl-D-Aspartate; Remifentanil; Shivering

The aim of this retrospective study was to evaluate the efficacy of dexamethasone with controlled hypotension on intraoperative bleeding and postoperative morbidity in rhinoplasty.. Sixty rhinoplasty patients required hump resection and lateral osteotomy were included in this study. The patients were randomized into four groups. In group I (n=15), a single dose of 10mg/kg dexamethasone was intravenously administered at the beginning of the operation. In group II (n=15), the patients were given 2 doses of 10mg/kg intravenously dexamethasone at the beginning of the operation, and 24 hours after the operation. In group III (n=15), 3 doses of 10mg/kg intravenously dexamethasone were given at the beginning of the operation, before osteotomy and 24 hours after the operation. Group IV (n=15) was assigned as control group and the patients were neither administered dexamethasone nor applied hypotension. All cases in groups I, II and III were operated under controlled hypotension. Systolic arterial pressure was aimed to keep between 65 and 75 mmHg for controlled hypotensive anaesthesia. Controlled hypotension was achieved by a remifentanil infusion of 0.1-0.5 microg/kg/min, following a bolus of 1 microg/kg. Degree of eyelid oedema and periorbital soft-tissue ecchymosis was evaluated separately using a scale of 0-4. Intraoperative blood loss was recorded for each patient. Patients were evaluated at 24 hours and postoperative days 2, 5, 7, and 10.. In groups I, II and III, intraoperative bleeding was more decreased and the operation time was significantly shorter compared with control group (P<0.001). Eyelid oedema and periorbital ecchymosis were significantly decreased in groups I, II and III at the following postoperative 7 and 10 days (P<0.001). There was statistically significant difference between group III and other groups at the postoperative 5 and 7 days in lower eyelid oedema (P<0.001), upper and lower eyelid ecchymosis (P<0.001 and 0.004, respectively). There were no postoperative complications with using steroid in any of the groups.. Three doses of dexamethasone with controlled hypotension considerably reduced postoperative morbidities of rhinoplasty with osteotomy as well as intraoperative bleeding. Thus, in group III receiving 3 doses of steroid, when compared to other groups, more uneventful postoperative period were provided for surgeon and the patients.

Topics: Adult; Anti-Inflammatory Agents; Blood Loss, Surgical; Blood Pressure; Dexamethasone; Ecchymosis; Edema; Eyelid Diseases; Female; Follow-Up Studies; Glucocorticoids; Humans; Hypnotics and Sedatives; Hypotension, Controlled; Male; Nasal Cartilages; Nasal Septum; Operative Time; Osteotomy; Patient Satisfaction; Piperidines; Postoperative Complications; Premedication; Remifentanil; Retrospective Studies; Rhinoplasty; Treatment Outcome; Young Adult

Sevoflurane is widely used in paediatric anaesthesia but frequently causes emergence agitation (EA). This study evaluated whether limiting the sevoflurane concentration by combining remifentanil with sevoflurane reduced the incidence of EA.. Eighty-four preschool children scheduled for adenotonsillectomy were randomly assigned to either the remifentanil or sevoflurane group. In the remifentanil group, anaesthesia was induced with thiopental, rocuronium, and 1% sevoflurane. It was maintained with 1% sevoflurane, 60% nitrous oxide in oxygen, and a continuous infusion of remifentanil. For the sevoflurane group, anaesthesia was induced with thiopental, rocuronium, and 8% sevoflurane, and was maintained with 2-3% sevoflurane. Both groups received ketorolac 1 mg/kg and dexamethasone 0.15 mg/kg. EA was measured using the paediatric anaesthesia emergence delirium (PAED) scale and a four-point EA scale in the post-anaesthesia care unit.. The scores on the PAED scales were significantly lower in the remifentanil group than in the sevoflurane group [median (interquartile range); 6 (4.25-10.25) vs. 11 (7.75-14.0), P = 0.007], and the proportion of patients with PAED scores ≥ 10 was significantly lower in the remifentanil group than in the sevoflurane group [15 (35.7%) vs. 27 (64.2%), P = 0.009]. The incidence of EA evaluated using the four-point scale was also lower in the remifentanil group [11 (26.1%) vs. 21 (50%), respectively, P = 0.025].. The incidence of EA was lower in children undergoing adenotonsillectomy who received a lower concentration of sevoflurane combined with remifentanil than in those given a higher concentration of sevoflurane without remifentanil.

Topics: Adenoidectomy; Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Child, Preschool; Delirium; Double-Blind Method; Female; Humans; Male; Methyl Ethers; Piperidines; Postoperative Complications; Psychomotor Agitation; Remifentanil; Sevoflurane; Tonsillectomy

The surgical pleth index (SPI) is an index based on changes in plethysmographic characteristics that correlate with the balance between the sympathetic and parasympathetic nervous system. It has been proposed as a measure of the balance between nociception and anti-nociception. The goal of this study was to test whether it could be used to titrate remifentanil in day-case anaesthesia.. A total of 170 outpatients were given total i.v. anaesthesia with propofol and remifentanil. The patients were randomized to have the remifentanil dose either adjusted according to the SPI (SPI group) or to clinical parameters (control group). The propofol dose was adjusted according to entropy in both groups. The consumption of anaesthetic drugs, recovery times, and complications were compared.. The mean [standard deviation (SD)] remifentanil and propofol infusion rates in the SPI and control groups were 0.06 (0.04) vs 0.08 (0.05) µg kg(-1) min(-1) and 6.0 (2.1) vs 7.5 (2.2) mg kg(-1) h(-1), respectively (both P<0.05). The mean (SD) times to eye opening were -0.08 (4.4) and 3.5 (4.3) min and to extubation were 1.2 (4.4) and 4.4 (4.5) min in the SPI and control groups, respectively (both P<0.05). There was no difference between the groups with regard to satisfaction with the anaesthetic or intensity of postoperative pain. No patient reported intraoperative awareness.. Adjusting the remifentanil dosage according to the SPI in outpatient anaesthesia reduced the consumption of both remifentanil and propofol and resulted in faster recovery.

Topics: Adolescent; Adult; Aged; Ambulatory Surgical Procedures; Anesthesia Recovery Period; Anesthesia, General; Anesthesia, Intravenous; Anesthetics, Intravenous; Arterial Pressure; Arthroscopy; Entropy; Female; Heart Rate; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Monitoring, Intraoperative; Piperidines; Plethysmography; Postoperative Complications; Postoperative Nausea and Vomiting; Propofol; Remifentanil; Survival Analysis; Young Adult

Ketamine has been used as part of a multimodal analgesia regime in opioid abusers undergoing general anesthesia. We studied the opioid-sparing effect of a very low-dose bolus of ketamine as part of moderate sedation for opioid abuse patients undergoing extracorporeal shock wave lithotripsy.. In this randomized, placebo-controlled clinical trial, 190 opioid abusers were enrolled. They were stratified into 2 blocks based on their daily opioid consumption. Both blocks were then randomized to receive 0.1 mg/kg IV ketamine (group K) or placebo (group P). Lithotripsy was performed under moderate sedation with intermittent bolus doses of remifentanil (0.2 µg/kg) to alleviate pain. The total remifentanil dose (primary outcome) and respiratory adverse events (secondary outcome) were compared in the 2 groups.. Remifentanil administration in the group with low-opioid consumers was 1.6 ± 0.4 µg/kg (group P) compared with 1.0 ± 0.2 µg/kg in group K (confidence interval [CI](of difference) 95%, 0.4-0.7; P < 0.001). Patients who had high-opioid consumption received 2.0 ± 0.5 µg/kg (group P) vs 1.5 ± 0.3 µg/kg (group K) remifentanil (CI(of difference) 95%, 0.40-0.75; P < 0.001). Ready to discharge time was statistically longer in high-consumption opioid abusers who received placebo compared with group K (55 ± 13 minutes vs 44 ± 8 minutes, CI(of difference) 95%, 6-15; P < 0.001). The incidences of bradypnea, apnea, nausea, vomiting, and hemodynamic changes were not statistically different between the ketamine and placebo groups.. Preemptive low-dose ketamine (0.1 mg/kg) as a bolus has opioid-sparing effects in opioid abusers undergoing moderate sedation.

Topics: Adolescent; Adult; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthetics, Dissociative; Conscious Sedation; Double-Blind Method; Female; Hemodynamics; Humans; Injections, Intravenous; Ketamine; Lithotripsy; Male; Middle Aged; Opioid-Related Disorders; Pain Measurement; Pilot Projects; Piperidines; Postoperative Complications; Postoperative Nausea and Vomiting; Remifentanil; Treatment Outcome; Young Adult

Intraoperative infusion of opioids has been associated with increased postoperative pain and analgesic requirements, but the development of tolerance in young children is less clear. This prospective, randomized, double-blinded study was designed to test the hypothesis that the intraoperative administration of remifentanil results in postoperative opioid tolerance in a dose-related manner in young children.. We enrolled 60 children (aged 1-5 yr) who were undergoing elective laparoscopic ureteroneocystostomy. Patients were randomized and received an intraoperative infusion of 0, 0.3, 0.6, or 0.9 µg·kg·min remifentanil. Postoperative pain was managed by a parent/nurse-controlled analgesia pump using fentanyl. The primary outcome included the total fentanyl consumptions at 24 and 48 h postsurgery. Secondary outcomes were the postoperative pain scores and adverse effects.. The children who received 0.6 and 0.9 µg·kg·min remifentanil required more postoperative fentanyl than the children who received saline or 0.3 µg·kg·min remifentanil (all P < 0.001) for 24 h after surgery. The children who received 0.3-0.9 µg·kg·min intraoperative remifentanil reported higher pain scores at 1 h after surgery than the children who received saline (P = 0.002, P = 0.023, and P = 0.006, respectively). No significant intergroup differences in recovery variables were observed, but vomiting was more frequent in the 0.9 µg·kg·min remifentanil group than in the other groups (P = 0.027).. The intraoperative use of 0.3 µg·kg·min remifentanil for approximately 3 h (range: 140-265 min) did not induce acute tolerance, but the administration of 0.6 and 0.9 µg·kg·min remifentanil to young children resulted in acute tolerance for 24 h after surgery in an apparently dose-related manner.

Topics: Analgesia; Analgesics, Opioid; Blood Pressure; Child, Preschool; Cystostomy; Dose-Response Relationship, Drug; Double-Blind Method; Drug Tolerance; Female; Heart Rate; Humans; Infant; Infusion Pumps; Infusions, Intravenous; Intraoperative Period; Laparoscopy; Male; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Sample Size

The authors conducted a prospective, randomized, double-blind study to evaluate the anti-shivering efficacy of palonosetron for patients after gynecological laparoscopy under total intravenous propofol-remifentanil anesthesia.. Sixty female patients were randomly assigned to one of two groups and administered palonosetron 0.075 mg (palonosetron group, n = 30) or the same volume of normal saline (control group, n = 30) immediately after anesthesia induction. Anesthesia was induced and maintained with propofol and remifentanil, using a target-controlled infusion device. Esophageal and index finger temperatures were measured immediately after anesthesia induction (baseline) and at 15-min intervals until the end of the surgery. Postanesthetic shivering and side effects were assessed in a postanesthetic care unit.. Incidence of shivering was comparable in the control and palonosetron groups (10/30 vs. 8/30, respectively, P = 0.779). No significant intergroup differences were observed between esophageal and index finger temperatures. Compared with baseline values, esophageal temperatures decreased immediately after pneumoperitoneum in the control group and from 30 min after pneumoperitoneum in the palonosetron group.. Use of palonosetron (0.075 mg) did not reduce the incidence of postanesthetic shivering after gynecological laparoscopy under propofol-remifentanil anesthesia. Further study including other 5-HT3 antagonists or male patients would elucidate the effect of palonosetron on shivering after propofol-remifentanil anesthesia.

Topics: Anesthesia Recovery Period; Anesthesia, Intravenous; Body Temperature; Double-Blind Method; Female; Humans; Isoquinolines; Laparoscopy; Middle Aged; Palonosetron; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Quinuclidines; Remifentanil; Shivering

Alvimopan has been shown to shorten time to return of bowel function (RBF), thereby decreasing length of stay (LOS). The aim of this study was to assess the clinical significance of this effect on actual practice. METJODS: A retrospective and prospective study of elective bowel resection patients was performed. Surgeons were assigned to alvimopan users (treatment) or nonusers (control). Primary outcome measures included LOS, RBF, and total hospital cost (THC).. Mean RBF was 2.93 ± 1.22 days in the treatment group and 4.22 ± 1.81 days in the control group (P < .001). Mean LOS was 7 ± 2.6 days in the treatment group and 7.2 ± 2.2 days in the control group. Mean THC was $7,584 ± $4,770 in the treatment group and $7,310 ± $5,471 in the control group (P > .81). LOS decreased by 2.5 days compared with the historical controls, independent of alvimopan use.. Alvimopan improved RBF but not LOS or THC. Reductions in average LOS of 1 day for ≤6 doses and 2 days if patients received >6 doses were needed to decrease THC.

Topics: Aged; Anastomosis, Surgical; Digestive System Surgical Procedures; Drug Costs; Elective Surgical Procedures; Female; Gastrointestinal Agents; Hospital Costs; Humans; Ileus; Intestines; Length of Stay; Male; Middle Aged; Piperidines; Postoperative Complications; Prospective Studies; Recovery of Function; Retrospective Studies; United States

An inhalation anesthetic-induced attenuation effect on the inflammatory reaction during one-lung ventilation (OLV) has been reported. Pulmonary inflammation is a substantive prognostic factor for Ivor Lewis operations. Blood inflammatory parameters and postoperative pulmonary complications between sevoflurane and propofol-remifentanil anesthesia in patients undergoing Ivor Lewis operations were compared.. A prospective, randomized study.. A medical university.. Forty-eight patients undergoing Ivor Lewis operation allocated randomly into 2 groups.. Patients received sevoflurane or total intravenous anesthesia using propofol and remifentanil (n = 24 per group).. Blood interleukin-6 (IL-6), malondialdehyde (MDA), oxygenation, abnormalities on a chest radiograph (CXR), extubation, intensive care unit (ICU) stay, length of hospitalization, and postoperative complications were compared between the 2 anesthetic techniques. The level of IL-6 at the end of surgery was lower for sevoflurane (69.5 [35.9-121.0] pg/mL) than propofol-remifentanil (128.2 [92.8-163.8] pg/mL, p = 0.03), but this difference was not maintained 24 hours after surgery. Frequencies of abnormalities measured by a CXR, PaO(2)/F(I)O(2)<300, and PaCO(2) <50 mmHg until discharge, the postoperative highest C-reactive protein level, white blood cells, and MDA did not differ between the 2 anesthetics. No differences in the extubation time, ICU stay, discharge day, or the incidence of hospital complications between sevoflurane and propofol-remifentanil anesthesia techniques were observed.. Sevoflurane anesthesia attenuated an increase in blood IL-6 at the end of surgery but did not provide any advantages over propofol remifentanil in terms of postoperative pulmonary complications in Ivor Lewis operations.

Topics: Aged; Anesthesia, Inhalation; Esophagoscopy; Female; Humans; Lung Diseases; Male; Methyl Ethers; Middle Aged; Morbidity; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Sevoflurane

Mesenteric traction syndrome (MTS) is caused by PGI(2) release during abdominal procedures and is often observed during abdominal surgery. We have demonstrated that MTS occurs more frequently in cases using remifentanil than in those that are not. The aim of this study was to assess the prophylactic benefit of flurbiprofen axetil on MTS in patients undergoing abdominal surgery using remifentanil.. Thirty ASA physical status I and II patients were enrolled. They were scheduled to undergo abdominal surgery under general anesthesia with remifentanil and were randomly assigned to receive flurbiprofen axetil (group F) or saline (group C) preoperatively (n = 15 each). MTS was defined according to our simplified diagnostic criteria. Arterial blood pressure and heart rate were recorded, and the plasma 6-keto-PGF(1α) (a stable metabolite of PGI(2)) concentration was measured just before skin incision and at 20 and 60 min after skin incision (T(0), T(20), T(60)) to confirm the diagnosis of MTS.. Twelve of 15 (80%) patients developed MTS in group C, whereas only 1 of 15 (6.7%) patients in group F developed MTS. At T(20), the group C patients showed significantly lower arterial blood pressure (P < 0.05) and a faster heart rate (P < 0.01) than those in group F. The mean plasma 6-keto-PGF(1α) concentration was significantly elevated in group C at T(20) (P < 0.01), whereas the plasma 6-keto-PGF(1α) level remained low throughout the observation period in group F.. We found that preoperative administration of flurbiprofen axetil reduced the incidence of MTS during abdominal surgery with remifentanil analgesia.

Topics: 6-Ketoprostaglandin F1 alpha; Abdomen; Aged; Anesthesia, General; Anesthetics, Intravenous; Anti-Inflammatory Agents, Non-Steroidal; Double-Blind Method; Epoprostenol; Female; Flurbiprofen; Humans; Hypnotics and Sedatives; Hypotension; Infusions, Intravenous; Laparotomy; Male; Midazolam; Middle Aged; Piperidines; Postoperative Complications; Preanesthetic Medication; Prospective Studies; Remifentanil; Splanchnic Circulation

This prospective randomised study compared the antitussive effect of remifentanil during recovery from either propofol or sevoflurane anaesthesia. Seventy-four female patients undergoing thyroidectomy were anaesthetised with either propofol and remifentanil or sevoflurane and remifentanil. During recovery, remifentanil was maintained at an effect-site concentration of 2 ng.ml(-1) until extubation and the occurrence of coughing, haemodynamic parameters and recovery profiles were compared between the two groups. During recovery, neither the incidence nor the severity of cough (incidence 20% with propofol; 24% with sevoflurane, p = 0.77), nor the haemodynamic parameters were different between the two groups. Time to awakening and time to extubation were significantly shorter in the propofol group (4.7 min, 6.1 min min, respectively) compared with the sevoflurane group (7.9 min and 8.9 min respectively) (p < 0.001 and p = 0.002, respectively). An effect-site concentration of 2 ng.ml(-1) of remifentanil was associated with smooth emergence from both propofol and sevoflurane anaesthesia.

Topics: Adult; Aged; Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Antitussive Agents; Blood Pressure; Cough; Device Removal; Female; Heart Rate; Humans; Intubation, Intratracheal; Methyl Ethers; Middle Aged; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Sevoflurane; Single-Blind Method; Thyroidectomy; Young Adult

I.V. lidocaine administration and target-controlled infusion (TCI) of remifentanil may each be used to reduce cough and haemodynamic stimulation during emergence from general anaesthesia. We therefore compared the effects of these two treatments on patients' responses to the tracheal tube during recovery from general anaesthesia after thyroid surgery.. Seventy female patients undergoing thyroidectomy under general anaesthesia using sevoflurane and remifentanil were randomly assigned to i.v. lidocaine (Group L, n=35) or remifentanil by TCI (Group R, n=35). At the end of surgery, sevoflurane was turned off, and the remifentanil infusion was stopped in Group L and maintained in Group R at an effect-site concentration of 2.0 ng ml(-1) until extubation. At the same time, i.v. lidocaine 1.5 mg ml(-1) was administered in Group L. The incidence and severity of cough, haemodynamic parameters, and recovery profiles were evaluated during the emergence.. The incidence of cough during the emergence was significantly higher in Group L than in Group R (72.7% vs 20.6%, P<0.001) and so was the grade of cough (P<0.001). The mean arterial pressure and heart rate were significantly lower in the R group than in the L group during the emergence period (P<0.05), although the two groups showed comparable recovery profiles.. TCI of remifentanil reduces responsiveness to the tracheal tube during emergence from general anaesthesia more effectively than does i.v. lidocaine in female patients undergoing thyroid surgery.

Topics: Adult; Aged; Anesthesia Recovery Period; Anesthesia, General; Antitussive Agents; Cough; Device Removal; Female; Humans; Infusions, Intravenous; Intubation, Intratracheal; Lidocaine; Middle Aged; Piperidines; Postoperative Complications; Remifentanil; Thyroidectomy; Treatment Outcome; Young Adult

To investigate whether the depth of total intravenous anesthesia affects postoperative cognitive dysfunction.. Ninety-six patients with facial spasm who were scheduled to receive microvascular decompression were randomly divided into 2 groups: deeper anesthesia (n = 50) and lighter anesthesia (n = 46). Exclusion criteria included: a history of neurologic or mental disease, serum creatinine in excess of 177 μmol/L, active liver disease, cardiac dysfunction, pulmonary dysfunction, endocrine disease, metabolic disease, a history of surgery, fewer than 6 years of school, inability to complete neuropsychologic testing, vision dysfunction, and auditory dysfunction. Propofol and sufentanil were used for anesthesia induction and propofol and remifentanil were used for the maintenance of anesthesia. A battery of 9 neuropsychologic was administered preoperatively and 5 days after surgery. A postoperative deficit was defined as a postop decrement to preop score greater than 1 standard deviation on any test. Patients who experienced 2 or more deficits were deemed to have early postoperative cognitive dysfunction.. Eighty patients completed both preoperative and postoperative neuropsychologic testing, of which 40 each were in the deeper and lighter anesthesia group. Postoperative early cognitive dysfunction occurred in 4 patients (10%) in the deeper anesthesia group and in 11 patients (27.5%) in the lighter anesthesia group. The incidence of the postoperative cognitive dysfunction was significantly reduced in the deeper anesthesia group compared with the lighter anesthesia group (P < 0.05, χ).. Deeper total intravenous anesthesia can decrease the incidence of cognitive dysfunction in the early postoperative period.

Topics: Adult; Aged; Anesthesia, Intravenous; Anesthetics, Intravenous; Cognition Disorders; Consciousness Monitors; Decompression, Surgical; Female; Hemifacial Spasm; Humans; Intraoperative Awareness; Male; Middle Aged; Neuropsychological Tests; Patient Dropouts; Piperidines; Postoperative Complications; Propofol; Remifentanil

Proton pump inhibitors have been reported to be more useful than histamine-2 receptor antagonists for the prevention of bleeding after endoscopic submucosal dissection (ESD) for superficial gastric neoplasia. The aim of this study was to assess the effects of the proton pump inhibitor lansoprazole and the histamine-2 receptor antagonist roxatidine for the prevention of bleeding and the promotion of ulcer healing after ESD and to compare the cost-effectiveness of these two drugs.. The study subjects were 129 patients who underwent ESD for superficial gastric neoplasia. The patients were randomly assigned to the lansoprazole group (L group) or the roxatidine group (R group). Either drug was administered intravenously from the morning of the ESD day to the day after the ESD, followed by oral treatment for an additional 8 weeks. A second-look endoscopy was performed on the day after the ESD, and a repeat endoscopy was performed at 8 weeks after the ESD. The incidence of bleeding and the ulcer-healing rate at 8 weeks after the ESD were analyzed, as well as the total cost of treatment with these antisecretory agents.. Three patients in each group were excluded from the analysis, leaving 62 patients in L group and 61 in R group. Two of the 62 patients (3.2%) in L group and three of the 61 patients (4.9%) in R group showed bleeding after ESD ; there was no significant difference between the two groups (P = 0.68). The ulcer-healing rate was 93.5% (58/62) in L group and 93.4% (57/61) in R group (P = 1). The total cost of treatment with the antisecretory agent from the day of the ESD to day 56 after the ESD was Yen 13,212 for lansoprazole and Yen 5,841 for roxatidine.. Roxatidine appears to have high cost-effectiveness in the prevention of bleeding and in the promotion of ulcer healing after ESD for superficial gastric neoplasia.

Topics: 2-Pyridinylmethylsulfinylbenzimidazoles; Aged; Aged, 80 and over; Anti-Ulcer Agents; Cost-Benefit Analysis; Dissection; Female; Gastric Mucosa; Gastrointestinal Hemorrhage; Gastroscopy; Humans; Lansoprazole; Male; Middle Aged; Pilot Projects; Piperidines; Postoperative Complications; Prospective Studies; Stomach Neoplasms; Stomach Ulcer; Treatment Outcome

To determine whether donepezil hydrochloride can reduce the prevalence and severity of delirium in older adults undergoing hip fracture repair.. Pilot double-masked randomized placebo-controlled trial.. Large academic medical center.. Sixteen individuals aged 70 and older with hip fracture.. Donepezil 5 mg or placebo was randomly allocated and initiated within 24 hours of surgery, preoperatively or postoperatively. Daily treatment was continued for 30 days or until side effects or the clinical situation required termination.. All outcomes were ascertained masked to treatment status. Information on drug tolerability and safety was obtained from the participant, nurse, and medical record. Delirium presence and severity were measured during daily hospital interviews and at 2, 4, and 6 weeks after surgery after a standardized assessment using the Confusion Assessment Method (CAM) and the Memorial Delirium Assessment Scale (MDAS).. Participants in the donepezil and placebo arms had similar baseline characteristics. Participants in the donepezil arm experienced significantly more side effects. In longitudinal models, there were no significant differences between the donepezil and placebo arms with regard to delirium presence over time (odds ratio = 0.9, 95% confidence interval (CI) = 0.4-2.3) or delirium severity over time (effect size = -0.2 on 30-point MDAS scale, 95%CI = -1.5-1.2).. Participants randomized to donepezil had no significant improvement in delirium presence or severity but experienced more side effects. Overall, sufficient evidence was not found from this pilot study to warrant a definitive Phase III trial.

Topics: Aged; Aged, 80 and over; Cholinesterase Inhibitors; Delirium; Donepezil; Double-Blind Method; Female; Hip Fractures; Humans; Indans; Male; Pilot Projects; Piperidines; Postoperative Complications; Prospective Studies

We investigated whether the early postoperative cognitive dysfunction (POCD) was affected by different perioperative analgesia methods using intravenous remifentanil or epidural ropivacaine in the elderly undergoing major upper abdominal surgery.. Twenty elderly patients (aged over 60 years) undergoing elective surgery for distal or pylorus-preserving gastrectomy under general anesthesia were enrolled in this study. The patients were randomly allocated to two groups : Group LV (n = 10) of intravenous remifentanil, and Group EPI (n = 10) of epidural ropivacaine. The dose of both analgesic agents was controlled to keep stable hemodynamics. We recorded postoperative outcome and complications, and assessed cognitive status at the preoperative period and on the 7th postoperative day using 6 cognitive assessment tests.. POCD occurred in one case (10%) in group IV and two cases (20%) in group EPI (P = 0.50). VAS score, the days of hospital stay and the frequency of additional analgesics were similar between the groups.. Perioperative analgesia using intravenous remifentanil and epidural ropivacaine showed no significant difference in the incidence of early POCD after upper abdominal surgery in elderly patients.

Topics: Aged; Amides; Analgesia; Analgesia, Epidural; Anesthesia, General; Cognition Disorders; Female; Gastrectomy; Humans; Incidence; Infusions, Intravenous; Male; Middle Aged; Perioperative Care; Piperidines; Postoperative Complications; Pylorus; Remifentanil; Ropivacaine

Alvimopan, a peripherally acting Mu-opioid receptor antagonist, has been shown to enhance recovery of gastrointestinal (GI) function in open bowel resection. The aim of this study was to determine the effect of Alvimopan on patients undergoing laparoscopic right colectomies in preventing postoperative ileus (POI). A prospective, nonrandomized trial of laparoscopic right colectomies was carried out with and without perioperative Alvimopan. The length of stay (LOS), time to first flatus, bowel movement, and tolerance of solid foods were recorded. Additionally, any occurrences of POI defined as the need for insertion of a nasogastric tube (NGT) were also noted. Student t tests were used for statistical analysis. A total of 33 patients underwent laparoscopic right colectomies for both benign and malignant diseases from October 2008, to December 2009. Sixteen patients received Alvimopan, whereas 17 patients did not. The demographics of both patient groups were similar. Patients receiving Alvimopan had an accelerated return of bowel function in terms of first flatus (2.37 vs 3.34; P = 0.03), tolerance of solid food (2.75 vs 3.94; P = 0.03), and first stool (2.53 vs 3.80; P = 0.04). There was a trend toward shorter LOS in patients receiving Alvimopan (P = 0.07). Two patients with POI requiring NGT did not receive Alvimopan. Alvimopan was successful in enhancing return of GI function in laparoscopic right colectomies and avoiding POI. The decreased LOS trended but did not approach statistical significance. A large randomized prospective trial will be needed to determine the validity of this study.

Topics: Administration, Oral; Aged; Colectomy; Colonic Diseases; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Follow-Up Studies; Gastrointestinal Agents; Gastrointestinal Motility; Humans; Ileus; Laparoscopy; Male; Piperidines; Postoperative Complications; Prospective Studies; Receptors, Opioid, mu; Recovery of Function; Treatment Outcome

The intravenous injection of microemulsion propofol to induce anaesthesia causes more intense and frequent pain than lipid emulsion propofol. This study investigated whether different target effect-site concentrations of remifentanil could prevent pain due to microemulsion propofol injection. In total, 96 patients were randomly assigned to one of three groups receiving target effect-site concentrations of remifentanil 0 (control group), 4 or 6 ng/ml, followed by injection with microemulsion propofol. Remifentanil pretreatment significantly reduced the incidence and severity of injection pain compared with the control group. Although no difference in pain reduction between the two remifentanil-treated groups was observed, those receiving a target effect-site concentration of 6 ng/ml exhibited an increased rate of complications, compared with those receiving 4 ng/ml. In conclusion, prior administration of remifentanil at a target effect-site concentration of 4 ng/ml is a useful strategy to decrease the injection pain of microemulsion propofol.

Topics: Adult; Anesthetics, Intravenous; Demography; Emulsions; Female; Humans; Infusions, Intravenous; Injections, Intravenous; Male; Middle Aged; Pain; Piperidines; Postoperative Complications; Propofol; Remifentanil

Opioids, including remifentanil, have been demonstrated to confer cardiac protection against ischemia reperfusion injury in animals. This study evaluated whether remifentanil preconditioning is protective in first-time elective on-pump coronary artery bypass surgery patients receiving a standardized fentanyl (25 μg/kg in total) and propofol anesthetic.. A prospective, double blind, randomized, controlled study.. University hospital; single institution.. Forty patients scheduled for first-time elective, on-pump coronary artery bypass surgery for at least 3 diseased vessels.. Patients randomized to the remifentanil group (n = 20) received a 1 μg/kg bolus followed by a 0.5 μg/kg/min infusion for 30 minutes after induction but before sternotomy, while the control group (n = 20) received normal saline. Serial samples for measurement of creatine kinase (CK-MB), cardiac troponin I (cTnI), ischemia-modified albumin (IMA) and heart-type fatty-acid-binding protein (hFABP) were taken at baseline, prebypass, T = 10 minutes, 2, 6, 12, and 24 hours after cross-clamp release, to assess the degree of myocardial damage.. Patients in the remifentanil group had lower levels of CK-MB from T = 2 hours to 24 hours, cTnI from T = 10 minutes to T = 12 hours, IMA from T = 10 minutes to T = 2 hours and h-FABP from T = 10 minutes to T = 12 hours (p < 0.05). The time to tracheal extubation was shorter in patients in the remifentanil group. The overall lengths of ICU and hospital stays were not different.. The addition of remifentanil to the anesthesia regimen reduced the degree of myocardial damage. This incremental benefit may be attributable either to remifentanil itself or to an overall increased opioid dose, the latter may be necessary to trigger cardiac protection.

Topics: Aged; Biomarkers; Coronary Artery Bypass; Double-Blind Method; Female; Humans; Male; Middle Aged; Myocardium; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil

A pooled post hoc responder analysis was performed to assess the clinical benefit of alvimopan, a peripherally acting mu-opioid receptor (PAM-OR) antagonist, for the management of postoperative ileus after bowel resection.. Adult patients who underwent laparotomy for bowel resection scheduled for opioid-based intravenous patient-controlled analgesia received oral alvimopan or placebo preoperatively and twice daily postoperatively until hospital discharge or for 7 postoperative days. The proportion of responders and numbers needed to treat (NNT) were examined on postoperative days (POD) 3-8 for GI-2 recovery (first bowel movement, toleration of solid food) and hospital discharge order (DCO) written.. Alvimopan significantly increased the proportion of patients with GI-2 recovery and DCO written by each POD (P < 0.001 for all). More patients who received alvimopan achieved GI-2 recovery on or before POD 5 (alvimopan, 80%; placebo, 66%) and DCO written before POD 7 (alvimopan, 87%; placebo, 72%), with corresponding NNTs equal to 7.. On each POD analyzed, alvimopan significantly increased the proportion of patients who achieved GI-2 recovery and DCO written versus placebo and was associated with relatively low NNTs. The results of these analyses provide additional characterization and support for the overall clinical benefit of alvimopan in patients undergoing bowel resection.

Topics: Aged; Colonic Neoplasms; Digestive System Surgical Procedures; Diverticulosis, Colonic; Female; Humans; Ileus; Intestines; Length of Stay; Male; Middle Aged; Piperidines; Postoperative Complications; Receptors, Opioid, mu; Recovery of Function; Rectal Neoplasms; Treatment Outcome

Remifentanil is associated with increased incidence of post-anaesthetic shivering (PAS). The aim of this study was to compare the effects of intraoperative high and low doses of remifentanil on PAS.. We investigated 50 consecutive patients, aged <60 yr, who underwent gynaecological laparotomy. Patients who underwent prolonged surgery (>4 h) were excluded from the study. Anaesthesia throughout surgery was maintained with i.v. propofol and remifentanil, and epidural ropivacaine, and no nitrous oxide was used. Fifty patients were randomly assigned to receive intraoperative remifentanil at 0.1 microg kg(-1) min(-1) (low-dose group, n=25) or 0.25 microg kg(-1) min(-1) (high-dose group, n=25) until the end of surgery. Intraoperative analgesia was achieved by a fixed infusion rate of remifentanil and titrated epidural ropivacaine. PAS was evaluated by nursing stuff over the first hour after surgery.. PAS occurred more frequently in the high-dose group than in the low-dose group (60% vs 20%, P=0.009). None of the patients complained of pain during the observation period due to epidural analgesia. There were no significant differences in rectal or palm skin temperature after extubation between the two dose groups.. Remifentanil-induced PAS is not a phenomenon of intraoperative hypothermia. The higher incidence of PAS with higher doses of remifentanil probably reflects acute opioid tolerance and stimulation of N-methyl-d-aspartate receptors, similar to hyperalgesia. We conclude that patients administered high doses of remifentanil are sensitive to shivering after sudden drug withdrawal.

Topics: Adult; Anesthetics, Intravenous; Body Temperature; Dose-Response Relationship, Drug; Female; Genital Diseases, Female; Humans; Intraoperative Period; Middle Aged; Piperidines; Postoperative Complications; Remifentanil; Shivering

This randomised, double-blinded, controlled trial was designed to identify the optimal dose of remifentanil for cough suppression without adverse effects during emergence from sevoflurane-remifentanil anaesthesia for thyroidectomy. One hundred and four patients were randomly assigned to maintain target effect-site concentrations of remifentanil at 0 (control group), 1.0 (remifentail 1 group), or 1.5 ng.ml(-1) (remifentanil 1.5 group) during emergence. The incidence of coughing was lower in the remifentanil 1.5 group (31%) than in the control group (74%) or remifentanil 1 group (63%) (p = 0.0004). In addition, the severity of coughing during extubation was lower in the remifentanil 1.5 group (median (IQR [range]) 0 (0-1 [0-1]) than in the control group (1 (0-2 [0-3])) and remifentanil 1 group (1 (0-2 [0-3])) (p = 0.004). Haemodynamic changes were reduced, but emergence time and stay in the post-anaesthesia care unit was prolonged in the remifentanil 1.5 group. Maintaining the remifentanil effect-site concentration at 1.5 ng.ml(-1) during emergence from sevoflurane-remifentanil anaesthesia reduces the incidence and severity of coughing without serious adverse events and may provide haemodynamic stability in patients undergoing thyroidectomy. However, awakening may be delayed.

Topics: Adult; Aged; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Cough; Device Removal; Double-Blind Method; Drug Administration Schedule; Female; Hemodynamics; Humans; Intubation, Intratracheal; Male; Methyl Ethers; Middle Aged; Piperidines; Postoperative Complications; Remifentanil; Sevoflurane; Thyroidectomy

The aim of this study was to determine whether the concurrent use of either of a subhypnotic dose of midazolam, propofol or ketamine with fentanyl just before discontinuing the sevoflurane anesthesia would effectively sedate the children as they recovered and significantly decrease the incidence and severity of emergence agitation and would not delay patient awakening and discharge.. Postoperative emergence agitation may occur in children after general anesthesia with volatile anesthetics. Children who undergo cataract surgery after sevoflurane induction and sevoflurane-remifentanil maintenance may experience this type of agitation.. In 120 un-premedicated children aged 1-7 years, mask induction with sevoflurane was performed and they were then randomly assigned to one of the three antiagitation postoperative groups (n = 40). We studied the postoperative antiagitation effects of subhypnotic doses of midazolam combined with fentanyl, propofol with fentanyl or ketamine with fentanyl administered just before discontinuing the sevoflurane anesthesia. A score for the level of agitation can be assigned based on the recovery mental state (RMS) scale and the recently published pediatric anesthesia emergence delirium scale (PAED). Postoperative factors assessed included emergence behaviors, the time to eye opening, the time to discharge from the postanesthesia care unit (PACU) to the ward.. There were significantly more agitated children in the ketamine-group when compared to the midazolam-group or to the propofol-group at all time P < 0.05), especially at 10 and 15 min. The PAED scale showed a significant advantage for midazolam-fentanyl [5 (2-15)] and propofol-fentanyl [6 (3-15)] versus ketamine-fentanyl [10 (3-20)] (P < 0.05). The time to discharge from the PACU to the ward was not significantly different among the groups.. Intravenous administration of a subhypnotic dose of midazolam or propofol in addition to a low dose of fentanyl just before discontinuing the sevoflurane anesthesia was both effective on decreasing the incidence and severity of emergence agitation in children undergoing cataract extraction without significant delaying recovery time and discharge. The effect of midazolam was clearer than that seen with propofol.

Topics: Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Dissociative; Anesthetics, Inhalation; Anesthetics, Intravenous; Cataract Extraction; Child; Child, Preschool; Delirium; Double-Blind Method; Female; Fentanyl; Humans; Hypnotics and Sedatives; Infant; Ketamine; Male; Methyl Ethers; Midazolam; Pain Measurement; Piperidines; Postoperative Complications; Propofol; Psychomotor Agitation; Remifentanil; Sevoflurane

We compared sedation by propofol combined with either fentanyl or remifentanil in pediatric outpatients undergoing diagnostic esophagogastroduodenoscopy.. Forty-two children scheduled for esophagogastroduodenoscopy in our institution were randomly assigned to receive 2 mg/kg propofol plus either 1 μg/kg bolus of fentanyl (group F; n = 20) or 0.5 μg/kg bolus of remifentanil (group R; n = 22). Cardiorespiratory parameters, sedation level, adverse effects related to the drugs and/or to the procedure, ease of performance for the endoscopist, and time to awakening were analyzed.. There were no clinically significant changes in hemodynamics. Apnea periods >20 seconds and decreases in SaO2 <90% occurred more frequently in group R (31.8% vs 0%, P < 0.01, and 27.3% vs 5.0%, P > 0.05, respectively). Children in group R had significantly shorter average time to awakening: 9.5 ± 5.6 vs 16.5 ± 10.5 minutes (P = 0.01), and received a significantly lower total dose of propofol (P = 0.034). Adverse effects within the first 24 hours postprocedure occurred less frequently in group R (P = 0.03).. Remifentanil in combination with propofol provides good analgesic and sedative effects, which were shorter lasting compared with fentanyl-based sedation, and caused fewer delayed adverse effects. The use of remifentanil was associated with respiratory depression, emphasizing the need for experienced anesthesiologists.

Topics: Analgesics, Opioid; Apnea; Child; Endoscopy, Digestive System; Female; Fentanyl; Hemodynamics; Humans; Hypnotics and Sedatives; Male; Piperidines; Postoperative Complications; Propofol; Remifentanil; Wakefulness

Alvimopan has received Food and Drug Administration approval to accelerate the time to upper and lower gastrointestinal recovery following partial large or small bowel resection with primary anastomosis.. To assess the efficacy, safety, and economic benefit of alvimopan in patients undergoing open or laparoscopic bowel resection in a community hospital system setting.. This 6-month, open-label, multi-hospital, prospective study combined with a retrospective chart review compared postoperative length of stay and postoperative ileus-related morbidity (nasogastric tube insertion, hospital readmission) for patients undergoing open or laparoscopic bowel resection who received alvimopan 12 mg (n = 108) versus historical control bowel resection patients (n = 91) who would have been eligible to receive alvimopan. Multivariate analysis assessed the effects of age and surgery type on postoperative length of stay. Additional-day hospital costs were estimated using ordinary least-squares regression to calculate costs based on length of stay in the control cohort.. Compared with historical controls, patients receiving alvimopan had a mean 1.8-day shorter postoperative length of stay (p = 0.01) and lower rates of nasogastric tube insertion (2% vs 15%, p < 0.001). Multivariate analysis revealed a statistically significant reduction in postoperative length of stay in the alvimopan group of approximately 1.2 days (p = 0.01), regardless of age or surgery type, with an even larger difference (3.2 days) observed in patients ≥70 years old. Mean cost savings associated with alvimopan use ranged from $531 (laparoscopic bowel resection) to $997 (open bowel resection) per patient.. Consistent with clinical trial data, alvimopan use resulted in an approximately 1 day shorter postoperative length of stay and was associated with substantial cost savings.

Topics: Age Factors; Aged; Anastomosis, Surgical; Cost Savings; Digestive System Surgical Procedures; Female; Gastrointestinal Agents; Hospitals, Community; Humans; Ileus; Intubation, Gastrointestinal; Laparoscopy; Least-Squares Analysis; Length of Stay; Male; Middle Aged; Multivariate Analysis; Piperidines; Postoperative Complications; Prospective Studies; Recovery of Function; Retrospective Studies

Excessive coughing may increase the risk of complications after sinus surgery. We hypothesized that remifentanil would decrease the incidence and severity of coughing after endoscopic sinus surgery with propofol and remifentanil anaesthesia.. Ninety patients scheduled for endoscopic sinus surgery were randomly assigned into three groups. Propofol was stopped at the completion of the surgical procedure. The remifentanil infusion was adjusted to an effect-site concentration of 1.5, 2.0 or 2.5 ng/ml, 10 min before the anticipated end of surgery, in each of the three groups (RF₁(.)₅, RF₂(.)₀ and RF₂(.)₅) and continued until after extubation. The incidence and severity of coughing was evaluated on a scale from 0 to 3.. The proportion of patients who did not cough was significantly higher in the RF₂(.)₀ (67.5%, 95% CI: 59.1– 75.9%) and RF₂(.)₅ (74.2%, 95% CI: 66.4–82.0%) groups than in the RF₁(.)₅ group (35.%, 95% CI: 26.5–43.5%) (P < 0.01). The incidence of grade 2 or 3 coughing was significantly higher in the RF₁(.)₅ group (grade 2: 15.1%, grade 3: 6.7%) than in the RF₂(.)₀ group (grade 2: 5.0%, grade 3: 0%) and the RF₂(.)₅ group (grade 2: 4.2%, grade 3: 0%) (P < 0.05). There was no statistically significant difference in the time to extubation among the three groups.. Maintaining anaesthesia with remifentanil to the end of the surgery, until after extubation, can suppress coughing without prolonging the recovery from anaesthesia. This effect is dose dependent and is more pronounced at higher concentrations of remifentanil (2.0 or 2.5 ng/ml).

Topics: Adolescent; Adult; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Intravenous; Blood Pressure; Consciousness Monitors; Cough; Double-Blind Method; Endoscopy; Female; Heart Rate; Humans; Infusions, Intravenous; Male; Middle Aged; Otorhinolaryngologic Surgical Procedures; Paranasal Sinuses; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Smoking; Young Adult

To compare the effect of remifentanil and morphine after coronary artery surgery in a patient-controlled analgesia (PCA) protocol.. A prospective, randomized, double-blind clinical study.. Single institution, university hospital.. Sixty cardiac surgical patients undergoing primary coronary artery bypass graft (CABG) surgery.. After the operation, patients were allocated to 1 of 2 groups. In the first group (group R, n = 30), the following intravenous PCA protocol was programmed: remifentanil infusion, 0.05 microg/kg/min; bolus, 0.25 microg/kg; and lockout time, 5 minutes. In the second group (group M, n = 30), the intravenous PCA protocol was as follows: morphine infusion, 0.3 mg/h; bolus, 1 mg; and lockout time, 5 minutes. In addition to intravenous opioids, paracetamol was administered during the study. In both groups, tramadol was added to the regimen after PCA had been terminated at 24 hours after surgery. In addition to tramadol and paracetamol, 10 mg of morphine sulfate was administered if the numeric rating scale (NRS) score for pain was 3 or more after the first postoperative day. Pain was assessed with an NRS in each patient at rest, while coughing, and during movement for 72 hours. Sedation levels were measured with the Ramsay sedation scale. Overall effectiveness of pain relief was evaluated with a 4-stage scale ("very good," "good," "moderate," or "bad").. During coughing, the NRS values were statistically significantly lower in group R than they were in group M at 12 and 24 hours after surgery (median 1 vs 3 at 12 hours and 2 v 3.5 at 24 hours) (p < 0.05). On movement, NRS values were statistically significantly lower in group R than they were in group M at 12 hours after surgery (median 1 v 2.5) (p < 0.05). After the first 24 hours, the requirement for additional analgesia was similar in both groups. The overall effectiveness of pain relief was rated "very good" or "good"' in 87% of patients in group R and in 72% of patients in group M (p > .05).. There was no difference in patient satisfaction between the 2 groups. On the basis of the reduction of pain scores (with cough and movement) at 1 or 2 postoperative time points, PCA-remifentanil infusion is a better analgesic technique; overall, both PCA techniques provided for effective pain scores (<3). In patients in whom PCA morphine is contraindicated after CABG surgery, PCA remifentanil is a safe alternative.

Topics: Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Chest Pain; Coronary Artery Bypass; Endpoint Determination; Female; Follow-Up Studies; Hemodynamics; Humans; Infusions, Intravenous; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Patient Satisfaction; Piperidines; Postoperative Complications; Remifentanil; Respiratory Function Tests

The aim of the present study was to compare the perioperative hemodynamics, propofol consumption and recovery profiles of remifentanil and dexmedetomidine when used with air-oxygen and propofol, in order to evaluate a postoperative analgesia strategy and explore undesirable side-effects (nausea, vomiting, shivering). In a prospective randomized double-blind study 50 ASAI-III patients scheduled for supratentorial craniotomy, were allocated into two equal Groups. Group D patients (n = 25), received i.v. dexmedetomidine 1 microg kg(-1) as preinduction over a 15-min period and 0.2-1 microg kg(-1) hr(-1) by continuous i.v. infusion during the operation period. Group R patients (n = 25), received remifentanil 1 microg kg(-1) as induction i.v. over a 15-min period and 0.05-1 microg kg(-1) min(-1) as maintenance. The propofol infusion was started at a rate of 10 mg kg(-1) h(-1) and titrated to maintain BIS in the range 40-50. Propofol doses for induction and maintenance of anesthesia was lower with dexmedetomidine (respectively p < 0.05, p < 0.01). The time for BIS to reach 50 was significantly shorter in Group D (p < 0.01). Comparison of the parameters of recovery revealed; extubation time (p < 0.01); response to verbal commands (p < 0.05) and time for orientation (p < 0.05) were longer with Group D. With respect to Post Anesthesia Care Unit (PACU) discharge time, dexmedetomidine patients required longer time when compared to remifentanil patients to achieve their first normal neurological score (33 min vs 31 min). The earliest opioid administration was at 38 min. in the dexmedetomidine group and 33 min. in the remifentanil group. Propofol-remifentanil and propofol-dexmedetomidine are both suitable for elective supratentorial craniotomy and provide similar intraoperative hemodynamic responses and postoperative adverse events. Propofol-remifentanil allows earlier cognitive recovery; however, it leads to earlier demand for postoperative analgesics. Undesirable side-effects were similar in two Groups.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesics, Non-Narcotic; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Intravenous; Blood Pressure; Cognition; Craniotomy; Dexmedetomidine; Double-Blind Method; Electroencephalography; Heart Rate; Humans; Middle Aged; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Tramadol; Young Adult

The administration of short-acting opioids can be a reliable and safe method to prevent coughing during emergence from anaesthesia but the proper dose or effect site concentration of remifentanil for this purpose has not been reported. We therefore investigated the effect site concentration (Ce) of remifentanil for preventing cough during emergence from anaesthesia with propofol-remifentanil target-controlled infusion.. Twenty-three ASA I-II grade female patients, aged 23-66 yr undergoing elective thyroidectomy were enrolled in this study. EC(50) and EC(95) of remifentanil for preventing cough were determined using Dixon's up-and-down method and probit analysis. Propofol effect site concentration at extubation, mean arterial pressure, and heart rate (HR) were compared in patients with smooth emergence and without smooth emergence.. Three out of 11 patients with remifentanil Ce of 1.5 ng ml(-1) and all seven patients with Ce of 2.0 ng ml(-1) did not cough during emergence; the EC(50) of remifentanil that suppressed coughing was 1.46 ng ml(-1) by Dixon's up-and-down method, and EC(95) was 2.14 ng ml(-1) by probit analysis. Effect site concentration of propofol at awakening was similar in patients with a smooth emergence and those without smooth emergence, but HR and arterial pressure were higher in those who coughed during emergence. Clinically significant hypoventilation was not seen in any patient.. We found that the EC(95) of effect site concentration of remifentanil to suppress coughing at emergence from anaesthesia was 2.14 ng ml(-1). Maintaining an established Ce of remifentanil is a reliable method of abolishing cough and thereby targeting smooth emergence from anaesthesia.

Topics: Adult; Aged; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Intravenous; Cough; Device Removal; Drug Administration Schedule; Female; Humans; Intubation, Intratracheal; Middle Aged; Piperidines; Postoperative Complications; Propofol; Remifentanil; Thyroidectomy; Young Adult

Remifentanil is an ultra-short-acting opioid, widely used for induction and maintenance of anaesthesia in various types of operations. We recently noted that a great number of patients receiving remifentanil in their anaesthetic regimen experienced postoperative abdominal pain. As a result, we performed this study to investigate its incidence. This randomised single-blinded clinical trial was conducted on 300 patients who were undergoing elective cataract surgery under general anaesthesia. The patients were randomly divided into two groups. In the control group (n = 150), anaesthesia was induced with fentanyl and propofol and maintained with propofol by infusion and 60% N2O. In the remifentanil group, anaesthesia was induced with remifentanil and propofol and maintained with remifentanil infusion and inhalation of 60% N2O. Atracurium was used for muscle relaxation in both groups. Abdominal pain was observed in 79 patients (52.6%) in the remifentanil group, 10 of whom required a therapeutic intervention, but in only three patients in the control group, none of whom required an intervention (P value = 0.001). Postoperative nausea and vomiting were reported in seven and 10 patients (4.7%) in the remifentanil and control group, respectively. These findings indicate that abdominal pain is very common in patients receiving remifentanil by infusion for cataract surgery.

Topics: Abdominal Pain; Adult; Aged; Aged, 80 and over; Anesthetics, Intravenous; Atracurium; Cataract Extraction; Drug Therapy, Combination; Elective Surgical Procedures; Female; Fentanyl; Humans; Incidence; Male; Middle Aged; Neuromuscular Nondepolarizing Agents; Piperidines; Postoperative Complications; Postoperative Nausea and Vomiting; Propofol; Prospective Studies; Remifentanil; Single-Blind Method

The intraoperative wake-up test is a standard procedure for early recognition of neurologic complications after posterior correction of idiopathic scoliosis. In this prospective, single-blinded cohort study, the impact of the wake-up test and the opioid used for anesthesia on the quality of the patients' sleep after scoliosis surgery was investigated up to 12 months postoperatively.. Patients were classified into three groups: posterior instrumentation with wake-up test using remifentanil, anterior instrumentation without wake-up test using sufentanil, and posterior instrumentation with wake-up test using sufentanil. The quality of sleep was assessed using the Pittsburgh Sleep Quality Index questionnaire preoperatively as well as 3, 6, and 12 months postoperatively. In addition, data were collected on patients' age, weight, and sex, as well as the duration of the operation and anesthesia, amount of blood loss, specific opioid dosages, and wake-up test times. Statistical analysis was conducted using the Mann-Whitney, Kruskal-Wallis, and Wilcoxon tests.. There were no differences between groups with regard to baseline characteristics. No explicit recall was assessed through all groups. At 3 and 6 months postoperatively, the sleep quality in the posterior-remifentanil group was significantly poorer than preoperatively and compared with the anterior- and posterior-sufentanil groups. No significant differences in wake-up test times between groups undergoing posterior instrumentation occurred.. This study suggests that patients undergoing scoliosis surgery with an intraoperative wake-up test using remifentanil had impaired sleep quality that lasted up to 6 months postoperatively. No deterioration in sleep quality was observed with sufentanil. Large randomized trials are now needed to confirm these preliminary results.

Topics: Adolescent; Adult; Analgesics, Opioid; Cohort Studies; Female; Humans; Male; Monitoring, Intraoperative; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Scoliosis; Single-Blind Method; Sleep Wake Disorders; Wakefulness

The need for muscular relaxation to improve intubating conditions and to reduce the incidence of laryngeal morbidity is still controversial. The aim of this study was to determine the incidence of symptomatic laryngeal injuries (SLI) and of acceptable intubating conditions (including both good and excellent conditions), both with and without cisatracurium during induction of anesthesia, along with moderate doses of remifentanil and propofol.. In this prospective, randomized double-blind equivalence trial, the intubating conditions were compared in 130 ASA I or II female patients. All subjects received remifentanil 2 microg x kg(-1) i.v. and propofol 2.5 mg x kg(-1) i.v., with either cisatracurium 0.15 mg x kg(-1) i.v. (group Cisatracturium), or saline (group Placebo). Tracheal intubating conditions were assessed with the Copenhagen Score. A systematic screening for postoperative hoarseness and sore throat was performed 24 and 48 hr after anesthesia, followed by a nasofibroscopic examination when laryngeal symptoms persisted at 48 hr.. Twenty-four hr after anesthesia, the incidence of postoperative hoarseness and sore throat in the Cisatracurium and Placebo groups was 26.5% and 21.5%, respectively, and 48 hr after anesthesia, the incidence was 7.8% and 6.1%, respectively (P = 0.32 and P = 0.50 between groups, respectively). In the clinically evaluable population, the incidence of SLI, assessed at 48 hr by nasofibroscopy, was equivalent in both groups, 1.6% vs 1.5% in group Placebo and group Cisatracurium, respectively (P < 0.001 for equivalence test), as was the occurrence of acceptable intubating conditions (95.4% vs 100%, P < 0.05 for equivalence test). However, the occurrence of excellent intubating conditions was more frequent in group Cisatracurium than in group Placebo (P = 0.0003).. Following induction of anesthesia with propofol and moderate-dose remifentanil, cisatracurium did not confer a higher rate of good-to-excellent conditions for tracheal intubation, nor did muscle relaxation with cisatracurium decrease the rate of SLI after tracheal intubation.

Topics: Adult; Anesthetics, Intravenous; Atracurium; Double-Blind Method; Female; Hoarseness; Humans; Intubation, Intratracheal; Larynx; Neuromuscular Blocking Agents; Pharyngitis; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Sodium Chloride; Time Factors

To investigate the efficacy and safety of alvimopan, 12 mg, administered orally 30 to 90 minutes preoperatively and twice daily postoperatively in conjunction with a standardized accelerated postoperative care pathway for managing postoperative ileus after bowel resection.. This multicenter, randomized, placebo-controlled, double-blind, phase 3 trial enrolled adult patients undergoing partial bowel resection with primary anastomosis by laparotomy and scheduled to receive intravenous, opioid-based, patient-controlled analgesia. A standardized accelerated postoperative care pathway including early ambulation, oral feeding, and postoperative nasogastric tube removal was used to facilitate gastrointestinal (GI) tract recovery in all of the patients.. The primary end point was time to GI-2 recovery (toleration of solid food and first bowel movement). Secondary end points included time to GI-3 recovery (toleration of solid food and first flatus or bowel movement), hospital discharge order written, and actual hospital discharge. Postoperative length of hospital stay based on calendar day of hospital discharge order written, opioid consumption, and overall postoperative ileus-related morbidity were recorded.. Alvimopan, 12 mg, was well tolerated and significantly accelerated GI-2 recovery, GI-3 recovery, and actual hospital discharge compared with a standardized accelerated postoperative care pathway alone (hazard ratio = 1.5, 1.5, and 1.4, respectively; P < .001 for all). Time to hospital discharge order written as measured by hazard ratio (1.4) and by postoperative calendar days (mean for alvimopan, 5.2 days; mean for placebo, 6.2 days) was also accelerated. Opioid consumption was comparable between groups, and alvimopan was associated with reduced postoperative ileus-related morbidity compared with placebo.. Alvimopan, 12 mg, administered 30 to 90 minutes before and twice daily after bowel resection is well tolerated, accelerates GI tract recovery, and reduces postoperative ileus-related morbidity without compromising opioid analgesia.

Topics: Adult; Critical Pathways; Double-Blind Method; Drug Administration Schedule; Female; Gastrointestinal Motility; Humans; Ileus; Intestines; Male; Middle Aged; Piperidines; Postoperative Care; Postoperative Complications; Recovery of Function; Treatment Outcome

Post-operative ileus (POI) affects most patients undergoing abdominal surgery.. To evaluate the effect of alvimopan, a peripherally acting mu-opioid receptor antagonist, on POI by negating the impact of opioids on gastrointestinal (GI) motility without affecting analgesia in patients outside North America.. Adult subjects undergoing open abdominal surgery (n = 911) randomly received oral alvimopan 6 or 12 mg, or placebo, 2 h before, and twice daily following surgery. Opioids were administered as intravenous patient-controlled analgesia (PCA) or bolus injection. Time to recovery of GI function was assessed principally using composite endpoints in subjects undergoing bowel resection (n = 738).. A nonsignificant reduction in mean time to tolerate solid food and either first flatus or bowel movement (primary endpoint) was observed for both alvimopan 6 and 12 mg; 8.5 h (95% CI: 0.9, 16.0) and 4.8 h (95% CI: -3.2, 12.8), respectively. However, an exploratory post hoc analysis showed that alvimopan was more effective in the PCA (n = 317) group than in the non-PCA (n = 318) group. Alvimopan was well tolerated and did not reverse analgesia.. Although the significant clinical effect of alvimopan on reducing POI observed in previous trials was not reproduced, this trial suggests potential benefit in bowel resection patients who received PCA.

Topics: Aged; Defecation; Dose-Response Relationship, Drug; Double-Blind Method; Female; Gastrointestinal Motility; Humans; Ileus; Male; Middle Aged; Narcotic Antagonists; Pain Measurement; Piperidines; Postoperative Complications; Stomach Diseases; Treatment Outcome

This was a pilot, phase 2a study to assess methodological feasibility and the safety and efficacy of donepezil in preventing postoperative delirium after elective total hip replacement surgery in older people without pre-existing dementia. The hypothesis was that donepezil would reduce the incidence of postoperative delirium.. A double blind, placebo controlled, parallel group randomized trial was undertaken. Patients were block randomized pre-operatively to receive placebo or donepezil 5 mg immediately following surgery and every 24 h thereafter for a further three days. The main outcome was the incidence of delirium (using the Delirium Symptom Interview). The secondary outcome was length of hospital stay.. Thirty-three patients (mean age 67 years; 17 males, 16 females) completed the study (19 donepezil, 14 placebo). Donepezil was well tolerated with no serious adverse events. Postoperative delirium occurred in 21.2% of subjects. Donepezil did not significantly reduce the incidence of delirium. The unadjusted risk ratio (donepezil vs placebo) for delirium was 0.29 (95% CI = 0.06,1.30) (chi(2) ([1]) = 3.06; p = 0.08). Mean length of hospital stay was 9.9 days for the donepezil group vs 12.1 days in the placebo group; difference in means = -2.2 days (95% CI = -0.39,4.78) (t([31]) = 1.73: p = 0.09).. The experimental paradigm was feasible and acceptable. Donepezil did not significantly reduce the incidence of delirium or length of hospital stay, however for both outcomes there was a consistent trend suggesting possible benefit. The sample size required for a definitive trial (99% power, alpha 0.05) would be 95 subjects per arm.

Topics: Aged; Aged, 80 and over; Arthroplasty, Replacement, Hip; Delirium; Donepezil; Double-Blind Method; Elective Surgical Procedures; England; Female; Hospitals, Teaching; Humans; Incidence; Indans; Length of Stay; Male; Mental Status Schedule; Middle Aged; Nootropic Agents; Odds Ratio; Piperidines; Postoperative Complications; Treatment Outcome

Postoperative ileus (POI), an interruption of coordinated bowel motility after operation, is exacerbated by opioids used to manage pain. Alvimopan, a peripherally acting mu-opioid receptor antagonist, accelerated gastrointestinal (GI) recovery after bowel resection in randomized, double-blind, placebo-controlled, multicenter phase III POI trials. The effect of alvimopan on POI-related morbidity for patients who underwent bowel resection was evaluated in a post-hoc analysis.. Incidence of POI-related postoperative morbidity (postoperative nasogastric tube insertion or POI-related prolonged hospital stay or readmission) was analyzed in four North American trials for placebo or alvimopan 12 mg administered 30 minutes or more preoperatively and twice daily postoperatively until hospital discharge (7 or fewer postoperative days). GI-related adverse events and opioid consumption were summarized for each treatment. Estimations of odds ratios of alvimopan to placebo and number needed to treat (NNT) to prevent one patient from experiencing an event of POI-related morbidity were derived from the analysis.. Patients receiving alvimopan 12 mg were less likely to experience POI-related morbidity than patients receiving placebo (odds ratio = 0.44, p < 0.001). Fewer patients receiving alvimopan (alvimopan, 7.6%; placebo, 15.8%; NNT = 12) experienced POI-related morbidity. There was a lower incidence of postoperative nasogastric tube insertion, and other GI-related adverse events on postoperative days 3 to 6 in the alvimopan group than the placebo group. Opioid consumption was comparable between groups.. Alvimopan 12 mg was associated with reduced POI-related morbidity compared with placebo, without compromising opioid-based analgesia in patients undergoing bowel resection. Relatively low NNTs are clinically meaningful and reinforce the potential benefits of alvimopan for the patient and health care system.

Topics: Digestive System Surgical Procedures; Double-Blind Method; Female; Gastrointestinal Agents; Humans; Ileus; Male; Middle Aged; Piperidines; Postoperative Complications; Receptors, Opioid, mu

To study the effect of donepezil in treating patients with cognitive decline following coronary artery bypass graft (CABG) surgery.. Forty-four patients, with at least a 0.5 SD decline at 1 year post-CABG on at least one cognitive domain compared to their pre-CABG baseline score, were randomized to treatment with donepezil (titrated to 10 mg daily) or placebo in a 12-week double-blind, single center, randomized study. A composite cognitive change score served as the primary outcome. Secondary outcome measures included tests of memory, attention, psychomotor speed, and executive function.. The composite cognitive outcome did not show significant treatment effects. Secondary measures varied in their sensitivity to donepezil effects with the largest effects seen on the Wechsler Visual Memory Scale-Delayed and Immediate recall tests. More than twice (52% vs. 22%) as many donepezil-treated patients showed a significant improvement compared with placebo patients on Delayed recall. Tests with weak effect sizes and minimal trends favoring donepezil were the Boston Naming and Digit Symbol. However, most of the other instruments (e.g., Digit Span, Trails B, and Controlled Word Association) showed no treatment benefits. More donepezil-treated than placebo-treated patients experienced diarrhea, but other adverse effects and safety measures did not differ between groups.. In the post-CABG mild cognitive decline setting, donepezil did not improve composite cognitive performance but improved some aspects of memory. Donepezil was well tolerated and had no significant effects on EKG parameters. Because of limitations such as small sample size and multiplicity of tests, these findings are preliminary but add to our knowledge of cholinergic effects in vascular mild cognitive decline.

Topics: Aged; Cardiopulmonary Bypass; Cognition Disorders; Coronary Artery Bypass; Donepezil; Dose-Response Relationship, Drug; Double-Blind Method; Drug Administration Schedule; Electrocardiography; Female; Follow-Up Studies; Humans; Indans; Male; Memory, Short-Term; Mental Recall; Middle Aged; Neuropsychological Tests; Nootropic Agents; Piperidines; Postoperative Complications; Wechsler Scales

Surgery and anesthetic method have immunomodulating effects on hemodynamic response and stress. We compared the effects of 2 intraoperative analgesic regimens on patients undergoing abdominal hysterectomy.. We conducted a randomized double-blind trial in ASA 1 and 2 patients undergoing abdominal hysterectomy under balanced anesthesia. Twenty-nine patients were randomized to 2 groups. One group received analgesia by infusion of remifentanil plus morphine and nonsteroidal anti-inflammatory drugs as rescue medications; the other received conventional analgesia with bolus doses of fentanyl according to changes in hemodynamic variables. We measured levels of proinflammatory (interleukin [IL]-6) and antiinflammatory (IL-10) cytokines, cortisol, and C-reactive protein preoperatively, at incision, and at 1, 4 and 24 hours after surgery.. There were no significant differences between the 2 groups in terms of the markers studied at baseline. In each group, however, there were significant changes from baseline at the various points in time. IL-6 and IL-10 levels were significantly elevated (P < .05) at 4 hours. The changes in cortisol levels were significantly different at 1 and 4 hours. Finally, there were significant increases in C-reactive protein at 24 hours.. Unlike other clinical trials, our study detected no differences between the 2 techniques in response to surgical stress evaluated by analyzing concentrations of pro- and anti-inflammatory cytokines, cortisol, and C-reactive protein.

Topics: Aged; Anesthesia, General; Anti-Inflammatory Agents, Non-Steroidal; Biomarkers; C-Reactive Protein; Dipyrone; Double-Blind Method; Drug Administration Schedule; Female; Fentanyl; Humans; Hydrocortisone; Hysterectomy; Inflammation; Infusions, Intravenous; Injections, Intravenous; Interleukin-10; Interleukin-6; Intraoperative Complications; Kinetics; Middle Aged; Morphine; Narcotics; Pain, Postoperative; Piperidines; Postoperative Complications; Remifentanil; Stress, Physiological

The effects of total intravenous anaesthesia (TIVA) and balanced anaesthesia (BAL) on coughing during emergence from the general anaesthesia have not yet been compared.. Fifty patients, aged 18-60 yr, undergoing elective lumbar disk surgery were randomly allocated to undergo TIVA (propofol-remifentanil) or BAL (fentanyl-nitrous oxide-sevoflurane). Extubation was performed in the knee-elbow position, documented on video, and subsequently evaluated by blinded examiners.. There was no difference between TIVA and BAL patients with respect to patient characteristics, proportion of smokers, surgical time, or time of emergence. The median number of coughs was significantly lower in the TIVA group (1, range 0-9) than in the BAL group (4, range 0-20, P = 0.007). Mean maximal heart rate and mean maximal arterial pressure measured during emergence were also significantly lower in the TIVA group (P = 0.009 and P = 0.006, respectively).. During emergence from anaesthesia in the knee-elbow position, TIVA is associated with significantly less coughing and reduced haemodynamic response when compared with BAL.

Topics: Adult; Anesthesia Recovery Period; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Cough; Female; Fentanyl; Humans; Intervertebral Disc; Lumbar Vertebrae; Male; Methyl Ethers; Middle Aged; Nitrous Oxide; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Sevoflurane

The effect of surgery and anesthesia on the immune response may have a significant effect on perioperative tumor surveillance. The aim of this study was to characterize the cellular immune response of patients undergoing simple abdominal hysterectomy under 3 types of anesthesia.. ASA 1-2 patients undergoing simple abdominal hysterectomy were enrolled prospectively after they gave informed consent; the patients were randomized to 3 groups of 20 each to receive balanced anesthesia (group A), remifentanil-based anesthesia and analgesia (group B), or combined general-epidural anesthesia (group C). Postoperative analgesia was provided in accordance with group assignment. Four and 24 hours after surgery, 20 mL of blood was drawn from each patient for analysis of leukocyte populations and lymphocyte subpopulations. Statistics were calculated with the SPSS software package, version 12.0.. All groups had elevated neutrophil counts after surgery; the lowest levels were in group C (P<.05). Patients in all 3 groups developed lymphopenia, which was still evident 24 hours after surgery (P<.05). CD3 cell counts at 4 hours were lowest in patients who had received combined anesthesia (group C), CD19 cell counts were highest in group A, and CD16 cell counts were lowest in group C; this last difference was maintained at 24 hours (P<.05 for all these comparisons).. Combined general-epidural anesthesia seems to lower the counts of natural killer cells that are involved in tumor surveillance and destruction.

Topics: Adenocarcinoma; Analgesia; Analgesia, Epidural; Analgesics; Anesthesia, Epidural; Anesthesia, General; Anesthetics, General; Endometrial Neoplasms; Female; Fentanyl; Humans; Hysterectomy; Immunologic Surveillance; Killer Cells, Natural; Lymphocyte Subsets; Lymphopenia; Methyl Ethers; Middle Aged; Morphine; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Sevoflurane

High-dose opioid anaesthesia contributes to decreasing metabolic and hormonal stress responses in patients undergoing cardiac surgery. However, the increase in context-sensitive half-life of opioids given as a high-dose regimen can affect postoperative respiratory recovery. In contrast, remifentanil can be given in high doses without prolonging context-sensitive half-life due to its rapid metabolism. Therefore, we performed a prospective, randomized trial to compare anaesthesia consisting of propofol/remifentanil or propofol/sufentanil with regard to postoperative respiratory function and outcome.. Patients undergoing coronary artery bypass grafting were randomized to a propofol/remifentanil (0.5-1.0 microg kg(-1) min(-1)) or propofol/sufentanil (30-40 ng kg(-1) min(-1)) based anaesthetic. Carbon dioxide response, forced expiratory volume in one second, vital capacity, and functional residual capacity were measured 1 day prior to the operation, 1 h before extubation, 1, 24 and 72 h after extubation. In addition, the incidence of atelectasis, pulmonary infiltrates, intensive care unit and postoperative length of stay were compared. Patients and physicians were blinded to the treatment group.. Twenty-five patients in each treatment group completed the study. There was no difference between patients of the treatment groups regarding demographics, risk- or pain scores. In all patients, carbon dioxide response, forced expiratory volume in one second, vital capacity and functional residual capacity were decreased postoperatively compared to baseline. Patients randomized to remifentanil had less depression of carbon dioxide response, less atelectasis and shorter postoperative length of stay (12 d vs. 10 d) than after sufentanil (P < 0.05).. Intraoperative use of high-dose remifentanil for coronary artery bypass grafting may be associated with improved recovery of pulmonary function and shorter postoperative hospital length of stay than sufentanil.

Topics: Aged; Analgesics, Opioid; Analysis of Variance; Coronary Artery Bypass; Female; Humans; Hypnotics and Sedatives; Intubation, Intratracheal; Length of Stay; Male; Pain Measurement; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Pulmonary Atelectasis; Remifentanil; Respiration; Respiratory Function Tests; Sufentanil; Time Factors; Treatment Outcome

Following strabismus surgery, immediate postoperative ophthalmic evaluation may be desired. Thus, an anaesthetic technique allowing rapid recovery of ocular motility is required. Saccadic eye movements is a biophysical monitor of ocular motility and may be used to assess recovery from anaesthesia. The aim of this study is to compare the time to the recovery of saccadic eye movements in patients, following one of two anaesthetic techniques: Propofol-remifentanil-based anaesthesia vs. sevoflurane-fentanyl-based anaesthesia.. Fifty adult patients undergoing strabismus surgery were randomly assigned to one of two groups: patients in Group R received induction and maintenance of anaesthesia with propofol and remifentanil, while patients in Group S received induction of anaesthesia with propofol and fentanyl and maintenance of anaesthesia with sevoflurane. Recovery from anaesthesia was measured from the time all anaesthetics were turned off and was assessed every 2 min. Recovery time was attained when patients were able to generate brisk saccadic eye movements. At recovery time, the ophthalmic evaluation was started.. The mean recovery time of saccadic eye movements was significantly shorter in the Group R when compared to the Group S (12.1 +/- 4.3 min vs. 21.5 +/- 4.7 min, respectively, P < 0.0001). More patients in Group S experienced nausea and vomiting postoperatively as compared to Group R (9/25 vs. 2/25, respectively, P = 0.037).. Propofol-remifentanil-based anaesthesia may be a useful technique in strabismus surgery when immediate postoperative ophthalmic evaluation is desired. When compared to sevoflurane maintenance of anaesthesia, it allows for a more rapid recovery from anaesthesia as judged by recovery of saccadic eye movements and a decreased incidence of postoperative nausea and vomiting.

Topics: Adolescent; Adult; Aged; Anesthetics, Intravenous; Biophysical Phenomena; Biophysics; Female; Fentanyl; Humans; Male; Methyl Ethers; Middle Aged; Piperidines; Postoperative Complications; Propofol; Remifentanil; Saccades; Sevoflurane

Remifentanil has a unique metabolic pathway that holds potential benefits for long-term sedation. We compared remifentanil-midazolam to sufentanil-midazolam in 41 critically ill adults requiring mechanical ventilation.. Randomized double-blind trial.. Infusion rates were titrated every 4 hours to achieve the desired Ramsay score. Five fold increases in dose requirement was considered as the development of tolerance. Drugs requirement, development of tolerance and weaning time of ventilation were compared.. The study was stopped after an interim analysis. The remifentanil and sufentanil groups were comparable regarding IGS II: 56+/-22 vs 64+/-26, mean+/-SD, ICU length of stay: 26 (8-45) vs 19 (11-34) days, and sedation duration: 6 (4-19) vs 6 (3-16)days, median [interquartile range, IQR]). There was a shorter weaning time in the remifentanil group as compared to sufentanil group: 22 h (12-53) vs 96 (47-142) h, median [IQR], p=0.04). The daily opioid infusion rate needed to be decreased over time only in sufentanil group, p < 0.001. Tolerance occurred in 6 (30%; CI(95), 10 to 40%) remifentanil and no sufentanil patients (P=0.02).. Sufentanil infusion needed to be reduced over time and prolonged the weaning time when compared to remifentanil.

Topics: Adult; Aged; Conscious Sedation; Critical Care; Dose-Response Relationship, Drug; Double-Blind Method; Drug Therapy, Combination; Drug Tolerance; Female; Hospital Mortality; Humans; Lung Diseases; Male; Midazolam; Middle Aged; Piperidines; Postoperative Complications; Remifentanil; Respiration, Artificial; Shock; Sufentanil; Ventilator Weaning

This randomized, double-blind study was designed to evaluate analgesic effectiveness and side effects of two remifentanil infusion rates in patients undergoing extracorporeal shock wave lithotripsy (ESWL) for renal stones. We included 200 patients who were administered remifentanil either 0.05 microg x kg(-1) x min(-1) (n = 100) or 0.1 microg x kg(-1) x min(-1) (n = 100) plus demand bolus of 10 microg of remifentanil via a patient-controlled analgesia (PCA) device. No other sedating drugs were given. The frequencies of PCA demands and deliveries were recorded. Arterial blood pressure, oxygen saturation, and respiratory rate were recorded throughout the procedure; postoperative nausea and vomiting (PONV), dizziness, itching, agitation, and respiratory depression were measured posttreatment. Visual analog scale (VAS) scores were taken preoperatively, directly postoperatively, and 30 min after finishing the procedure. There were no statistically significant differences in the frequency of PCA demands and delivered boluses or among perioperative VAS scores. The extent of PONV and frequency of dizziness and itching immediately after and dizziness 30 min after the end of treatment were significantly reduced in the smaller dose group. We conclude that a remifentanil regimen of 0.05 microg x kg(-1) x min(-1) plus 10 microg demands is superior to 0.1 microg x kg(-1) x min(-1) plus demands, as there was no difference in the VAS scores recorded between groups and it has a less frequent incidence of side effects in patients receiving ESWL.. Remifentanil is an appropriate analgesic choice for patients undergoing extracorporeal shock wave lithotripsy (ESWL) therapy, as it has both fast onset and offset times. We studied remifentanil as a sole drug for ESWL and have shown that an infusion rate of 0.05 microg x kg-1 x min-1 plus patient-controlled analgesia demands of 10 microg provides adequate analgesia and has significantly less side effects than a dose of 0.1 microg x kg-1 x min-1 plus 10 microg demands.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesia, Patient-Controlled; Analgesics, Opioid; Dizziness; Dose-Response Relationship, Drug; Female; Humans; Infusions, Intravenous; Kidney Calculi; Lithotripsy; Male; Middle Aged; Pain Measurement; Piperidines; Postoperative Complications; Postoperative Nausea and Vomiting; Pruritus; Remifentanil; Single-Blind Method

Delirium is a frequent complication of major surgery in older persons. The authors evaluated the possible benefit of donepezil versus placebo in the prevention and treatment of postoperative delirium in an older population without dementia undergoing elective total joint-replacement surgery.. A sample of 80 patients participated in this randomized, double-blind, placebo-controlled trial of donepezil. Each participant was evaluated before surgery and then received donepezil or placebo for 14 days before surgery and 14 days afterward. Postoperative delirium was assessed with the Delirium Symptom Interview, Confusion Assessment Method, daily medical record, nurse-observation reviews, and DSM-IV diagnostic criteria for delirium. Subsyndromal delirium was also assessed for each participant.. Delirium, diagnosed by DSM-IV criteria, was found on at least 1 postoperative day in 18.8% of subjects, but there were no significant differences between the donepezil and placebo groups. When delirium was present, it lasted only 1 day, and there was no difference between the groups. Subsyndromal delirium was found on at least 1 postoperative day for 68.8% of subjects, and, when this occurred, lasted 2 days or less, on average. There was no difference between the groups in the occurrence or duration of subsyndromal delirium. There was no difference between the groups in disposition to home or to another facility.. This pilot study was unable to demonstrate a benefit for donepezil in preventing or treating delirium in a relatively young and cognitively-intact group of elderly patients undergoing elective orthopedic surgery. Furthermore, postoperative delirium was not a major problem in this population.

Topics: Aged; Aged, 80 and over; Cholinesterase Inhibitors; Delirium; Donepezil; Double-Blind Method; Female; Humans; Indans; Male; Middle Aged; Pilot Projects; Piperidines; Postoperative Complications

The randomized, patient- and observer-blinded study was performed in 120 patients undergoing ear, nose and throat surgery to test the hypothesis that intravenous anaesthesia with propofol-remifentanil when compared with a balanced anaesthesia technique using isoflurane-alfentanil improves the speed of recovery, minimizes postoperative side-effects and, thus, leads to an improved quality of recovery without increasing total costs.. The total costs for each anaesthesia technique were calculated considering drug acquisition costs, personnel costs for the additional time spent in the operating room and the postanaesthesia care unit until fast-tracking eligibility, and the costs to treat the side-effects during and after operation.. The times from the end of surgery to tracheal extubation and the time until leaving the operating room were not different between the two groups. However, more patients receiving intravenous anaesthesia (80 versus 49%) were eligible for fast tracking and thus could bypass the recovery room. This was associated with an average cost saving of 6.00 euros per patient. However, intravenous anaesthesia was associated with higher total costs (89 euros versus 78 euros) mainly because of higher acquisition costs of the anaesthetics (34.60 euros versus 16.50 euros). There was no difference in the quality of recovery as measured by a Quality of Recovery score and patient satisfaction between the two groups.. The higher acquisition costs of the intravenous anaesthetics propofol and remifentanil cannot be compensated for by improved speed of recovery. This anaesthesia technique is more cost intensive than balanced anaesthesia using isoflurane and alfentanil.

Topics: Adult; Alfentanil; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Drug Costs; Female; Health Care Costs; Humans; Isoflurane; Length of Stay; Male; Otorhinolaryngologic Surgical Procedures; Outcome Assessment, Health Care; Piperidines; Postoperative Complications; Propofol; Recovery Room; Remifentanil

There are conflicting results concerning the pre-emptive effect of ketamine on central sensitization following surgery. The aim of this prospective, randomized, double-blind, placebo-controlled study was to assess the effect of the N-methyl-D-aspartate receptor antagonist ketamine on postoperative morphine consumption and pain score after remifentanil-based anaesthesia in adult patients scheduled for tonsillectomy.. We studied 40 adult patients undergoing elective tonsillectomy. Total intravenous anaesthesia was induced and maintained with remifentanil (0.125-1.0 microg kg(-1) min(-1)) and propofol target-controlled infusion. Patients in group K received a bolus dose of ketamine 0.5 mg kg(-1) immediately after anaesthetic induction, followed by a continuous infusion of 2 microg kg(-1) min(-1). Saline was administered in the same sequence in group S. Propofol, remifentanil, and the study drug infusions were discontinued at the end of surgery.. Intraoperative remifentanil consumption (0.57 +/- 0.18 in group K vs. 0.55 +/- 0.14 microg kg(-1) min(-1) in group S), morphine requirement in the PACU (11 +/- 3 in group K vs. 9 +/- 4 mg in group S) and in the ward (22 +/- 11 in group K vs. 25 +/- 14 mg in group S), median time to first analgesia in the ward (338 +/- 126 in group K vs. 328 +/- 144 min in group S), and VAS pain scores were comparable in both groups.. Small-dose of ketamine does not seem to be a useful adjunct to remifentanil-based anaesthesia during short, painful surgical procedures.

Topics: Adult; Analgesics; Analgesics, Opioid; Analysis of Variance; Anesthesia, Intravenous; Anesthetics, Intravenous; Double-Blind Method; Female; Humans; Ketamine; Male; Middle Aged; Morphine; Pain; Pain Measurement; Patient Satisfaction; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Sodium Chloride; Time Factors; Tonsillectomy

The pharmacokinetic properties of the short-acting micro opioid receptor-agonist remifentanil makes it possible to give cardiac surgical patients a deep intraoperative anesthesia without experiencing postoperative respiratory depression and a prolonged stay in the intensive care unit (ICU). However, previous investigations have shown that patients who received remifentanil required additional analgesia during the early postoperative period as compared to patients who received fentanyl. The aim of the present study therefore was to investigate the effects of supplementing remifentanil to a standard fentanyl-based anesthesia in coronary artery bypass grafting (CABG).. The study was prospective, randomized, double-blind, and placebo-controlled. Twenty male patients aged 55-70 years were included. All patients received a standard fentanyl and isoflurane-based anesthesia. In addition, the patients were randomized to receive either remifentanil 0.5 micro g kg(-1) min(-1) or placebo during surgery. Hemodynamic recordings and measurements of blood glucose and plasma adrenaline and noradrenaline were performed intra- and postoperatively.. Remifentanil reduced the hemodynamic and metabolic response to surgical stress compared to the standard fentanyl-based anesthetic regimen. However, the patients in the remifentanil group had a lower cardiac output (CO), left ventricular stroke work index (LVSWI), and mixed venous oxygen saturation (SvO(2)), and a higher central venous pressure (CVP) than the patients in the placebo group during the early postoperative phase, indicating a postoperative cardiac depression in the remifentanil group.. In CABG, remifentanil reduces the hemodynamic and metabolic responses during surgery but seems to give a cardiac depression in the early postoperative phase.

Topics: Aged; Anesthesia, General; Anesthesia, Intravenous; Anesthetics, Intravenous; Arrhythmias, Cardiac; Biomarkers; Blood Gas Analysis; Coronary Artery Bypass; Creatine Kinase; Depression, Chemical; Double-Blind Method; Electrocardiography, Ambulatory; Hemodynamics; Humans; Isoenzymes; Male; Middle Aged; Monitoring, Intraoperative; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Troponin I

To demonstrate that alvimopan (6 or 12 mg) accelerates recovery of gastrointestinal (GI) function in patients undergoing laparotomy for bowel resection or radical hysterectomy.. Postoperative ileus (POI) following laparotomy may increase morbidity and extend hospitalization. Opioids can contribute to the duration of POI. Alvimopan is a novel opioid receptor antagonist in development for the management of POI.. A total of 510 patients scheduled for bowel resection or radical hysterectomy were randomized (1:1:1) to receive alvimopan 6 mg, alvimopan 12 mg, or placebo orally > or =2 hours before surgery, then twice a day (b.i.d.) until hospital discharge or for up to 7 days. The primary efficacy end point was a composite of time to recovery of upper and lower GI function. An associated secondary end point was time to hospital discharge order written.. The modified intent-to-treat population included 469 patients (451 bowel resection and 18 radical hysterectomy patients). Time to recovery of GI function was accelerated for the alvimopan 6 mg (hazard ratio [HR] = 1.28; P < 0.05) and 12 mg (HR = 1.54; P < 0.001) groups with a mean difference of 15 and 22 hours, respectively, compared with placebo. The time to hospital discharge order written was also accelerated in the alvimopan 12 mg group (HR = 1.42; P = 0.003) with a mean difference of 20 hours compared with placebo. The incidence of adverse events was similar among treatment groups.. Alvimopan accelerated GI recovery and time to hospital discharge order written compared with placebo in patients undergoing laparotomy and was well tolerated.

Topics: Adult; Aged; Aged, 80 and over; Defecation; Double-Blind Method; Female; Gastrointestinal Agents; Humans; Hysterectomy; Ileus; Intestine, Large; Intestine, Small; Laparotomy; Male; Middle Aged; Patient Discharge; Piperidines; Placebos; Postoperative Complications; Premedication; Receptors, Opioid, mu; Recovery of Function; Time Factors

Comparison of the length of mechanical ventilation and postoperative complications after coronary surgery in elderly patients anaesthetised with propofol associated with either alfentanil or remifentanil.. Retrospective study with an historic control group.. Three hundred thirty-eight consecutive patients (75-year-old or more) undergoing isolated coronary surgery. One hundred and fifty seven patients operated between January 1998 and June 2000 received alfentanil (1 microg/kg/minute) with a manually control infusion of propofol, 181 operated between July 2000 and 2002, remifentanil 0.25 microg/kg/minute with target controlled infusion of propofol (target blood concentration: 1.5 to 2 microg/ml).. The two groups were compared for preoperative and surgical data. The length of mechanical ventilation, stay in ICU and the main postoperative complications were compared between the two groups.. Length of mechanical ventilation was significantly reduced in the remifentanil group (6 +/- 9 h vs. 13 +/- 63 h ; p <0.0001), 70% of the patients were extubated before the 6th postoperative hours against 53% in the alfentanil group (p =0.0023). This was not associated with a reduction of stay in ICU or postoperative complications. During surgery, an increased used of vasopressor was observed in the remifentanil group (40.2% vs 2.4% ; p <0.0001) with a postoperative elevation of blood concentration of CKMb (35.7 +/- 38.2 microg/l, vs. 27.7 +/- 31.9 microg/l, p =0.02).. Elderly patients undergoing coronary surgery were extubated earlier with remifentanil. However, this had no effect on duration of ICU stay but was associated with an increased used of vasopressor.

Topics: Aged; Anesthetics, Intravenous; Coronary Disease; Humans; Infusions, Intravenous; Orthopedic Procedures; Piperidines; Postoperative Complications; Propofol; Remifentanil; Stroke; Treatment Outcome

Stapedotomy for otosclerosis presents particular anaesthesiology demands as the surgeon has to assess functional results during the operation, work with some bleeding, be ensured the collaboration of the patient, and limit the occurrence of intra- and post-operative symptoms (dizziness, nausea, vomiting and pain). Remifentanyl, a micro-opioid selective agonist characterised by short latency and duration, has been used for about 2 years at the Otolaryngological Unit of the "Federico II" University of Naples for patients with otosclerosis undergoing stapedotomy. Aim of the study was, therefore, to assess: efficacy and tolerability of Remifentanyl in combination with a local anaesthetic in surgical procedures for otosclerosis; intra- and post-operative reduction in patient symptoms of dizziness, nausea, vomiting and pain; reduction of intra-operative bleeding; degree of patient collaboration and optimisation of anaesthesiological and vital parameters monitored during surgery. The study was carried out on 92 patients with otosclerosis, (17 M, 75 F), median age 41 years (range 25-56), undergoing stapedotomy. Patients were randomly assigned to one of two groups, which were homogeneous as far as concerns age, sex and pre-operative hearing: i. Group A (50 patients), received Remifentanyl infusion in combination with canal injection for local anaesthesia with Mepivacaine 2% and Adrenalin 1/100,000; ii. Group B (42 patients), received only local anaesthetic by infiltration of the external canal ear. Remifentanyl led to an improvement over the local anaesthetic technique previously used, with a clear decrease in intra- and post-operative neurovegetative symptoms such as dizziness, nausea, vomiting and pain, as well as reduced bleeding.

Topics: Adult; Analgesics, Opioid; Dizziness; Female; Humans; Hypnotics and Sedatives; Intraoperative Complications; Male; Middle Aged; Nausea; Otosclerosis; Pain; Piperidines; Postoperative Complications; Remifentanil; Stapes Surgery; Vomiting

Remifentanil is a potent ultra-short-acting opioid, which permits rapid emergence. However, remifentanil is expensive and may have detrimental effects on hemodynamics in case of overdose. Target-controlled infusion (TCI) permits adapting infusion to pharmacokinetic models. In this prospective randomized study, we compared intra- and postoperative hemodynamics, remifentanil requirement during anesthesia, and postoperative morphine requirement in patients scheduled for carotid surgery, and receiving either continuous IV weight-adjusted infusion of remifentanil (RIVA) or TCI for remifentanil (TCIR). Forty-six patients were enrolled in this study: all were anesthetized by using TCI for propofol. Twenty-three received RIVA (0.5 micro g. kg(-1) x min(-1)) for the induction of anesthesia and endotracheal intubation, with the infusion rate decreased to 0.25 micro g x kg(-1) x min(-1) after intubation, then adapted by step of 0.05 micro g x kg(-1) x min(-1) according to hemodynamics. Twenty-three patients received TCIR (Minto model, Rugloop), with an effect-site concentration at 4 ng/mL during induction, then adapted by step of 1 ng/mL according to hemodynamics. All patients received atracurium and a 50% mixture of N(2)O/O(2). Hemodynamic variables were recorded each minute. The number and duration of hemodynamic events were collected, and total doses of anesthetics (remifentanil and propofol) and vasoactive drugs were noted in both groups of patients. Data were analyzed by using unpaired t-tests. RIVA was significantly associated with more frequent episodes of intraoperative hypotension (16 versus 6, P < 0.001) and more frequent episodes of postoperative hypertension and/or tachycardia requiring more frequent administration of beta-adrenergic blockers (16 vs 10, P < 0.04) in comparison with TCIR. The need for morphine titration was not significantly different between groups. TCIR led to a significantly smaller requirement of remifentanil (700 +/- 290 versus 1390 +/- 555 micro g, P < 0.001) without difference in propofol requirement. This prospective randomized study demonstrated that, during carotid endarterectomy, in comparison with patients receiving remifentanil using continuous RIVA, TCI results in less hypotensive episodes during the induction of anesthesia, in fewer episodes of tachycardia and/or hypertension and a smaller beta-adrenergic blocker requirement during recovery, and a decrease in remifentanil requirement. Recommendations to prefer TCI for remif. Remifentanil for intraoperative analgesia in carotid artery surgery is associated with a better stability in perioperative hemodynamics when administered in target-controlled infusion compared with continuous weight-adjusted infusion. This may be related to a smaller requirement of this drug when using target-controlled infusion, as well as a smooth mode of administration.

Topics: Adrenergic beta-Antagonists; Aged; Analgesics, Opioid; Anesthesia, General; Endarterectomy, Carotid; Endpoint Determination; Female; Hemodynamics; Humans; Hypotension; Infusions, Intravenous; Male; Monitoring, Intraoperative; Pain, Postoperative; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Vascular Surgical Procedures

The aim of this study was to investigate how many patients, after anesthesia with either propofol/remifentanil or propofol/fentanyl/alfentanil, within 20 minutes from the end of surgery could be transferred directly to the general ward. The number of undesired preoperative incidents, the anesthetists', the surgeons', and the patients' evaluations of the anesthesia were registered. An evaluation of the economic consequences of the two methods was also intended.. The study was clinically controlled, randomised, and partly blinded. A total of 80 patients undergoing eye surgery were recruited. The patients were scored 10, 15, and 20 minutes after the end of surgery according to a modified Aldrete score. With sufficient awakening score, the patients were transferred to the general ward.. Thirty-six patients in each group underwent the examination. In the propofol/remifentanil-group 31 (86%) could be transferred to the general ward compared to 15 (42%) in the proponol/fentanyl/alfentanil-group. In the propofol/remifentanil-group there were less reactions to the start of surgery, more episodes with preoperative hypotension and postoperative shivering. Otherwise there were no differences between the groups. It was estimated that the additional expenses for medcine were by far outweighed by the lower costs postoperatively.. With a propofol/remifentanil-anesthesia, the patients had a predictably short awakening time, so they could be transferred directly to the general ward. This may, especially in ambulatory surgery, mean cost savings and perhaps higher patient satisfaction.

Topics: Adolescent; Adult; Aged; Alfentanil; Anesthesia Recovery Period; Anesthetics, Intravenous; Cost-Benefit Analysis; Female; Fentanyl; Humans; Intraoperative Complications; Male; Middle Aged; Patient Satisfaction; Piperidines; Postoperative Complications; Propofol; Remifentanil; Retinal Detachment

This study compares remifentanil/propofol (remi/prop) with isoflurane/fentanyl (iso/fen) anesthesia to determine which provides the greater hemodynamic stability, lesser myocardial ischemia, and morbidity with better postoperative outcomes after carotid endarterectomy. Sixty patients undergoing unilateral carotid endarterectomy were randomized to receive either a remi/prop or iso/fen anesthetic. Hemodynamic variables were recorded during the surgical procedure. In addition, transesophageal echocardiography was used to assess evidence of intraoperative regional wall motion abnormalities suggestive of cardiac ischemia. Emergence and extubation times, recovery from anesthesia, hemodynamic instability, nausea, vomiting, and pain in post anesthesia recovery, discharge delays, ICU admittance, hospital discharge, and preoperative and postoperative troponin levels were compared using appropriate statistical methods with P < 0.05 considered significant. The groups were demographically alike. Hemodynamic variables were similar during intubation and throughout surgery. Twenty-two percent of patients receiving iso/fen developed intraoperative regional wall motion abnormalities suggestive of ischemia, whereas no remi/prop patients had changes (P < 0.05). There was no difference in ST-T wave changes after surgery, and no patient had an elevation in troponin I levels. Postoperative variables were similar except that patients who received iso/fen had lower Stewart recovery scores during the first 15 minutes after post anesthesia care unit admission and a higher incidence of nausea and vomiting the day after surgery, whereas patients receiving remi/prop had discharge delays secondary to hypertension. ICU admittance, time to first void, oral intake, and time to hospital discharge were similar between the groups. At 9 times the cost of an iso/fen anesthesia technique, remi/prop offers little advantage over inhalational anesthesia for carotid endarterectomy.

Topics: Aged; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Carotid Artery Diseases; Endarterectomy, Carotid; Female; Fentanyl; Hemodynamics; Humans; Intraoperative Complications; Isoflurane; Male; Myocardial Ischemia; Piperidines; Postoperative Complications; Propofol; Remifentanil

We studied stent thrombosis in 4,607 patients with acute coronary syndromes who received a coronary stent as part of routine care during 2 trials of aspirin versus sibrafiban for secondary prevention. In these patients, stent thrombosis occurred more often than in previous patients who underwent elective percutaneous coronary intervention. These patients and their outcomes may be more representative of patients with typical acute coronary syndromes undergoing stenting in clinical practice.

Topics: Acute Disease; Aspirin; Causality; Coronary Disease; Coronary Thrombosis; Female; Humans; Incidence; Male; Middle Aged; Multivariate Analysis; Myocardial Ischemia; Oximes; Piperidines; Platelet Aggregation Inhibitors; Postoperative Complications; Stents; Syndrome

Minimal inflation pressures are recommended for limb surgery to eliminate complications attributable to high inflation pressures with the pneumatic tourniquets. We applied controlled hypotension and a minimal inflation pressure (CHAMIP) technique to provide a bloodless surgical field. Thirty-six patients scheduled for upper extremity surgery were randomized equally to receive either normotensive anesthesia and conventional inflation pressures or controlled hypotension (systolic arterial blood pressure of 80-100 mm Hg and mean arterial blood pressure >60 mm Hg) and minimum inflation pressures. Anesthesia was induced with propofol IV bolus and remifentanil IV continuous infusion and maintained with propofol and remifentanil IV continuous infusion. To determine the minimal inflation pressure, the digital plethysmograph was applied to the second finger at the side of the operation and the tourniquet was inflated slowly until the arterial pulsations disappeared on the oscilloscope. A bloodless surgical field was obtained in almost all patients, even though systolic arterial blood pressures (100-138 mm Hg versus 80-100 mm Hg) and applied tourniquet inflation pressures (270 mm Hg versus 110-140 mm Hg) were significantly lower in the hypotensive group. No complications associated with controlled hypotension were encountered. In conclusion, CHAMIP may be a safe and reliable method for upper extremity surgery performed with pneumatic tourniquets.. Pneumatic tourniquets are associated with adverse effects resulting from high inflation pressures. Therefore, minimal inflation pressures are recommended in extremity surgery. To reach real minimal inflation pressure the patient's blood pressure must be reduced. We used controlled hypotension with remifentanil and propofol to reach minimal inflation pressures.

Topics: Adult; Air Pressure; Anesthesia, General; Anesthesia, Intravenous; Anesthetics, Intravenous; Blood Pressure; Female; Humans; Hypotension, Controlled; Male; Orthopedic Procedures; Piperidines; Plethysmography; Postoperative Complications; Propofol; Remifentanil; Tourniquets; Upper Extremity

Remifentanil may be beneficial in patients undergoing coronary artery bypass graft surgery, by promoting hemodynamic stability, reducing drug requirements, and attenuating the neurohumoral "stress response." We enrolled 77 cardiac surgical patients in a double-blinded, randomized trial and randomly allocated them to one of three groups: remifentanil infusion at 0.83 micro g. kg(-1). min(-1) (Group R); fentanyl bolus, small dose, at 12 micro g/kg (Group FLD); and fentanyl bolus, moderate dose, at 24 micro g/kg (Group FMD). We found a significant difference in the median time to tracheal extubation: Group FLD, 6.5 h; Group R, 7.3 h; and Group FMD, 9.7 h (P = 0.025). Group R patients had similar times to those of Groups FLD (P = 0.14) and FMD (P = 0.30). Group FLD patients had a longer length of hospital stay (P = 0.030). Patients in Group R had a significantly infrequent rate of hypertension but a frequent rate of hypotension (P < 0.01). The urinary cortisol excretion was larger in Group FLD patients (P < 0.0005), and urine flow was smaller (P < 0.0005). Remifentanil was associated with a propofol dose reduction (P = 0.0005) and a concomitant higher bispectral index (P = 0.032). Three Group FLD patients, but none in groups FMD and R, had postoperative myocardial infarctions (P = 0.032). Remifentanil has larger drug acquisition costs but does not increase the total hospital costs associated with cardiac surgery.. Remifentanil did not significantly reduce the duration of tracheal intubation after cardiac surgery. Remifentanil, when compared with fentanyl (total doses of approximately 15 and 28 micro g/kg), blunts the hypertensive responses associated with cardiac surgery but is associated with more hypotension; when compared with fentanyl 15 micro g/kg, remifentanil reduces cortisol excretion. Larger-dose opioids (remifentanil 0.85 micro g. kg(-1). min(-1) or fentanyl 28 micro g/kg) were associated with a decreased rate of myocardial infarction after cardiac surgery.

Topics: Aged; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Cardiac Surgical Procedures; Costs and Cost Analysis; Double-Blind Method; Electrocardiography; Electroencephalography; Female; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Monitoring, Intraoperative; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Respiration, Artificial; Treatment Outcome

To determine if the combined remifentanil and intrathecal morphine (RITM) anesthetic technique facilitates early extubation in patients undergoing coronary artery bypass graft (CABG) surgery.. Prospective, randomized, controlled clinical trial.. Referral center for cardiothoracic surgery at a university hospital.. Patients (n = 24) undergoing first-time elective CABG surgery.. Two groups represented RITM (n = 12) and fentanyl-based (controls, n = 12) anesthesia. Premedication was standardized to temazepam, 0.4 mg/kg, and anesthesia was induced with etomidate, 0.3 mg/kg, in both groups. The RITM group received remifentanil, 1 microg/kg bolus followed by 0.25 to 1 microg/kg/min infusion, and intrathecal morphine, 2 mg. The control group received fentanyl, 12 microg/kg in 3 divided doses. Anesthesia was maintained with isoflurane and pancuronium in both groups. After completion of surgery, the remifentanil infusion was stopped. Complete reversal of muscle relaxation was ensured with a nerve stimulator, and a propofol infusion, 0.5 to 3 mg/kg/h, was started in both groups. All patients were transferred to the intensive care unit (ICU) to receive standardized postoperative care. Intensivists and ICU nurses were blinded to the group assignment. Propofol infusion was stopped, and the tracheal extubation was accomplished when extubation criteria were fulfilled.. Both groups were similar with respect to demographic data and surgical characteristics. Extubation times were 156 +/- 82 minutes and 258 +/- 91 minutes in the RITM and control groups (p = 0.012). Patients in the RITM group exhibited lower visual analog scale pain scores during the first 2 hours after extubation (p < 0.04). Morphine requirements during the 24 hours after extubation were 2.5 +/- 3 mg in the RITM group and 16 +/- 11 mg in the control group (p = 0.0018). Sedation scores were lower in the RITM group during the first 3 hours after extubation (p < 0.03). Pulmonary function tests as assessed by spirometry were better in the RITM group at 6 and 12 hours after extubation (p < 0.04). There were no significant differences in PaO(2) and PaCO(2) after extubation between the 2 groups. None of the patients had episodes of apnea during the immediate 24-hour postextubation period. Two patients from the RITM group required reintubation on the second and sixth postoperative days. There were no differences in ICU and hospital length of stay between the 2 groups.. Implementation of the RITM technique provided earlier tracheal extubation, decreased level of sedation, excellent analgesia, and improved spirometry in the early postoperative period. The impact of RITM on ICU and hospital length of stay and potential cost benefits require further evaluation.

Topics: Analgesics, Opioid; Anesthesia; Anesthetics, Combined; Anesthetics, Intravenous; Coronary Artery Bypass; Device Removal; Female; Fentanyl; Humans; Injections, Spinal; Intubation, Intratracheal; Length of Stay; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil

The objective of this study was to determine a dosing regimen for remifentanil-sevoflurane anaesthesia that achieves an optimal balance between quality of anaesthesia and time to recovery. Patients undergoing elective laparoscopic cholecystectomy were randomly allocated to receive 0.4, 0.8 or 1.2 MAC (minimal alveolar concentration) of sevoflurane combined with remifentanil as required to maintain stable anaesthesia. For induction of anaesthesia, the remifentanil dose was 25 microg x kg(-1) x h(-1) and the mean propofol dose which was required to obtain loss of consciousness was 1.59 mg x kg(-1). During the maintenance phase, the mean remifentanil dose was 16.0, 14.1 and 13.0 microg x kg(-1) x h(-1) for the 0.4, 0.8 and 1.2 MAC groups, respectively. The mean sevoflurane maintenance dose was 0.91, 1.24 and 2.1% end-tidal for the 0.4, 0.8 and 1.2 MAC groups, respectively. The incidence of somatic responses was significantly higher in the 0.4 MAC sevoflurane group. Recovery times were significantly faster in the 0.4 compared to the 0.8 and 1.2 MAC groups and in the 0.8 compared to the 1.2 MAC group. The combination of 14 microg x kg(-1) x h(-1) remifentanil and 1.24% end-tidal sevoflurane achieved the optimal balance between the quality, and recovery from anaesthesia.

Topics: Adult; Anesthesia Recovery Period; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Cholecystectomy, Laparoscopic; Dose-Response Relationship, Drug; Female; Hemodynamics; Humans; Male; Methyl Ethers; Middle Aged; Piperidines; Postoperative Complications; Remifentanil; Sevoflurane

Postoperative vomiting (POV) after strabismus surgery in children results in discomfort and prolonged hospital stays. Opioids increase the incidence of POV. Remifentanil has a context-sensitive half-life of 3 to 4 min, and how this short half-life influences POV in those patients is unknown. We conducted a prospective, double-blinded study in 81 ASA status I or II children from 2 to 12 yr of age undergoing elective strabismus surgery under general anesthesia. Patients were randomized to receive either remifentanil (bolus 1 microg/kg; infusion 0.1-0.2 microg x kg(-1) x min(-1)) or fentanyl (2 microg/kg, and 1 microg/kg every 45 min). POV episodes were recorded for 25 h. Pain scores were obtained by using an objective pain scale for 60 min during recovery. The number of patients who experienced POV did not differ significantly between groups (49% vs 48%). However, in the Remifentanil group, POV episodes were significantly less frequent (0.95 vs 2.2 episodes). In contrast, fentanyl was associated with lower pain scores during the first 30 min of recovery. We conclude that children undergoing strabismus surgery under balanced anesthesia with remifentanil, compared with fentanyl, showed less frequent POV. However, early postoperative analgesia was better with fentanyl.. Opioids increase the incidence of postoperative vomiting (POV). Remifentanil is characterized by the shortest half-life of all opioids used in anesthetic practice. Therefore, we studied the effect of remifentanil on POV compared with the longer-acting opioid fentanyl in children undergoing strabismus surgery.

Topics: Analgesics, Opioid; Child; Child, Preschool; Double-Blind Method; Female; Fentanyl; Humans; Incidence; Male; Pain, Postoperative; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Strabismus; Vomiting

We compared (a) the perioperative complications; (b) times to eligibility for, and actual time of the following: extubation, less intense monitoring, intensive care unit (ICU), and hospital discharge; and (c) resource utilization of nursing ratio for patients receiving either a typical fentanyl/isoflurane/propofol regimen or a remifentanil/isoflurane/propofol regimen for fast-track cardiac anesthesia in 304 adults by using a prospective randomized, double-blinded, double-dummy trial. There were no differences in demographic data, or perioperative mortality and morbidity between the two study groups. The mini-mental status examination at postoperative Days 1 to 3 were similar between the two groups. The eligible and actual times for extubation, less intense monitoring, ICU discharge, and hospital discharge were not significantly different. Further analyses revealed no differences in times for extubation and resource utilization after stratification by preoperative risk scores, age, and country. The nurse/patient ratio was similar between the remifentanil/isoflurane/propofol and fentanyl/isoflu-rane/propofol groups during the initial ICU phase and less intense monitoring phase. Increasing preoperative risk scores and older age (>70 yr) were associated with longer times until extubation (eligible), ICU discharge (eligible and actual), and hospital discharge (eligible and actual). Times until extubation (eligible and actual) and less intense monitoring (eligible) were significantly shorter in Canadian patients than United States' patients. However, there was no difference in hospital length of stay in Canadian and United States' patients. We conclude that both anesthesia techniques permit early and similar times until tracheal extubation, less intense monitoring, ICU and hospital discharge, and reduced resource utilization after coronary artery bypass graft surgery.. An ultra-short opioid technique was compared with a standard fast-track small-dose opioid technique in coronary artery bypass graft patients in a prospective randomized, double-blinded controlled study. The postoperative recovery and resource utilization, including stratification of preoperative risk score, age, and country, were analyzed.

Topics: Aged; Analgesics, Opioid; Anesthetics, Combined; Anesthetics, Intravenous; Coronary Artery Bypass; Double-Blind Method; Female; Fentanyl; Health Resources; Humans; Infusions, Intravenous; Injections, Intravenous; Intensive Care Units; Intraoperative Complications; Intubation, Intratracheal; Isoflurane; Length of Stay; Male; Middle Aged; Monitoring, Physiologic; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Time Factors

Postoperative recovery of gastrointestinal function and resumption of oral intake are critical determinants of the length of hospital stay. Although opioids are effective treatments for postoperative pain, they contribute to the delayed recovery of gastrointestinal function.. We studied the effects of ADL 8-2698, an investigational opioid antagonist with limited oral absorption that does not readily cross the blood-brain barrier, on postoperative gastrointestinal function and the length of hospitalization. We randomly assigned 79 patients--including 1 whose surgery was canceled--to receive one capsule containing 1 mg or 6 mg of ADL 8-2698 or an identical-appearing placebo capsule two hours before major abdominal surgery and then twice daily until the first bowel movement or until discharge from the hospital. Data were analyzed for 26 patients in each of the three groups; all received opioids for postoperative pain relief. Observers who were unaware of the group assignments evaluated the outcomes.. Fifteen patients underwent partial colectomy and 63 underwent total abdominal hysterectomy. Patients given 6 mg of ADL 8-2698 had significantly faster recovery of gastrointestinal function than those given placebo. The median time to the first passage of flatus decreased from 70 to 49 hours (P=0.03), the median time to the first bowel movement decreased from 111 to 70 hours (P=0.01), and the median time until patients were ready for discharge decreased from 91 to 68 hours (P=0.03). Effects in the group that received 1 mg of ADL 8-2698 were less pronounced.. Selective inhibition of gastrointestinal opioid receptors by an antagonist with limited oral absorption that does not readily cross the blood-brain barrier speeds recovery of bowel function and shortens the duration of hospitalization.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Colectomy; Defecation; Digestive System; Female; Flatulence; Humans; Hysterectomy; Intestinal Obstruction; Length of Stay; Male; Meperidine; Middle Aged; Morphine; Narcotic Antagonists; Pain, Postoperative; Piperidines; Postoperative Complications; Receptors, Opioid; Time Factors

Pyloric stenosis is sometimes associated with hemodynamic instability and postoperative apnea. In this multicenter study we examined the hemodynamic response and recovery profile of remifentanil and compared it with that of halothane in infants undergoing pyloromyotomy. After atropine, propofol, and succinylcholine administration and tracheal intubation, patients were randomized (2:1 ratio) to receive either remifentanil with nitrous oxide and oxygen or halothane with nitrous oxide and oxygen as the maintenance anesthetic. Pre- and postoperative pneumograms were done and evaluated by an observer blinded to the study. Intraoperative hemodynamic data and postanesthesia care unit (PACU) discharge times, PACU recovery scores, pain medications, and adverse events (vomiting, bradycardia, dysrhythmia, and hypoxemia) were recorded by the study's research nurse. There were no significant differences in patient age or weight between the two groups. There were no significant differences in hemodynamic values between the two groups at the various intraoperative stress points. The extubation times, PACU discharge times, pain medications, and adverse events were similar for both groups. No patient anesthetized with remifentanil who had a normal preoperative pneumogram had an abnormal postoperative pneumogram, whereas three patients with a normal preoperative pneumogram who were anesthetized with halothane had abnormal pneumograms after.. The use of ultra-short-acting opioids may be an appropriate technique for infants less than 2 mo old when tracheal extubation after surgery is anticipated.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Halothane; Hemodynamics; Humans; Infant; Infant, Newborn; Nitrous Oxide; Pain, Postoperative; Piperidines; Postoperative Complications; Pyloric Stenosis; Pylorus; Remifentanil

Although former preterm birth infants are at risk for postoperative apnea after surgery, it is unclear whether the same is true of full-term birth infants. We evaluated the incidence of apnea in 60 full-term neonates and infants undergoing pyloromyotomy both before and after anesthesia. All subjects were randomized to a remifentanil- or halothane-based anesthetic. Apnea was defined by the presence of prolonged apnea (>15 s) or frequent brief apnea, as observed on the pneumocardiogram. Apnea occurred before surgery in 27% of subjects and after surgery in 16% of subjects, with no significant difference between subjects randomized to remifentanil or halothane anesthesia. This apnea was primarily central in origin, occurred throughout the recording epochs, and was associated with severe desaturation in some instances. Of the subjects with normal preoperative pneumocardiograms, new onset postoperative apnea occurred in 3 (23%) of 13 subjects who received halothane-based anesthetics versus 0 (0%) of 22 subjects who received remifentanil-based anesthetics (P = 0.04). Thus, postoperative apnea can follow anesthesia in otherwise healthy full-term infants after pyloromyotomy and is occasionally severe with desaturation. New-onset postoperative apnea was not seen with a remifentanil-based anesthetic.. Abnormal breathing patterns can follow anesthesia in infants after surgical repair of pyloric stenosis. Occasionally, these patterns can be associated with desaturation. New-onset postoperative apnea was not seen with a remifentanil-based anesthetic.

Topics: Anesthetics, Inhalation; Anesthetics, Intravenous; Apnea; Halothane; Heart Rate; Humans; Infant; Infant, Newborn; Piperidines; Postoperative Complications; Pyloric Stenosis; Pylorus; Remifentanil; Respiration

Alvimopan (ADL 8-2698; Adolor Corporation, Exton, PA, USA) is a novel, peripherally restricted opioid antagonist. After oral administration, it has activity specific to the gastrointestinal (GI) tract. ADL 8-2698 has low systemic absorption and a high affinity for mu-opioid receptors. In healthy subjects, ADL 8-2698 antagonized loperamide-induced changes in GI transit and prevented morphine-induced delays in oral-cecal transit time without antagonizing centrally mediated opioid effects, such as analgesia or pupillary constriction. In the treatment of opioid naive patients who underwent surgery and received opioids for acute pain, oral ADL 8-2698 (6.0 mg) improved the management of postoperative ileus (POI) by shortening the time to achieve normal bowel function and, ultimately, hospital stay. Postoperative nausea and vomiting and the overall incidence of all GI side effects were reduced in patients treated with ADL 8-2698 for POI. Analgesia was not compromised, because there were no changes in median opioid consumption or Visual Analog Scale (VAS) pain scores in patients treated with ADL 8-2698 versus patients treated with placebo. No drug-related side effects were observed in acute pain postsurgical patients in the initial POI study. In patients treated with opioids for chronic pain or opioid addiction, lower doses of oral ADL 8-2698 (0.5 to 3.0 mg) reversed opioid bowel dysfunction (OBD) and normalized GI activity. These effects were evident without compromising opioid analgesia or inducing central nervous system symptoms of withdrawal. Some chronic opioid patients receiving apparently supramaximal doses of ADL 8-2698 (> or = 3.0 mg) reported localized GI side effects, possibly indicative of a localized GI withdrawal response. The most common side effects of ADL 8-2698 in chronic pain patients with OBD were abdominal pain, flatulence, and diarrhea. These effects were not observed in most OBD patients receiving lower doses of ADL 8-2698. Overall, ADL 8-2698 was well tolerated in clinical trials. Further studies to evaluate the efficacy and safety of ADL 8-2698 in clinical practice are in progress.

Topics: Analgesia; Analgesics, Opioid; Animals; Gastrointestinal Transit; Humans; Intestinal Pseudo-Obstruction; Intestines; Narcotic Antagonists; Pain Measurement; Piperidines; Postoperative Complications

In ambulatory anaesthesia the time required to recover from cognitive impairment should be as short as possible. The aim of this study was to compare the early cognitive recovery after remifentanil/propofol (R/P) and sevoflurane/fentanyl (S/F) anaesthesia.. Sixty patients scheduled for elective gynaecological laparoscopy and 24 female volunteers tested for the assessment of learning effects were investigated. After praemedication with midazolam anaesthesia was induced with propofol, atracurium and either 1 microgram/kg fentanyl or 1 microgram/kg remifentanil. For maintenance 0.25 microgram/kg/min remifentanil and 0.6 mg/kg/min propofol (R/P) or 1.7 vol% sevoflurane (S/F) were given. Both groups were ventilated with 30% oxygen in air and received metamizol for postoperative analgesia. Verbal Learning Test, Stroop Colour and Word Interference Test, Digit Symbol Substitution Test and Four Boxes Test were performed the day before surgery and 30 min, 1 h, 2 h and 4 h after termination of anaesthesia.. For remifentanil/propofol cognitive function was still impaired 2 h (Verbal Learning) and 4 h (Stroop, Digit Symbol Substitution and Four Boxes Test) after termination of anaesthesia. After sevoflurane/fentanyl anaesthesia cognitive impairment lasted the same duration in Four Boxes Test, but shorter in Stroop and Digit Symbol Substitution and could not be found in Verbal Learning Test.. The duration of cognitive impairment in the early postoperative period differed by the test procedures and the anaesthetic procedures used in this investigation. Recovery appeared to be faster after sevoflurane/fentanyl than after remifentanil/propofol at least in aspects of cognitive function.

Topics: Adult; Anesthesia, Inhalation; Anesthetics, Inhalation; Anesthetics, Intravenous; Cognition Disorders; Female; Fentanyl; Humans; Laparoscopy; Methyl Ethers; Neuropsychological Tests; Piperidines; Postoperative Complications; Propofol; Remifentanil; Sevoflurane

Anaesthesia comprising remifentanil plus isoflurane, enflurane or propofol was randomly evaluated in 285, 285 and 284 patients, respectively, undergoing short-procedure surgery.. Anaesthesia was induced with propofol (0.5 mg x kg(-1) and 10 mg x 10 s(-1)), and a remifentanil bolus (1 microg x kg(-1)) and infusion at 0.5 microg x g(-1) x min(-1). Five minutes after intubation, remifentanil infusion was halved and 0.5 MAC of isoflurane or enflurane, or propofol at 100 microg x kg(-1) x min(-1) were started and titrated for maintenance.. Patient demography and anaesthesia duration were similar between the groups. Surgery was performed as daycases (52%) or inpatients (48%). The median times (5-7 min) to extubation and postoperative recovery were similar between the groups. Responses to tracheal intubation (15% vs 8%) and skin incision (13% vs 7%) were significantly greater in the total intravenous anaesthesia (TIVA) group (P<0.05). Fewer patients given remifentanil and isoflurane (21%) or enflurane (19%) experienced > or =1 intraoperative stress response compared to the TIVA group (28%) (P<0.05). Median times to qualification for and actual recovery room discharge were 0.5-0.6 h and 1.1-1.2 h, respectively. The most common remifentanil-related symptoms were muscle rigidity (6-7%) at induction, hypotension (3-5%) and bradycardia (1-4%) intraoperatively and, shivering (6-7%), nausea and vomiting postoperatively. Nausea (7%) and vomiting (3%) were significantly lower with TIVA compared with inhaled anaesthetic groups (14-15% and 6-8%, respectively; P<0.05).. Anaesthesia combining remifentanil with volatile hypnotics or TIVA with propofol was effective and well tolerated. Times of extubation, postanaesthesia recovery and recovery room discharge were rapid, consistent and similar for all three regimens.

Topics: Adolescent; Adult; Aged; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Arthroscopy; Enflurane; Female; Humans; Isoflurane; Laparoscopy; Male; Middle Aged; Piperidines; Postoperative Complications; Propofol; Remifentanil; Varicose Veins; Vascular Surgical Procedures

We conducted a randomized trial to compare the incidence of vomiting and the quality of emergence from anesthesia associated with the use of remifentanil versus a nonopiate. It was expected that remifentanil would provide smoother emergence from anesthesia with a comparably low rate of vomiting. The study sample consisted of 115 pediatric patients undergoing dental restoration and extraction who were randomly assigned to the nonopiate or remifentanil groups based on their hospital admission numbers. The nonopiate patients received sufficient desflurane to prevent movement, typically 7%-9%. The remifentanil group received remifentanil 0.2 microg x kg(-1) x min(-1) and enough desflurane to prevent movement, typically 3.2%-3.6%. A trained postanesthesia care unit nurse, blinded to the anesthetic technique, assessed the quality of emergence and incidence of vomiting. Sixty-three patients received remifentanil and 52 received the nonopiate. The groups were not significantly different in either quality of emergence or incidence of vomiting. Remifentanil provided results comparable to a nonopiate with no increase in emesis.. A randomized, controlled clinical trial of 115 patients undergoing dental restoration indicated that an anesthetic technique using remifentanil provided quality of emergence comparable to and no greater incidence of vomiting than a nonopiate technique.

Topics: Anesthesia; Anesthetics, Intravenous; Child; Child, Preschool; Female; Humans; Male; Piperidines; Postoperative Complications; Remifentanil; Vomiting

Extubation and the immediate postoperative period are critical periods with strong sympatho-adrenergic stimulation. The aim of the present study was to investigate this period after balanced anaesthesia with remifentanil and alfentanil in cardiac risk patients.. 52 patients with coronary artery disease or with risk factors for coronary heart disease scheduled for elective extraperitoneal and extrathoracic operation were included in this study. Anaesthesia was induced by intravenous administration of etomidate, vecuronium and remifentanil (n = 27, 1 microgram/kg) or alfentanil (n = 25, 25 micrograms/kg). Anaesthesia was maintained with an Isoflurane/N2O/O2 mixture and by continuous intravenous infusion of remifentanil (0.25 microgram/kg/min) or alfentanil (45 micrograms/kg/h). During the first 60 minutes after extubation haemodynamic parameters were monitored and catecholamines were determined at defined time intervals. Parameters of recovery, the requirement of analgesics and cardiac medications were compared in both groups. Myocardial ischaemia was assessed by two-channel Holter electrocardiography.. The beginning of spontaneous respiration and time of extubation were similar in both groups. The time interval until opening eyes and the time between the beginning of spontaneous respiration and extubation was shorter in the patients treated with remifentanil. In this group patients suffered earlier from pain and had a higher pain score. Although the plasma catecholamines were comparable in both groups, in the patients treated with remifentanil changes in haemodynamic parameters were more pronounced. The incidence of shivering and the requirements of analgesics and cardiac medications were higher in these patients. The incidence of ST-segment changes indicating myocardial ischaemia was similar.. After balanced anaesthesia with remifentanil a more pronounced sympatho-adrenergic stimulation occurs because of the more rapid clearance of the analgesic effect in the recovery period compared to alfentanil requiring more analgesics and medications for the control of the haemodynamic parameters. Because of these specific pharmacological effects the use of remifentanil in cardiac risk patients has to be critically discussed.

Topics: Aged; Alfentanil; Anesthesia, Intravenous; Anesthetics, Intravenous; Cardiovascular Diseases; Catecholamines; Electrocardiography; Electrocardiography, Ambulatory; Female; Hemodynamics; Humans; Male; Piperidines; Postoperative Complications; Remifentanil; Risk Factors; Sympathetic Nervous System

This study was designed to investigate the differences between TIVA with propofol/remifentanil (P/R) and balanced anaesthesia with sevoflurane/fentanyl (S/F) in gynaecological laparoscopic surgery. Emphasis was put on haemodynamic reaction, recovery profile, postoperative side effects and patient satisfaction.. Sixty patients were randomly assigned to receive either total intravenous anaesthesia with propofol/remifentanil or anaesthesia with sevoflurane/fentanyl. After premedication (midazolam) and induction of anesthesia (propofol, atracurium) in both groups, either 1 microgram/kg fentanyl (S/F) or 1 microgram/kg remifentanil (P/R) was injected. Anaesthesia was maintained with 0.5 microgram/kg/min remifentanil (reduced to 50% after 5 min) and 0.06 microgram/kg/min propofol (P/R) or 1.7 vol % sevoflurane (S/F). Both groups were mechanically ventilated with 30% oxygen in air. The administration of sevoflurane and the infusion of the anaesthetics were adjusted to maintain a surgical depth of anaesthesia. For postoperative analgesia 1 g paracetamol was administered rectally prior to surgery. After recovery 20 mg/kg metamizol was given intravenously. At the end of surgery the anaesthetics were discontinued and haemodynamics, early emergence from anaesthesia, pain level, frequency of analgesic demand, incidence of PONV, shivering and patient satisfaction were assessed. Parameters were recorded for 24 h postoperatively.. Recovery time after propofol-remifentanil anaesthesia was significantly shorter than after administration of sevoflurane and fentanyl (spontaneous ventilation 4.1 vs. 6.3 min, extubation 4.3 vs. 9.3 min, eye opening 4.4 vs 8.2 min, stating name 5.3 vs. 13.2 min, stating date of birth 5.4 vs. 13.3 min). There were no significant differences between the groups in shivering, pain score, analgesic demand and PONV. The S/F group responded to tracheal intubation with significantly higher blood pressure than the P/R group. During maintenance of anaesthesia heart rate in patients with S/F was significantly higher (P/R:HR max +16/-10; S/F:HR max +24/-0.). Measured on a scale (S/F 62%).. Compared with patients given balanced anaesthesia with sevoflurane and fentanyl, TIVA with propofol and remifentanil proved to be particularly suited for gynaecological laparoscopic surgery. Its major advantages are haemodynamic stability, significantly shorter times of emergence, and the exceptional acceptance by the patients.

Topics: Adult; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Female; Fentanyl; Gynecologic Surgical Procedures; Hemodynamics; Humans; Laparoscopy; Methyl Ethers; Patient Satisfaction; Piperidines; Postoperative Complications; Propofol; Remifentanil; Sevoflurane; Wakefulness

To ascertain whether there is a difference between total intravenous anaesthesia with propofol (P) and remifentanil (R) and inhalational anaesthesia with desflurane (D) and nitrous oxide (N) with regard to haemodynamic reactions, recovery profile and postoperative analgesic demand in patients scheduled for elective microsurgical vertebral disc resection.. 50 patients (ASA I-II, 18-65 years) were randomly assigned to receive total intravenous anaesthesia with propofol and remifentanil or inhalational anaesthesia with desflurane and nitrous oxide. After standardised induction of anaesthesia in both groups (1 microgram.kg-1 remifentanil, 1.5 mg.kg-1 propofol 0.1 mg.kg-1 cisatracurium), anaesthesia was maintained in the D/N group with desflurane in 50% N2O. The patients of the P/R group received a constant infusion of 2 mg.kg-1.h-1 propofol and a constant infusion of 0.5 microgram.kg-1.min-1 remifentanil, which was reduced after 15 min by 50%. The administration of desflurane and the infusion of the anaesthetics were adjusted to maintain a surgical depth of anaesthesia. At the end of surgery the anaesthetics were discontinued and early emergence from anaesthesia was assessed by measuring time to spontaneous ventilation (VT > 4 ml/kg), tracheal extubation, opening of the eyes and stating correct name and data of birth. The frequency of analgesics and total demand for analgesics were determined using patient-controlled analgesia and recorded for 2 h postoperatively. In addition the pain level of the patients was measured on a visual analogue scale and the incidence of postoperative shivering, nausea and vomiting was noted.. Patients anaesthetised with desflurane responded to tracheal intubation and skin incision with increasing blood pressure and showed higher heart rates than patients anaesthetised with propofol and remifentanil, but there were no other haemodynamic differences between the groups in response to surgical stimuli. There were significantly shorter times to spontaneous ventilation (3.2 vs. 6.3 min), extubation (3.8 vs. 9.5 min), eye opening (3.0 vs. 11.5 min) and giving name and date of birth (4.8 vs. 14.3 min) in patients anaesthetised with remifentanil and propofol than in those receiving desflurane and nitrous oxide. In addition, patients anaesthetised with remifentanil and propofol had a greater incidence of postoperative shivering. There were no significant differences between the two groups in the patients' pain scores, analgesic demand and incidence of nausea and vomiting.. Patients anaesthetised with propofol and remifentanil have significantly shorter emergence times than patients anaesthetised with desflurane and nitrous oxide. The low incidence of postoperative pain after microsurgical vertebral disc resections requires no large-scale analgesic therapy, even after total intravenous anaesthesia including remifentanil.

Topics: Adult; Anesthesia Recovery Period; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Desflurane; Female; Hemodynamics; Humans; Intervertebral Disc; Isoflurane; Male; Nitrous Oxide; Piperidines; Postoperative Complications; Propofol; Remifentanil

Administration of cisapride, 3 x 5 mg in a suspension one day before surgery and 30 mg 3 and 8 hours after abdominal surgery with subsequent administration of 2 x 30 mg in suppositories up to the time when oral ingestion is possible, hastens significantly the restoration of GIT motility as compared with placebo. It can be therefore recommended as effective medication in the prevention of complications caused by impaired motility of the digestive tract.

Topics: Cisapride; Female; Gastrointestinal Agents; Gastrointestinal Motility; Gastroparesis; Humans; Male; Middle Aged; Piperidines; Postoperative Complications

The effect of cisapride pretreatment on gastric emptying in horses was determined by measuring serum concentrations of acetaminophen, a drug known to be readily absorbed in the small intestine but not in the stomach. The time to reach maximum serum acetaminophen concentrations (Tmax), the maximum serum concentrations (Cmax) and the area under the serum acetaminophen concentration vs. time curves (AUC) were compared among treatment groups. In the first part of the study, the effect of orally administered cisapride (0.1, 0.2 and 0.4 mg/kg bwt) on gastric emptying was examined in 6 normal fasted horses. In the second part of the study, gastric emptying in horses given endotoxin i.v. (n = 6) was compared to those that received cisapride per os prior to administration of endotoxin (n = 6) and those that received neither compound (n = 6). Cisapride did not alter gastric emptying in normal horses. Endotoxin caused a profound delay in gastric emptying and pretreatment with cisapride significantly attenuated this effect. It is concluded that cisapride may be useful as a prophylactic measure when administered prior to the development of endotoxaemia.

Topics: Acetaminophen; Administration, Oral; Analgesics, Non-Narcotic; Animals; Area Under Curve; Cisapride; Endotoxins; Female; Gastric Emptying; Gastrointestinal Agents; Horse Diseases; Horses; Intestinal Obstruction; Piperidines; Postoperative Complications

There are few data in the literature that describe the use of remifentanil when administered as a component of an inhalation or total i.v. anaesthetic (TIVA) technique. We studied 251 male and female patients, aged 18-75 years, ASA I-II, undergoing inguinal hernia repair, arthroscopic knee surgery or varicose vein surgery of at least 30 min duration without premedication. Patients were randomized to receive a remifentanil loading dose of 1.0 microgram kg-1 followed by a continuous infusion of 0.5 microgram kg-1 min-1 in combination with isoflurane (end-tidal concentration 0.6%), (Group I, n = 115) or propofol (initial infusion rate 9 mg kg-1 h-1 reduced to 6 mg kg-1 h-1 after 10 min), (Group P, n = 118). The remifentanil infusion rate was reduced by 50%, 5 min after tracheal intubation. Intraoperative stresses were treated with a remifentanil bolus (1 microgram kg-1) followed by an increase in the remifentanil infusion rate. At the insertion of the last suture, the remifentanil infusion and concomitant anaesthetic were switched off simultaneously. Times to spontaneous respiration, adequate respiration and tracheal extubation were significantly shorter in group I compared with group P (6.4 min vs 7.6 min, P < 0.01; 7.6 min vs 9.3, P < 0.003; 7.8 min vs 9.5 min, P < 0.015). Overall mean systolic blood pressures during surgery were greater in group P compared with group I (P < 0.05) but the absolute differences were clinically insignificant (4-5 mm Hg).

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Anesthetics, Inhalation; Anesthetics, Intravenous; Female; Humans; Isoflurane; Length of Stay; Male; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil

To compare the intraoperative effects and recovery characteristics of remifentanil hydrochloride and alfentanil when administered as part of balanced anesthesia, and to assess the effects of an additional remifentanil infusion administered as analgesic pretreatment before removal of the uterus.. Multicenter, double-blind, randomized, parallel-group study.. Two university hospitals.. 35 ASA physical status I, II, and III women scheduled for elective total abdominal hysterectomy with general endotracheal anesthesia.. Patients were premedicated with midazolam 0.05 mg/kg intravenously (i.v.). Anesthesia was induced with thiopental 2 mg/kg, vecuronium 0.15 mg/kg, and a single dose of opioid over 60 seconds (Pump 1): remifentanil 2 micrograms/kg (Remi/Placebo and Remi/Remi groups) or alfentanil 50 micrograms/kg (Alf/Placebo group). Anesthesia was maintained with a nitrous oxide/oxygen mixture (66:34 ratio) and a continuous opioid infusion: remifentanil 0.25 microgram/kg/min (Remi/Placebo and Remi/Remi) or alfentanil 0.5 microgram/kg/min (Alf/Placebo). At skin incision, a second blinded drug infusion was also initiated (Pump 2): remifentanil 0.25 microgram/kg/min (Remi/Remi) or saline placebo (Remi/Placebo and Alf/Placebo). Intraoperative responses were controlled with single doses of opioid and/or rate titrations via Pump 1. Pump 2 was terminated on removal of the uterus. Pump 1 was terminated at skin closure.. The mean (+/- SD) opioid infusion rates administered for the duration of Pump 2 to suppress responses to removal of the uterus were 0.49 +/- 0.27 microgram/kg/min, 1.99 +/- 1.34 micrograms/kg/min, and 0.49 +/- 0.07 microgram/kg/min for the Remi/Placebo, Alf/Placebo, and Remi/Remi groups, respectively. At these rates, similar proportions of patients in the Remi/Placebo (67%) and the Alf/Placebo (60%) groups had responses. Fewer patients had responses in the Remi/Remi group (8%) compared with the Remi/Placebo and Alf/Placebo groups (p < 0.05). The mean total opioid doses used during maintenance were 84.6 micrograms/kg (Remi/Placebo), 393 micrograms/kg (Alf/Placebo), and 68.7 micrograms/kg (Remi/Remi). Awakening times were significantly shorter (p < 0.05) in the remifentanil population compared with the alfentanil population, but discharge times were similar. More patients received naloxone to reverse opioid effects in the alfentanil population (60%) than in the remifentanil population (20%) (p < 0.05).. A mean remifentanil infusion of 0.49 microgram/kg/min is as effective as a mean alfentanil infusion of 1.99 micrograms/kg/min in suppressing intraoperative responses. Doubling of the remifentanil infusion to 0.5 microgram/kg/min before the major stress event improves suppression of responses and lowers intraoperative use of remifentanil without prolonging recovery times. Remifentanil allows faster awakening times than alfentanil, but preemptive administration of postoperative analgesics is recommended to facilitate discharge.

Topics: Adult; Alfentanil; Anesthesia, Intravenous; Anesthetics, Intravenous; Double-Blind Method; Female; Humans; Hysterectomy; Middle Aged; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Treatment Outcome

To assess the efficacy of cisapride in reducing ileus persisting to the tenth postoperative day after neonatal abdominal surgery.. A prospective, randomised, double blind trial comparing rectal cisapride (1.4-2.3 mg/kg/day) with placebo over seven days was undertaken in 33 neonates.. Seven of 12 (58%) patients receiving placebo and eight of 11 (73%) receiving cisapride achieved a first sustained feed during treatment. Of those receiving cisapride, the first sustained feed occurred at 2.3 days (SEM 0.6) compared with 4.7 days (SEM 0.8) with placebo. By the seventh day the mean daily net enteral balance was 69 (SEM 18) ml/kg in the cisapride subgroup and 17 (SEM 8) ml/kg for those receiving placebo. Stool was passed on 6.3 (SEM 0.4) treatment days in the cisapride subgroup compared with 4.1 (SEM 1.0) treatment days in the placebo subgroup.. Cisapride is effective in neonates with a prolonged ileus after abdominal surgery.

Topics: Administration, Rectal; Cisapride; Double-Blind Method; Gastrointestinal Agents; Gastrointestinal Motility; Humans; Infant, Newborn; Intestinal Obstruction; Piperidines; Postoperative Complications; Prospective Studies

This study was designed to investigate the modulatory effect of cisapride on colonic motility in the postoperative period.. A prospective, double-blind, randomized, placebo-controlled trial of 14 patients undergoing left colonic anastomosis was carried out. Manometric probes were positioned with transducers on either side of the anastomosis, and colonic activity was recorded continuously for a median of 98 (range, 72-144) hours using an ambulatory system. Quantitative indices of motility were calculated with an automated analysis program.. Isolated waveform activity returned at a median of 1.8 (interquartile range, 1-3) hours and motor complex activity at 24 (interquartile range, 19-30) hours in the placebo group and at similar times in the cisapride group. All motility variables except mean amplitude increased significantly with time in both groups. In the cisapride group the motility index was significantly increased compared with the placebo group (P = 0.03), resulting from an increase in percentage duration of activity (P = 0.002). Activity index, mean amplitude of waveforms, and number of waves greater than 50 cm H2O did not differ between groups. In contrast to placebo, cisapride significantly increased the median number of waves greater than 13 cm H2O and percentage duration of activity distal to the anastomosis compared with proximally. The return of bowel sounds (median, 43, interquartile range, 24-48 hours vs. 67, 29-69 hours; P = 0.2) or first passage of flatus (78, 54-94 hours vs. 94, 81-105 hours; P = 0.1) did not differ between groups.. Although cisapride may have a differential effect on the colon proximal and distal to an anastomosis and significantly increases some indices of motility in the early postoperative period, these are unlikely to be of any clinical relevance.

Topics: Aged; Aged, 80 and over; Anastomosis, Surgical; Cisapride; Colon; Double-Blind Method; Drug Administration Schedule; Gastrointestinal Motility; Humans; Intestinal Obstruction; Manometry; Middle Aged; Piperidines; Postoperative Complications; Prospective Studies; Reoperation; Serotonin Antagonists

The effect of cisapride on duration of post-operative ileus after surgery was investigated in a randomized, double-blind, placebo-controlled study. Patients undergoing elective upper gastrointestinal (n = 47) or colonic (n = 22) surgery were pre-operatively randomly allocated to treatment with either cisapride 30 mg t.d.s., by rectal administration, or placebo. Treatment started exactly 48 h after surgery if the patient at this time had not passed stool. Time to passage of first stool after surgery was estimated. Mean time to passage of stool was 85 (32) h (s.d.) for cisapride-treated and 91 (43) h for placebo-treated patients. No difference between the treatment groups was noted. Treatment with cisapride did not shorten the duration of postoperative ileus after either upper gastrointestinal or colonic surgery.

Topics: Aged; Aged, 80 and over; Cisapride; Defecation; Double-Blind Method; Humans; Intestinal Obstruction; Middle Aged; Piperidines; Postoperative Complications; Time Factors

The effect of cisapride on postoperative colonic motility was studied in 40 patients undergoing cholecystectomy under randomized, double-blind conditions. The patients received 10 mg of cisapride or placebo by intravenous injection starting on the day of surgery and repeated every 12 h until the 3rd postoperative day. The return of propagative motility in the colon was visualized by means of radiopaque markers and serial abdominal radiographs. Cisapride induced a significantly earlier return of propulsive motility in the right colon, as indicated by the propagation of markers from the ascending colon to the transverse colon (p less than 0.05). Radiopaque markers reached the descending colon (p less than 0.05) and the rectosigmoid colon (p less than 0.05) significantly earlier in the cisapride group than in controls. The first passage of feces occurred significantly earlier in cisapride-treated patients than in controls (p less than 0.05). The first passage of gas after surgery did not differ significantly between the groups. Our results suggest that cisapride can be used to induce earlier return of propagative motility in the colon after major abdominal surgery.

Topics: Cholecystectomy; Cisapride; Colonic Diseases; Double-Blind Method; Female; Gastrointestinal Motility; Humans; Intestinal Pseudo-Obstruction; Male; Middle Aged; Piperidines; Postoperative Complications; Serotonin Antagonists

The study evaluates the effect of 20 mg cisapride twice daily on symptoms and biliary drainage in patients with the postcholecystectomy syndrome. Nineteen patients, all female, went through a randomized, double-blind, placebo-controlled, crossover trial with two 4-week treatment periods separated by a 2-week washout period. Symptoms were registered on diary cards. Biliary drainage was studied with dynamic cholescintigraphy. The down slope of the time-activity curve (T1/2 and elimination index) was used as a measure of the biliary drainage. More symptoms were registered during cisapride therapy than with placebo. This unfavourable effect of cisapride was statistically significant in a subgroup of patients with postcholecystectomy complaints identical to the biliary pain they experienced during injection of contrast at the endoscopic retrograde cholangiopancreatographic examination. Cisapride statistically significantly hastened biliary drainage. The median T1/2 values were 24 and 28 min after cisapride and placebo, respectively (p less than 0.01). In conclusion, cisapride promoted biliary drainage in patients with the postcholecystectomy syndrome but had an unfavourable symptomatic effect in those with bile duct-triggered postcholecystectomy complaints.

Topics: Adult; Aged; Cholangiopancreatography, Endoscopic Retrograde; Cholecystectomy; Cholestasis; Cisapride; Female; Humans; Imino Acids; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Complications; Radionuclide Imaging; Serotonin Antagonists

Cisapride and domperidone were both effective in restoring electrical and mechanical activity, coordination between gastric and small intestinal activity cycles and the stomach to anus transit time in three ponies in which post operative ileus was induced experimentally. Cisapride (0.1 mg/kg bodyweight intramuscularly) for three to eight doses prevented idiopathic post operative ileus in 22 clinical cases requiring colic surgery. The only side effects after cisapride were increased bowel sounds and slight, transient sounds of discomfort. No adverse side effects were seen in 16 cases following anastomosis or enterotomy. Cisapride appears safe and effective in the prophylaxis of equine post operative ileus.

Topics: Animals; Antiemetics; Cholinergic Agents; Cisapride; Domperidone; Dose-Response Relationship, Drug; Female; Gastrointestinal Motility; Horse Diseases; Horses; Intestinal Obstruction; Intestine, Small; Male; Piperidines; Postoperative Complications

For the evaluation of postoperative upper gastrointestinal transit, the breath hydrogen test is a convenient method, which is simple but more reliable than the recording of clinical parameters such as bowel sounds. The test was used to study the effect of cisapride on the postoperative mouth-to-caecum transit time. Twenty patients undergoing cholecystectomy were tested pre-operatively and on the first postoperative day after having received either 10 mg of cisapride i.v. or matching placebo under double-blind conditions. The median preoperative transit time in the placebo group was 45 min, and the median postoperative transit time at least 3 h longer. The postoperative transit time after cisapride dosing was still longer than before the operation but was significantly (p = 0.02) reduced as compared with that after placebo administration.

Topics: Adult; Aged; Aged, 80 and over; Breath Tests; Cholecystectomy; Cisapride; Clinical Trials as Topic; Double-Blind Method; Female; Gastrointestinal Transit; Humans; Male; Middle Aged; Piperidines; Postoperative Complications; Random Allocation

The effect of 4 mg of the gastrointestinal motility enhancing agent cisapride on postoperative ileus was compared with that of a placebo in 53 patients who had undergone various types of surgery. They received one i.v. injection of the double-blind medication, or two if no distinct flatus occurred within an hour after the first injection. The placebo response was very limited; borborygmi or flatus did not occur in more than 12% of the patients not even after the second injection. Cisapride was significantly effective: bowel sounds were present in 43% and 50% within 1 hour after the first and second injection of 4 mg, respectively, and flatus in 36% and 43%. The recognition that colon inactivity probably is the major determinant of the ileus, may be indicative of a substantial relative impact of cisapride's stimulating effects on colon motility.

Topics: Adult; Cisapride; Clinical Trials as Topic; Double-Blind Method; Female; Gastrointestinal Diseases; Gastrointestinal Motility; Humans; Intestinal Obstruction; Male; Piperidines; Postoperative Complications

Topics: Cisapride; Clinical Trials as Topic; Double-Blind Method; Humans; Intestinal Pseudo-Obstruction; Piperidines; Postoperative Complications; Random Allocation

The effect of loperamide and diphenoxylate on diarrhoea following jejuno-ileostomy for morbid obesity was investigated in 27 patients by means of a randomized fixed sample size, three-period cross-over trial. Both loperamide and diphenoxylate had significant effect on the diarrhoeas when compared with no treatment, but no significant difference was found between the two drugs. Loperamide is an acceptable alternative in the treatment of diarrhoea following jejuno-ileostomy.

Topics: Adult; Clinical Trials as Topic; Diarrhea; Diphenoxylate; Female; Humans; Ileum; Isonipecotic Acids; Jejunum; Loperamide; Male; Obesity; Piperidines; Postoperative Complications; Random Allocation

Loperamide hydrochloride (4 mg t.d.s.) was compared with codeine phosphate (60 mg t.d.s.) in a double blind crossover study of patients with loose output from their ileostomies. Both drugs significantly decreased the daily output and water content of ileostomy fluid. Daily losses of sodium and potassium were less when the patients were treated with loperamide. Loperamide was also associated with less side effects. It is concluded that loperamide hydrochloride was more effective in the treatment of ileostomy diarrhoea than codeine phosphate. In this group of patients those with the highest outputs from their ileostomies benefited most from this treatment.

Topics: Adult; Aged; Body Weight; Clinical Trials as Topic; Codeine; Diarrhea; Double-Blind Method; Electrolytes; Female; Humans; Ileostomy; Loperamide; Male; Middle Aged; Nausea; Piperidines; Postoperative Complications; Potassium; Sodium

A double-blind cross-over study of the antidiarrhoeal effects of loperamide and diphenoxylate in 29 patients with chronic diarrhoea due to intestinal resection is presented. Most of these subjects had had surgery for Crohn's disease which was in a stable and nonactive phase during the study. Loperamide and diphenoxylate were presented as identical capsules. Each was administered for a minimum duration of 25 days. The number of capsules required to control diarrhoea was significantly smaller in the loperamide group than in the diphenoxylate group. Loperamide was also statistically superior to diphenoxylate at reducing the number of stools and improving the faecal consistency. Nineteen of the 29 patients considered loperamide to be the most effective antidiarrhoeal drug, five preferred diphenoxylate and five did not notice any difference.

Topics: Adult; Aged; Chronic Disease; Clinical Trials as Topic; Crohn Disease; Diarrhea; Diphenoxylate; Double-Blind Method; Female; Humans; Intestines; Isonipecotic Acids; Loperamide; Male; Middle Aged; Piperidines; Postoperative Complications; Random Allocation

The influence of Domperidone and Metoclopramide on the Serum Gastrin Level and Gastric Acid Secretion was investigated in a crossed, randomized double blind study in 12 male subjects aged 29 years on the average and presenting a healthy stomach. Neither after Domperidone nor after Metoclopramide could a significant change in Gastrin Level and Acid Secretion be observed. Since both Domperidone and Metoclopramide exert a motility promoting but not secretagogue effect on the upper gastrointestinal tract, both drugs are suitable for the treatment of disordered motility and evacuation related to ulcer disease, as well as for the treatment of postoperative gastroatonia.

Topics: Adult; Antiemetics; Benzimidazoles; Domperidone; Gastric Acid; Gastrins; Gastrointestinal Motility; Humans; Male; Metoclopramide; Piperidines; Postoperative Complications; Stomach Ulcer

The effects of oral loperamide, in doses of 2-6 mg per day, on the stool consistency, daily number of bowel movements and general inconvenience was investigated in seven children and juveniles suffering from incontinence and abnormal bowel habits due to congenital abnormalities. The study was conducted as a double-blind, cross-over analysis. According to the data collected loperamide essentially improves the quality of life of these patients.

Topics: Adolescent; Child; Child, Preschool; Diarrhea; Dose-Response Relationship, Drug; Double-Blind Method; Fecal Incontinence; Female; Humans; Loperamide; Male; Piperidines; Postoperative Complications

In a double-blind comparison of domperidone 10 mg, domperidone 4 mg, metoclopramide 10 mg and a placebo, 176 adult patients were given an intravenous injection of one of these substances after postoperative vomiting had occurred. Patients were then observed for 6 hours. Those who failed to respond sufficiently to the double-blind injection were given an open dose of domperidone 4 mg i.v. Vomiting recurred in 52% of patients in each of domperidone groups compared with 75% of patients in the metoclopramide group and 84% of patients in the placebo group. Thus domperidone was significantly more effective than the other two substances (p < 0.05). Significantly more patients in the placebo group required a supplementary injection than in the domperidone and metoclopramide groups (p < 0.05). No side effects were observed in any patient.

Topics: Adult; Aged; Antiemetics; Benzimidazoles; Clinical Trials as Topic; Domperidone; Double-Blind Method; Female; Humans; Male; Metoclopramide; Middle Aged; Piperidines; Placebos; Postoperative Complications; Vomiting

One hundred patients (14-82 years) were given either domperidone 10 mg I.V. or a placebo after they had vomited postoperatively. The patients were then observed for six hours. A supplementary injection of domperidone 10 mg I.V. from an open supply was given if required. In the placebo group 47.9% of patients needed another injection but only 25% of patients in the domperidone group (p less than 0.01). Vomiting occurred later after domperidone than after the placebo (p less than 0.01). At the end of six hours 74% of patients in the domperidone group had no recurrence of vomiting compared with 38% in the control group. In this study neither vomiting nor the efficacy of domperidone were found to be related to the type of surgery, the type of anaesthetic or the physical status (ASA I-III) of the patient (p greater than 0.05).

Topics: Adolescent; Adult; Aged; Antiemetics; Benzimidazoles; Clinical Trials as Topic; Domperidone; Double-Blind Method; Female; Humans; Male; Middle Aged; Piperidines; Postoperative Complications; Random Allocation; Vomiting

In a series of open pilot studies, intravenous domperidone was given to three groups of post-operative patients, at doses ranging from 10 mg to 60 mg. As a result of these studies, it was decided that a regime of 20 mg initially, followed by maintenance doses of 10 mg at 6 hourly intervals was highly effective in preventing post-operative nausea and vomiting. Consequently this regime was chosen to evaluate domperidone against placebo in a double-blind study involving 106 patients. The results showed that only three out of 53 patients (5.7%) on active treatment were having nausea and vomiting compared with 16 of 53 patients (30.2%) on placebo. It is concluded that this regime is effective in preventing post-operative nausea and vomiting.

Topics: Antiemetics; Benzimidazoles; Clinical Trials as Topic; Double-Blind Method; Female; Humans; Male; Nausea; Pilot Projects; Piperidines; Postoperative Complications; Vomiting

Forty seven patients received either 4 mg or 10 mg domperidone I.V. in a double blind study after they had vomited postoperatively. The patients were then observed for six hours. If necessary, the same dose of domperidone was repeated double blind but not during the first hour. When the two groups were compared there was little difference between them for the first half hour after the initial dose, thereafter both the frequency and severity of vomiting was reduced in the 10 mg group. Also fewer patients in the 10 mg group needed a second injection. These differences were statistically significant (p less than 0.05).

Topics: Adolescent; Adult; Aged; Antiemetics; Benzimidazoles; Clinical Trials as Topic; Domperidone; Double-Blind Method; Female; Humans; Male; Middle Aged; Piperidines; Postoperative Complications; Vomiting

The effect of domperidone on postoperative nausea and vomiting was evaluated in two consecutive studies. Fifty-eight patients with postoperative nausea and vomiting were included in an open pilot study and 38 other patients in a double-blind trial. In the first study 4 mg of domperidone was found to be significantly superior to 2 mg, in controlling nausea and vomiting. In the double-blind trial, vomiting recurred significantly later in domperidone than in placebo-treated patients. Side-effects were not seen nor reported in either study.

Topics: Antiemetics; Benzimidazoles; Double-Blind Method; Female; Humans; Male; Nausea; Piperidines; Postoperative Complications; Vomiting

Topics: Anesthesia, General; Female; Humans; Hypotension; Isonipecotic Acids; Meperidine; Nitriles; Pain, Postoperative; Perphenazine; Piperidines; Postoperative Complications; Sleep; Sterilization, Tubal

Topics: Analgesics; Benzimidazoles; Clinical Trials as Topic; Dextromoramide; Female; Humans; Male; Middle Aged; Pain; Pentazocine; Piperidines; Postoperative Complications

Topics: Analgesics; Blood Pressure; Clinical Trials as Topic; Humans; Hypnotics and Sedatives; Isonipecotic Acids; Morphine; Nausea; Nitriles; Piperidines; Postoperative Complications; Vomiting

Topics: Aminopyrine; Analgesics; Barbiturates; Chlordiazepoxide; Female; Humans; Imidazoles; Italy; Ketones; Male; Pain; Perphenazine; Piperidines; Placebos; Postoperative Complications; Rural Population; Surgical Procedures, Operative; Urban Population

Topics: Atropine; Codeine; Diarrhea; Duodenal Ulcer; Humans; Piperidines; Placebos; Postoperative Complications; Pylorus; Vagotomy

Topics: Clinical Trials as Topic; Diarrhea; Humans; Piperidines; Postoperative Complications; Vagotomy

Topics: Colitis, Ulcerative; Colonic Pouches; Humans; Infliximab; Piperidines; Postoperative Complications; Proctocolectomy, Restorative

Topics: Humans; Leukemia, Lymphocytic, Chronic, B-Cell; Mohs Surgery; Piperidines; Postoperative Complications; Protein Kinase Inhibitors

Post-operative ileus and delayed return of gastrointestinal function are complications seen frequently in patients undergoing colorectal surgery. Many enhanced recovery after surgery protocols include alvimopan to inhibit the effects of opiates in the gastrointestinal tract and lidocaine to augment analgesics. Limited data exist regarding alvimopan's efficacy in opiate-sparing regimens.. This single-center, retrospective cohort analysis was conducted in a randomly selected population of adult patients undergoing colorectal resection between February 2018 and October 2019. Patients meeting inclusion criteria were divided into four groups dependent upon whether or not they received alvimopan (A or a) and/or lidocaine (L or l). The primary endpoint in this study was median time to first bowel movement or discharge, whichever came first. Our secondary endpoint was length of stay.. Of the 430 patients evaluated, a total of 192 patients were included in the final evaluation in the following groups: AL (n = 93), Al (n = 34), aL (n = 44), and al (n = 21). A significant difference was found among the groups for the primary outcome of median time to bowel movement or discharge (p = 0.001). Three subsequent pair-wise comparisons resulted in a significant difference in the primary outcome: group AL 39.4 h vs. group aL 54.0 h (p = 0.003), group AL 39.4 h vs. group al 55.4 h (p = 0.001), and group Al 44.9 h vs. group al 55.4 h (p = 0.01). Length of stay was significantly reduced by 1.8 days in groups AL and Al compared to group aL (p < 0.001).. Treatment with alvimopan resulted in a significant improvement in time to GI recovery and decreased length of stay in an established ERAS program. While lidocaine's reduction in opiates was minimal, the group receiving both alvimopan and lidocaine had the greatest reduction in time to GI recovery and length of stay.

Topics: Adult; Colorectal Surgery; Gastrointestinal Agents; Humans; Ileus; Length of Stay; Lidocaine; Opiate Alkaloids; Piperidines; Postoperative Complications; Recovery of Function; Retrospective Studies

The use of alvimopan at the time of cystectomy has been associated with improved perioperative outcomes. Naloxegol is a less costly alternative that has been used in some centers. This study aims to compare the perioperative outcomes of patients undergoing cystectomy with urinary diversion who receive the mu-opioid antagonist alvimopan versus naloxegol.. This was a retrospective review that included all patients who underwent cystectomy with urinary diversion at our institution between 2007-2020. Comparisons were made between patients who received perioperative alvimopan, naloxegol and no mu-opioid antagonist (controls).. In 715 patients who underwent cystectomy, 335 received a perioperative mu-opioid antagonist, of whom 57 received naloxegol. Control patients, compared to naloxegol and alvimopan patients, experienced a significantly (p < 0.05) delayed return of bowel function (4.3 vs. 2.5 vs. 3.0 days) and longer hospital length of stay (7.9 vs. 7.5 vs. 6.5 days), respectively. The incidence of nasogastric tube use (14.2% vs. 12.5% vs. 6.5%) and postoperative ileus (21.6% vs. 21.1% vs. 13.3%) was also most common in the control group compared to the naloxegol and alvimopan cohorts, respectively. A multivariable analysis revealed that when comparing naloxegol and alvimopan, there was no difference in return of bowel function (OR 0.88, p = 0.17), incidence of postoperative ileus (OR 1.60, p = 0.44), or hospital readmission (OR 1.22, p = 0.63).. Naloxegol expedites the return of bowel function to the same degree as alvimopan in cystectomy patients. Given the lower cost of naloxegol, this agent may be a preferable alternative to alvimopan.

Topics: Cystectomy; Gastrointestinal Agents; Humans; Ileus; Length of Stay; Morphinans; Narcotic Antagonists; Piperidines; Polyethylene Glycols; Postoperative Complications; Urinary Diversion

Topics: Colitis, Ulcerative; Humans; Liver Transplantation; Male; Middle Aged; Piperidines; Postoperative Complications; Protein Kinase Inhibitors; Pyrimidines

To study the effect of alvimopan and the Enhanced Recovery After Surgery protocol on length of hospital stay in patients undergoing radical cystectomy.. Our retrospective study involved 296 consecutive patients undergoing radical cystectomy for bladder cancer at our institution from 2010 through 2018. Patients were grouped according to three stages of the Enhanced Recovery After Surgery protocol implementation: (i) pre-Enhanced Recovery After Surgery (group A; n = 146); (ii) pre-alvimopan Enhanced Recovery After Surgery (group B; n = 102); and (iii) Enhanced Recovery After Surgery plus alvimopan (group C; n = 48). The primary outcome was the length of hospital stay. Secondary outcomes were time to first bowel movement, time to tolerate a regular diet, the incidence of postoperative ileus, postoperative complications and 30-day readmission rate.. Group C showed a significantly shorter median length of hospital stay (7 days, P = 0.003), shorter gastrointestinal recovery time (4 days, P = 0.018) and a lower rate of postoperative ileus (14.6%, P = 0.005). The reduction in length of hospital stay, gastrointestinal recovery time and a lower rate of postoperative ileus was significant after controlling for other confounders on multivariable regression analysis. With the open approach, group C showed a significantly shorter length of hospital stay and gastrointestinal recovery time (P = 0.005, P = 0.001, respectively); however, in robotic cohorts, no significant differences were observed. There was no difference among groups in the 30-day readmission rate or postoperative complications.. Patients undergoing radical cystectomy and managed by an Enhanced Recovery After Surgery protocol experience a significantly shorter length of hospital stay when receiving alvimopan as part of the protocol. Patients seem to derive the optimum benefits of alvimopan when it is used with an open approach; however, these benefits become less obvious with the robotic approach.

Topics: Cystectomy; Enhanced Recovery After Surgery; Gastrointestinal Agents; Humans; Length of Stay; Piperidines; Postoperative Complications; Retrospective Studies

The literature regarding monoclonal antibodies and increased postoperative complications in inflammatory bowel disease remains controversial. There have been no studies investigating tofacitinib. The aim of this work was to determine preoperative exposure to the small-molecule inhibitor tofacitinib and postoperative outcomes.. We conducted a retrospective review of all adult patients exposed to tofacitinib within 4 weeks of total abdominal colectomy for medically refractory ulcerative colitis between 1 January 2018 and 1 September 2020 at four inflammatory bowel disease referral centres. Data collected included patient demographics and 90-day postoperative morbidity, readmission and reoperation rates.. Fifty-three patients (32 men, 60%) with ulcerative colitis underwent a total abdominal colectomy (n = 50 laparoscopic, 94%) for medically refractory disease. Previous exposure to monoclonal antibodies included infliximab (n = 34), adalimumab (n = 35), certolizumab pegol (n = 5), vedolizumab (n = 33) and ustekinumab (n = 10). Twenty-seven (51%) patients were on concurrent prednisone at a median daily dose of 30 mg by mouth (range 5-60 mg). There were no postoperative deaths. Ninety-day postoperative complications included ileus (n = 7, 13.2%), superficial surgical site infection (n = 4, 7.5%), intra-abdominal abscess (n = 2, 3.8%) and venous thromboembolism (VTE) (n = 7, 13.2%). Locations of VTE included portomesenteric venous thrombus (n = 4), internal iliac vein (n = 2) and pulmonary embolism (n = 1). Nine (17%) patients were readmitted to hospital and five (9%) patients had a reoperation.. Mirroring the recently issued US Food and Drug Administration black box warning of an increased risk of VTE in medically treated ulcerative colitis patients taking tofacitinib, preoperative tofacitinib exposure may present an increased risk of postoperative VTE events. Consideration should be given for prolonged VTE prophylaxis on hospital discharge.

Topics: Adult; Colitis, Ulcerative; Humans; Male; Piperidines; Postoperative Complications; Pyrimidines; Retrospective Studies

Postoperative ileus (POI) is a temporary delay of coordinated intestinal peristalsis. Alvimopan, an oral peripherally acting mu-opioid receptor antagonist approved for accelerating gastrointestinal recovery, has never been studied specifically in patients with inflammatory bowel disease (IBD).. To investigate the efficacy of alvimopan in preventing POI among IBD patients.. A retrospective chart review was conducted on 246 IBD patients undergoing bowel surgery between 2012 and 2017. Data collected included demographics, IBD subtype, length of stay (LOS), postoperative gastrointestinal symptoms, and administration of alvimopan. The primary outcome was POI; secondary gastrointestinal recovery outcomes were: time to first flatus, time to first bowel movement, time to tolerating a liquid diet, time to tolerating solid food, and LOS.. When compared with the control group, patients in the alvimopan group had shorter times to tolerating liquids and solids, first flatus, and first bowel movements (p < 0.01). LOS was shorter in the alvimopan group when compared with controls (p < 0.01). The overall incidence of POI was higher in controls than in the alvimopan group (p = 0.07). For laparoscopic surgeries, the incidence of POI was also higher in controls than in the alvimopan group (p < 0.01). On multivariable analysis, alvimopan significantly decreased time to all gastrointestinal recovery endpoints when compared to controls (p < 0.01).. Alvimopan is effective in accelerating time to gastrointestinal recovery and reducing POI in IBD patients. While the benefits of alvimopan have been demonstrated previously, this is the first study of the efficacy of alvimopan in IBD patients.

Topics: Adult; Female; Gastrointestinal Agents; Humans; Ileus; Inflammatory Bowel Diseases; Male; Middle Aged; Piperidines; Postoperative Complications; Retrospective Studies

To assess whether the beneficial perioperative effects of alvimopan differ with surgical approach for patients who undergo open radical cystectomy (ORC) vs robot-assisted radical cystectomy (RARC).. This retrospective study reviewed all patients who underwent cystectomy with urinary diversion at our institution between January 1, 2007, and January 1, 2018. Data were collected on demographic characteristics, comorbidities, surgical approach, alvimopan therapy, hospital length of stay (LOS), days until return of bowel function (ROBF), and complications. Outcomes and interactions were evaluated through regression analysis.. Among 573 patients, 236 (41.2%) underwent RARC, 337 (58.8%) underwent ORC, and 205 (35.8%) received alvimopan. Comparison of 4 cohorts (ORC with alvimopan, ORC without alvimopan, RARC with alvimopan, and RARC without alvimopan) showed that patients who underwent ORC without alvimopan had the highest rate of postoperative ileus (25.6%, P = .02), longest median hospital LOS (7 days, P < .001), and longest time until ROBF (4 days, P < .001). On multivariable analysis, the interaction between surgical approach and alvimopan use was significant for the outcome of ROBF (estimate, 1.109; 95% confidence interval, 0.418-1.800; P = .002). In the RARC cohort, multivariable analysis showed no benefit of alvimopan with respect to ileus (P = .27), LOS (P = .09), or ROBF (P = .36). Regarding joint effects of robotic approach and alvimopan, RARC had no effect on gastrointestinal tract outcomes.. We observed a diminished beneficial effect of alvimopan among patients undergoing RARC and a statistically significant benefit of alvimopan among patients undergoing ORC. The implications of these findings may permit more selective medication use for patients who would benefit the most from this drug.

Topics: Aged; Cystectomy; Female; Gastrointestinal Agents; Humans; Lower Gastrointestinal Tract; Male; Neoplasm Staging; Patient Selection; Piperidines; Postoperative Complications; Receptors, Opioid, mu; Recovery of Function; Retrospective Studies; Robotic Surgical Procedures; Treatment Outcome; Urinary Bladder Neoplasms; Urinary Diversion

To evaluate the impact of alvimopan in patient undergoing radical cystectomy (RC) for bladder cancer. We hypothesize that alvimopan can decrease cost for RC by reducing length of stay (LOS).. We identified patients who underwent elective RC for bladder cancer from 2009 to 2015 in the Premier Healthcare Database, a nationwide, all-payer hospital-based database, and compared patients who received and did not receive alvimopan in the perioperative period. Hospitals that had no record of administering alvimopan for patients undergoing RC were excluded. The primary outcomes were LOS and the direct hospital costs. The secondary outcomes were 90-day readmission for ileus and major complications.. After applying the inclusion criteria, the study cohort consisted of 1087 patients with 511 patients receiving perioperative alvimopan. Alvimopan was associated with a reduction in hospital costs by -$2709 (95% confidence interval: -$4507 to -$912, P = .003), decreased median LOS (7 vs 8 days, P < .001), and lower likelihood of readmission for ileus (adjusted odds ratio: 0.63, P = .041). While alvimopan use led to higher pharmacy costs, this was outweighed by lower room and board costs due to the reduced LOS. There was no significant difference between 2 groups regarding major complications. These results were robust across multiple adjusted regression models.. Our data show that alvimopan is associated with a substantial cost-saving in patients undergoing RC, and suggest that routine use of alvimopan may be a potential cost-effective strategy to reduce the overall financial burden of bladder cancer.

Topics: Aged; Cost-Benefit Analysis; Cystectomy; Female; Gastrointestinal Agents; Hospital Costs; Humans; Ileus; Length of Stay; Lower Gastrointestinal Tract; Male; Neoplasm Staging; Piperidines; Postoperative Complications; Recovery of Function; Retrospective Studies; United States; Urinary Bladder Neoplasms

Alvimopan (Entereg), a peripherally acting opioid receptor antagonist, is effective in reducing the rate of postoperative ileus and length of hospital stay in patients undergoing colorectal surgery, and is now approved for use after radical cystectomy (RC). Using data from Vizient (formerly University Health System Consortium), we assessed the utilization of alvimopan and its effect on perioperative factors after RC.. The Vizient database, contributed to by over 200 US academic hospitals, was evaluated from 2014 to 2016. Patients who had undergone radical cystectomy were included. Alvimopan exposure and postoperative outcomes were collected.. 7472 patients underwent cystectomy in the 3 years examined, with 3391 (45.4%) patients receiving alvimopan over this time period. The use of alvimopan increased from 35 to 59%. The receipt of alvimopan was associated with a decrease in perioperative morbidity (10.53% vs 19.23%, p = 0.027).. This study, the largest to examine the real-world utilization of alvimopan since FDA approval for RC, shows that alvimopan utilization has increased substantially and is associated with reduced perioperative morbidity in patients undergoing cystectomy.

Topics: Aged; Cystectomy; Drug Utilization; Female; Gastrointestinal Agents; Humans; Male; Piperidines; Postoperative Care; Postoperative Complications; Retrospective Studies

Alvimopan has been shown to reduce length of stay after bowel resection. Use remains variable among institutions due to cost and efficacy concerns in laparoscopic surgery. Additionally, alvimopan's effects have not been isolated from other medications within enhanced recovery protocols. The aim of this study was to distinguish the relationship between alvimopan use, length of stay, and cost in both open and laparoscopic segmental colectomies.. The Vizient dataset was queried to identify patients undergoing open and laparoscopic colectomies from 2015 to 2017. Patient demographics and treatment details were collected. Primary outcomes of interest included duration of stay and total direct costs.. In the study, 12,727 patients met inclusion criteria and 3,358 (26.4%) received alvimopan. For both open and laparoscopic groups, alvimopan was associated with decreased length of stay in unadjusted (4.0 vs 6.0 days, P < .01 and 3.0 vs 4.0 days, P < .01, respectively) and adjusted analysis (effect ratio 0.79, P < .01 and 0.85, P < .01, respectively). Alvimopan was associated with a 7% decrease in direct cost after adjustment (effect ratio 0.93, P = .04), with no cost difference in laparoscopic procedures (effect ratio 0.99, P = .71).. Alvimopan use is associated with decreased length of stay for both open and laparoscopic colon resections, decreased cost in open procedures, and no cost difference for laparoscopic procedures.

Topics: Aged; Cohort Studies; Colectomy; Cost Savings; Databases, Factual; Elective Surgical Procedures; Female; Gastrointestinal Agents; Health Care Costs; Humans; Laparoscopy; Laparotomy; Length of Stay; Linear Models; Male; Middle Aged; Multivariate Analysis; Piperidines; Postoperative Complications; Retrospective Studies; United States

The development of enhanced recovery after surgery (ERAS) protocols for patients undergoing radical cystectomy (RC) represents a significant advance in perioperative care.. To evaluate gastrointestinal (GI) complications following RC and urinary diversion (UD) using our institutional ERAS protocol.. We identified 377 consecutive cases of open RC and UD for which our ERAS protocol was used from May 2012 to December 2015. Exclusion criteria were consent refusal; non-bladder primary disease; palliative, salvage, or additional surgery; and prolonged postoperative intubation. A matched cohort of 144 patients for whom a traditional postoperative protocol (pre-ERAS) was used between 2003 and 2012 was selected for comparison.. A total of 292 ERAS patients with median age of 70 yr were included in the study, 65% of whom received an orthotopic neobladder. The median time to first flatus and bowel movement was 2 d. The median length of stay was 4 d. GI complications occurred in 45 patients (15.4%) during the first 30 d following RC, 93% of which were of minor grade. The most common GI complication was postoperative ileus (POI) in 34 cases (11.6%). Some 22 patients (7.5%) required a nasogastric tube, and parenteral nutrition was required in three patients. The rate of 30-d GI complications was significantly lower in the ERAS cohort than in the control group (13% vs 27%; p=0.003), as was the rate of POI (7% vs 23%; p<0.001). This effect was independent of other variables (hazard ratio 0.38, 95% confidence interval 0.18-0.82; p=0.01).. Our institutional ERAS protocol for RC is associated with significantly improved perioperative GI recovery and lower rates of GI complications. This protocol can be tested in multi-institutional studies to reduce GI morbidity associated with RC.. In this study, we showed that an enhanced recovery protocol for patients undergoing radical cystectomy for bladder cancer was associated with a significantly shorter length of hospital stay and lower rates of gastrointestinal complications, especially postoperative ileus.

Topics: Adult; Aged; Aged, 80 and over; Anemia; Carcinoma, Transitional Cell; Case-Control Studies; Clinical Protocols; Cystectomy; Dehydration; Female; Gastrointestinal Agents; Gastrointestinal Diseases; Humans; Ileus; Intubation, Gastrointestinal; Length of Stay; Male; Middle Aged; Parenteral Nutrition; Perioperative Care; Piperidines; Postoperative Complications; Proportional Hazards Models; Urinary Bladder Neoplasms; Urinary Diversion; Urinary Tract Infections

Postoperative ileus is a significant complication after bowel resection surgeries. Alvimopan is the only US Food and Drug Administration-approved therapy for accelerating the return of bowel function after large- and small-bowel resection.. The purpose of this study was to estimate the healthcare use and in-hospital morbidities associated with on-label use of alvimopan in patients undergoing bowel resection surgeries.. A retrospective observational propensity-matched cohort study was conducted using a large hospital administrative database.. The study included inpatient postsurgical patients.. Patients aged ≥18 years undergoing a primary large or small segmental bowel resection with discharge dates between January 2010 and December 2014 were included.. Patients receiving 2 to 15 doses of alvimopan were defined as the treatment cohort, and those without any alvimopan use were included as control subjects.. The primary outcome was postoperative length of stay. Secondary outcomes included postoperative in-hospital morbidities, inpatient mortality, intensive care unit length of stay, discharge disposition, and 30-day readmission.. Each propensity-score matched cohort included 18,559 patients. The mean (±SD) postoperative length of stay was 4.62 ± 2.45 days in alvimopan-treated patients compared with 5.24 ± 3.35 days in control subjects (p < 0.001). Alvimopan-treated patients had lower rates of postoperative GI complication (12.15% vs 16.50%; p < 0.001). The rates of urinary tract infections; other postoperative infections; and cardiovascular, pulmonary, thromboembolic, and cerebrovascular events were also lower compared with the control subjects.. The study was limited by its inability to generalize to the US population, because the database included a convenience sample of hospital discharges. The identification of patients undergoing bowel resection and their clinical conditions relied on the accuracy and completeness of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure coding. There may be a confounding effect by the use of enhanced recovery pathways associated with the use of alvimopan.. The use of alvimopan was associated with a reduction of 0.62 days in postsurgery length of stay and lower rates of postoperative GI complications, infections, and other in-hospital morbidities. See Video Abstract at http://links.lww.com/DCR/A703.

Topics: Aged; Female; Gastrointestinal Agents; Hospital Mortality; Humans; Intensive Care Units; Intestines; Length of Stay; Male; Middle Aged; Patient Readmission; Piperidines; Postoperative Complications; Propensity Score; Recovery of Function; Retrospective Studies

Opioid analgesics exacerbate ileus through peripheral μ-opioid receptor action. Alvimopan, a μ-opioid receptor antagonist, has been proposed to alleviate postoperative ileus, leading to decreased time to return of gastrointestinal function and hospital discharge. As opioid-induced motility issues are only one factor affecting postoperative ileus, continued examination of the cost of the use and efficacy of the drug is needed. Data for this study were collected retrospectively from the charts of 55 patients who received an anastomosis and were given alvimopan at Morristown Medical Center between 2010 and 2013 as well as from 58 appropriately matched controls. The billing record and chart for each patient was examined, and information on total hospital charges, age, sex, body mas index, primary diagnosis, procedure type, length of stay (days), time to return of bowel function (hours), and outcomes were recorded for analysis. No difference between patients given alvimopan and controls was observed for the length of hospital stay (4.6 vs 4.8 days) or for time to return of bowel function (68.5 vs 67.3 hours). Total hospital charges were higher for treated patients (p=0.0080), averaging $48 705.15 and $41 068.80, respectively. Alvimopan was not associated with improved clinical outcome but was associated with an increase in hospital charges within this population.

Topics: Aged; Body Mass Index; Female; Gastrointestinal Diseases; Health Care Costs; Humans; Ileus; Length of Stay; Male; Middle Aged; Piperidines; Postoperative Complications; Postoperative Period; Receptors, Opioid, mu; Retrospective Studies; Treatment Outcome

Enhanced recovery after surgery protocols have the potential to reduce postoperative morbidity after major urologic surgery for the aging patient.

Topics: Aged; Aged, 80 and over; Aging; Cystectomy; Gastrointestinal Agents; Humans; Length of Stay; Male; Morbidity; Patient Selection; Piperidines; Postoperative Complications; Postoperative Period; Recovery of Function; Stress, Physiological; Urologic Surgical Procedures

Acute kidney injury (AKI) after cardiopulmonary bypass (CPB) is a well-known postoperative complication. Remifentanil, which is a commonly used ultra-short-acting opioid, has antiinflammatory and sympatholytic effects with improvement of microcirculation.. A retrospective study was conducted to clarify the effect of the use of remifentanil during CPB on the incidence of postoperative AKI. Patients who underwent valve surgery while under cardiopulmonary bypass between January 2012 and December 2014 in our hospital were enrolled in this study. The incidences of postoperative AKI were compared in patients who received remifentanil during CPB (group R) and those who did not (group N). Univariate and multivariate regression analyses were performed to determine risk factors for AKI.. Eighty patients received remifentanil (group R) and 50 patients did not (group N). The incidences of AKI were not significantly different in group R and group N (51% vs. 36%, P = 0.10). In multivariate regression analysis, age [adjusted odds ratio (OR) 1.048, 95% CI 1.008-1.089, P = 0.017], male gender (adjusted OR 3.101, 95% CI 1.303-7.378, P = 0.011), and use of preoperative calcium channel blockers (adjusted OR 3.240, 95% CI 1.302-8.063, P = 0.011) and diuretics (adjusted OR 2.673, 95% CI 1.178-6.066, P = 0.019) were associated with the incidence of AKI. The use of remifentanil was not associated with AKI (adjusted OR 2.321, 95% CI 0.997-5.402, P = 0.051).. The use of remifentanil during CPB did not decrease the incidence of postoperative AKI after cardiac surgery.

Topics: Acute Kidney Injury; Aged; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Female; Humans; Incidence; Male; Middle Aged; Odds Ratio; Piperidines; Postoperative Complications; Remifentanil; Retrospective Studies; Risk Factors

Emergence agitation (EA) is a common phenomenon in preschool children during emergence from general anesthesia. This study evaluated the safety and efficacy of dezocine for emergence agitation in preschool children anesthetized with sevoflurane-remifentanil.. A total of 100 preschool children, scheduled for elective laparoscopic repair of an inguinal hernia by high ligation of the hernia sac under sevoflurane-remifentanil anesthesia were randomized into two groups: Group C (n = 50) received Ringer's lactate 10 mL and Group D received Ringer's lactate 10 mL containing dezocine 0.1 mg/kg, postoperatively.. Incidence of EA, defined as a score ≥ 3 on Aono's four point scale or Pediatric Anesthesia Emergence Delirium (PAED) score ≥ 10 in the PACU (10% vs. 76%) and the percentage of patients with severe EA (PAED score ≥ 13) (12% vs. 76%) were significantly lower in Group D compared to Group C (P < 0.05). Mean Children and Infants Postoperative Pain Scale (CHIPPS) score was significantly lower in Group D compared to Group C (1.2 ± 0.5 vs. 5.2 ± 0.6; P < 0.05). Patients need for fentanyl (18% vs. 4%) or propofol rescue (20% vs. 0) was significantly greater in Group C compared to Group D. No significant differences in other relative aspects after surgery between groups.. Administration of dezocine 0.1 mg/kg decreased the incidence and severity of EA in preschool children that had undergone laparoscopic repair of an inguinal hernia by high ligation of the hernia sac under sevoflurane-remifentanil anesthesia.. A single dose of dezocine suppresses emergence agitation in preschool children anesthetized with sevoflurane-remifentanil effectively: A double-blind, prospective, randomized, controlled study, Chinese Clinical Trial Registry (ID: ChiCTR-IOR-16010033), retrospectively registered on November 21, 2016.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Inhalation; Bridged Bicyclo Compounds, Heterocyclic; Child, Preschool; Double-Blind Method; Female; Humans; Male; Methyl Ethers; Piperidines; Postoperative Complications; Prospective Studies; Psychomotor Agitation; Remifentanil; Sevoflurane; Tetrahydronaphthalenes

Alvimopan has decreased ileus and need for nasogastric tube (NGT) after radical cystectomy (RC). However, the natural history of ileus versus intestinal obstruction in patients receiving alvimopan is not well defined. We sought to examine the implications of NGT placement before and after the introduction of alvimopan for RC patients.. Retrospective review identified 278 and 293 consecutive patients who underwent RC before and after instituting alvimopan between June 2009 and May 2014. Baseline characteristics and postoperative outcomes were compared by alvimopan status. Multivariate logistic regression was performed to assess the impact of alvimopan on rates of NGT placement and reoperation for bowel complications.. The cohorts had similar age, stage, approach, and BMI. Patients receiving alvimopan had decreased ileus (16 vs 32 %, p < 0.01) but similar rates of reoperation for bowel complications (2.8 vs 2.7 %). On multivariate analysis, alvimopan was associated with lower risk of NGT placement (OR 0.30, p < 0.01). For patients requiring NGT placement, there was an increased rate of reoperation among patients receiving alvimopan compared with those who did not (28 vs 11 %, p = 0.03). Patients receiving alvimopan who needed NGT had significantly increased median length of stay (22 vs 7 days), need for TPN (66 vs 5.3 %), and readmission for ileus (10.3 vs 2.3 %) compared with those who did not require NGT.. Alvimopan significantly reduced the incidence of ileus and NGT placement following RC. NGT placement was associated with an increased need for reoperation for bowel complications in the setting of alvimopan.

Topics: Aged; Carcinoma, Transitional Cell; Cystectomy; Female; Gastrointestinal Agents; Humans; Ileus; Intubation, Gastrointestinal; Logistic Models; Male; Middle Aged; Multivariate Analysis; Piperidines; Postoperative Care; Postoperative Complications; Reoperation; Retrospective Studies; Urinary Bladder Neoplasms; Urinary Diversion

Postoperative ileus (POI) is a major cause of morbidity, increased length of stay (LOS) and hospital cost after colorectal surgery. Alvimopan is a µ-opioid antagonist used to accelerate upper and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan would reduce LOS in patients undergoing colorectal resection with stoma, a situation that has not been evaluated.. A retrospective review (2010-2015) identified 58 patients who underwent colorectal resection for benign or malignant disease with stoma creation and received alvimopan. They were case-matched to 58 non-alvimopan patients based on age, BMI, baseline comorbidities, stoma type created and surgical approach. We compared overall LOS, incidence of POI and other postoperative complications.. There were equal numbers of laparoscopic (N = 18) and open resections (N = 40) in the alvimopan group and non-alvimopan group. There were also equal numbers of patients with an ileostomy (N = 37) or colostomy (N = 21) in each group. Overall, 41 patients underwent resection for malignant disease in the alvimopan group compared to 37 in the non-alvimopan group. There was a significant reduction in median LOS overall (alvimopan 5 (4-7) versus control 6 (4.75-9.25) days, P = 0.03). While the 6-day median LOS was similar for patients undergoing ileostomy creation (P = 0.25), alvimopan patients had a 3-day decreased median LOS that approached statistical significance (P = 0.06). The overall 30-day complication rate was higher in the control group (41.4 vs. 51.7%, P = 0.26), but the readmission rate within 30 days was higher in the alvimopan group (19 vs. 13.8%, P = 0.45). Neither of these differences reached statistically significance.. The use of alvimopan in patients undergoing colorectal resection with stoma is associated with a significantly shorter LOS, but the increased readmission rate warrants further study. Based on these data, alvimopan should be evaluated in a controlled setting for patients undergoing colorectal resection with colostomy creation.

Topics: Adult; Aged; Colectomy; Colonic Diseases; Female; Gastrointestinal Agents; Humans; Ileus; Length of Stay; Male; Middle Aged; Ostomy; Piperidines; Postoperative Complications; Rectal Diseases; Rectum; Retrospective Studies; Treatment Outcome

Although some studies have examined the efficacy and safety of remifentanil in patients undergoing neurosurgical procedures, none has examined its safety in transsphenoidal operations specifically. In this study, all transsphenoidal operations performed by a single author from 2008 to 2015 were retrospectively reviewed to evaluate the safety of remifentanil in a consecutive series of patients. During the study period, 540 transsphenoidal operations were identified. Of these, 443 (82.0%) patients received remifentanil intra-operatively; 97 (18.0%) did not. The two groups were well-matched with regard to demographic categories, comorbidities, and pre-operative medications (p>0.05), except pre-operative tobacco use (p=0.021). Patients were also well-matched with regard to radiographic features and surgical techniques. Patients who received remifentanil were more likely to harbor a macroadenoma (78.1% vs. 67.0%, p=0.025), and had slightly longer anesthesia time on average (269.2minvs. 239.4min, p=0.024). All pathologic diagnoses were well-matched between the two groups, except that patients receiving remifentanil were more likely to harbor a non-functioning adenoma (46.5% vs. 26.8%, p<0.001). Analysis of post-operative complications showed no significant difference between patients who received remifentanil and those who did not, and length of stay and prevalence of ICU stay did not differ between the two groups. In a well-matched series of 540 patients undergoing transsphenoidal surgery, remifentanil was found to be a safe anesthetic adjunct. There were no significant differences in post-operative hospital course or complications in patients who did and did not receive intra-operative remifentanil.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anesthetics, Intravenous; Female; Humans; Male; Middle Aged; Neurosurgical Procedures; Piperidines; Postoperative Complications; Remifentanil; Retrospective Studies; Sphenoid Sinus; Young Adult

Remifentanil induced hyperalgesia (RIH) is characterized by stimulation evoked pain including allodynia and thermal hyperalgesia after remifentanil infusion. N-methyl-D-aspartate (NMDA) receptor was reported to be involved in the progress of RIH. We hypothesized that intrathecal MgSO. Thirty two rats were randomly allocated into control group, model of RIH group, RIH plus 100ug MgSO. Intrathecal MgSO. Remifentanil induced hyperalgesia/allodynia could be ameliorated by Mg-mediated blockade targeting the NR

Topics: Analgesics; Animals; Hyperalgesia; Hypnotics and Sedatives; Injections, Spinal; Lumbar Vertebrae; Magnesium Sulfate; Phosphorylation; Piperidines; Postoperative Complications; Rats, Sprague-Dawley; Receptors, N-Methyl-D-Aspartate; Remifentanil; Signal Transduction; Spinal Cord; Tyrosine

Alvimopan's goal is to minimize postoperative ileus and optimize outcomes; however, evidence in laparoscopic surgery is lacking. Our goal was to evaluate the benefit of alvimopan in laparoscopic colorectal surgery with an enhanced recovery pathway (ERP).. Laparoscopic colorectal cases were stratified into alvimopan and control cohorts, then case-matched for comparability. All followed an identical ERP. The main outcomes were length of stay, complications, readmissions, and costs in the alvimopan and control groups.. About 321 patients were analyzed in each cohort. Operative times were comparable (P = .08). Postoperatively, complication rates were similar (P = .29), with no difference in ileus (P = 1.00). The length of stay (3.69 vs 3.49 days; P = .16), readmission (2.8% vs 3.7%; P = .66) and reoperation rates (2.2% vs 1.6%; P = .77) were comparable for alvimopan and controls, respectively. Total costs were similar ($14,932.47 alvimopan vs $14,846.56 controls; P = .90), but the additional costs in the alvimopan group could translate to savings of $27,577 in the cohort.. Alvimopan added no benefit in patient outcomes in laparoscopic colorectal surgery with an ERP. These results could drive a change in current practice. Controlled studies are warranted to define the cost and/or benefit in clinical practice.

Topics: Aged; Colorectal Surgery; Cost-Benefit Analysis; Databases, Factual; Elective Surgical Procedures; Female; Follow-Up Studies; Gastrointestinal Agents; Humans; Ileus; Laparoscopy; Male; Middle Aged; Minimally Invasive Surgical Procedures; Piperidines; Postoperative Complications; Recovery of Function; Reference Values; Retrospective Studies; Risk Assessment; Statistics, Nonparametric; Treatment Outcome

Topics: Gastrointestinal Agents; Humans; Ileus; Piperidines; Postoperative Complications

Alvimopan is an US-FDA approved, peripherally acting mu opioid receptor antagonist which when started pre-operatively has been shown to hasten intestinal motility and reduce the duration of post-operative ileus. However the logistics involved in procuring, storing and dispensing the drug and the cost of the drug for fifteen doses as approved by FDA prohibits the use of it on a regular basis.

Topics: Humans; Ileus; Piperidines; Postoperative Complications; Receptors, Opioid, mu

Topics: Analgesia, Epidural; Digestive System Surgical Procedures; Gastrointestinal Agents; Humans; Ileus; Intestines; Piperidines; Postoperative Complications

This study sought to describe and analyze ocular findings associated with nonocular surgery in patients who underwent general anesthesia.. The authors retrospectively collected a series of 39,431 surgeries using standardized data forms.. Ocular findings were reported in 9 cases (2.3:10,000), which involved patients with a mean age of 58.9±19.5 years. These cases involved patients classified as ASA I (33%), ASA II (55%) or ASA III (11%). General anesthesia with propofol and remifentanil was used in 4 cases, balanced general anesthesia was used in 4 cases, and regional block was used in combination with balanced general anesthesia in one case. Five patients (55%) underwent surgery in the supine position, one patient (11%) underwent surgery in the lithotomy position, two patients (22%) underwent surgery in the prone position, and one patient (11%) underwent surgery in the lateral position. Ocular hyperemia was detected in most (77%) of the 9 cases with ocular findings; pain/burning of the eyes, visual impairment, eye discharge and photophobia were observed in 55%, 11%, 11% and 11%, respectively, of these 9 cases. No cases involved permanent ocular injury or vision loss.. Ophthalmological findings after surgeries were uncommon, and most of the included patients were relatively healthy. Minor complications, such as dehydration or superficial ocular trauma, should be prevented by following systematic protocols that provide appropriate ocular occlusion with a lubricating ointment and protect the eye with an acrylic occluder. These procedures will refine the quality of anesthesia services and avoid discomfort among patients, surgeons and anesthesia staff.

Topics: Adult; Aged; Aged, 80 and over; Anesthesia, General; Anesthetics, Intravenous; Elective Surgical Procedures; Eye Diseases; Female; Humans; Lubricant Eye Drops; Male; Middle Aged; Patient Positioning; Piperidines; Postoperative Complications; Propofol; Remifentanil; Retrospective Studies; Risk Factors; Young Adult

The dietary pigment curcumin is a natural polyphenol extracted from the Curcuma longa rhizomes native to South Asia. The antioxidative, antimicrobial, and anti-inflammatory activities besides its unknown side effects suggest that curcumin could be a promising antiresorptive agent to prevent replacement resorption in replanted teeth after traumatic avulsion. Piperine, an alkaloid present in black pepper, seems to enhance the bioavailability and activity of curcumin. Therefore, this study evaluated the biocompatibility of curcumin and piperine in cultures of periodontal ligament cells as well as their effects in an in vitro osteoclastogenesis model of RAW 264.7 macrophages.. The cytotoxicity in human periodontal ligament fibroblasts, human osteogenic sarcoma cells (SAOS-2), and murine osteoclastic precursors (RAW 264.7) was analyzed by using cell number determination and proliferation assays. The ability of curcumin and its conjugate to suppress the receptor activator of nuclear factor kappa B ligand-induced osteoclastogenesis was assessed by tartrate-resistant acid phosphatase (TRAP) staining and activity as well as real-time polymerase chain reaction.. Curcumin at concentrations ≥ 10 μmol/L was cytotoxic in all cell types tested, whereas piperine showed only slight cytotoxicity at 30 μmol/L in RAW and SAOS cultures. Although curcumin caused already significant effects, the combination with piperine completely suppressed the osteoclastogenesis by decreasing the TRAP activity and inhibiting the expression of the specific osteoclast markers TRAP, cathepsin K, and calcitonin receptor.. We demonstrated that curcumin combined with piperine suppressed the osteoclastogenesis in vitro without causing cytotoxic effects in periodontal ligament cells. These findings suggest its potential therapeutic application for the prevention and treatment of replacement resorption in replanted avulsed teeth.

Topics: Alkaloids; Animals; Benzodioxoles; Cells, Cultured; Curcumin; Fibroblasts; Humans; Mice; Osteogenesis; Periodontal Ligament; Piperidines; Polyunsaturated Alkamides; Postoperative Complications; RAW 264.7 Cells; Root Resorption; Tooth Avulsion; Tooth Replantation

Topics: Acute Disease; Adult; Anesthesia, General; Cholecystectomy; Cholecystitis; Emergencies; Humans; Intraoperative Complications; Male; Mitochondrial Encephalomyopathies; Monitoring, Intraoperative; Piperidines; Postoperative Complications; Propofol; Remifentanil

Three major processes, constrictive vessel remodeling, intimal hyperplasia (IH), and retarded re-endothelialization, contribute to restenosis after vascular reconstructions. Clinically used drugs inhibit IH but delay re-endothelialization and also cause constrictive remodeling. Here we have examined halofuginone, an herbal derivative, for its beneficial effects on vessel remodeling and differential inhibition of IH versus re-endothelialization.. Two weeks after perivascular application to balloon-injured rat common carotid arteries, halofuginone versus vehicle (n=6 animals) enlarged luminal area 2.14-fold by increasing vessel size (adaptive remodeling; 123%), reducing IH (74.3%) without inhibiting re-endothelialization. Consistent with its positive effect on vessel expansion, halofuginone reduced collagen type 1 (but not type 3) production in injured arteries as well as that from adventitial fibroblasts in vitro. In support of its differential effects on IH versus re-endothelialization, halofuginone produced greater inhibition of vascular smooth muscle cell versus endothelial cell proliferation at concentrations ≈50 nmol/L. Furthermore, halofuginone at 50 nmol/L effectively blocked Smad3 phosphorylation in smooth muscle cells, which is known to promote smooth muscle cell proliferation, migration, and IH, but halofuginone had no effect on phospho-Smad3 in endothelial cells.. Periadventitial delivery of halofuginone dramatically increased lumen patency via adaptive remodeling and selective inhibition of IH without affecting endothelium recovery. Halofuginone is the first reported small molecule that has favorable effects on all 3 major processes involved in restenosis.

Topics: Adaptation, Biological; Angiogenesis Inhibitors; Angioplasty, Balloon; Animals; Carotid Arteries; Carotid Artery Injuries; Cell Proliferation; Cells, Cultured; Collagen Type I; Endothelium, Vascular; Fibroblasts; Humans; Hyperplasia; Male; Models, Animal; Myocytes, Smooth Muscle; Organ Specificity; Piperidines; Postoperative Complications; Quinazolinones; Rats; Rats, Sprague-Dawley; Smad3 Protein; Vascular Remodeling

Off-label uses of the peripheral μ-opioid receptor antagonists alvimopan and methylnaltrexone are reviewed.. Alvimopan is approved by the Food and Drug Administration (FDA) for postoperative ileus after surgeries that include partial bowel resection with primary anastomosis, while methylnaltrexone is approved for the treatment of opioid-induced constipation (OIC) in patients with advanced illness who are receiving palliative care. Literature describing the off-label use of alvimopan in the treatment of OIC and of methylnaltrexone in postoperative ileus was reviewed and included retrospective studies and prospective Phase II-IV trials. Randomized controlled trials did not demonstrate consistent benefit of alvimopan in OIC nor of methylnaltrexone in postoperative ileus. A greater proportion of patients receiving alvimopan for OIC experienced severe adverse cardiovascular events, leading to a risk evaluation and mitigation strategy and discontinuation of its study in this condition. Data are limited and unreplicated for the off-label use of alvimopan for postoperative ileus in patients undergoing abdominal hysterectomy. Individual studies suggest benefit with methylnaltrexone for OIC in unlabeled populations, including patients with non-cancer-related pain, opioid dependence, opioid sedation, and opioid use after orthopedic surgery; however, confirmatory evaluations have not been performed.. Trials of alvimopan in the FDA-approved use of methylnaltrexone (OIC) indicate potentially serious cardiovascular safety concerns and conflicting findings of efficacy. Similarly, trials of methylnaltrexone in the FDA-approved use of alvimopan (postoperative ileus) consistently showed no benefit. Evaluations of both drugs in their labeled conditions in populations not endorsed in their product labeling have been limited and largely unreplicated.

Topics: Analgesics, Opioid; Constipation; Gastrointestinal Agents; Humans; Ileus; Naltrexone; Narcotic Antagonists; Off-Label Use; Piperidines; Postoperative Complications; Quaternary Ammonium Compounds

Congenital myasthenic syndromes (CMS) are heterogeneous disorders of neurotransmission caused by genetic mutations of neuromuscular junction molecules. We report anesthetic management of a CMS patient who was a 14-year-old boy with endplate acetylcholinesterase deficiency. The patient used noninvasive positive pressure ventilation (NPPV) at night. He underwent a corrective maneuver for severe scoliosis under general anesthesia. General anesthesia was maintained using propofol and remifentanil. Intraoperative mechanical ventilation remained stable. Extubation was performed on the next day and NPPV was started. Several hours later, he complained of a stomachache and intense abdominal bloating. Computed tomography revealed a massive amount of air in the stomach and intestine. He recovered from abdominal bloating the next day without treatment for decompression. Lung-thoracic compliance has been reported to decrease immediately after a corrective maneuver for scoliosis patients. In our case, we suspected a relative increase of abdominal compliance to lung-thoracic compliance as a cause of intense abdominal bloating by air injection from NPPV with his daily setting. In CMS, symptoms, therapy and contraindicated drugs vary according to the location of dysfunction. Therefore, anesthetic management according to each genotype should be designed to avoid drugs that could either trigger or worsen CMS. Intensive respiratory care is advisable after surgery.

Topics: Adolescent; Air; Anesthesia, General; Humans; Intestines; Lung Compliance; Male; Myasthenic Syndromes, Congenital; Perioperative Care; Piperidines; Positive-Pressure Respiration; Postoperative Complications; Propofol; Remifentanil; Respiration, Artificial; Scoliosis; Stomach

The study is designed to evaluate the influence of remifentanil/propofol anesthesia on ventilator-associated pneumonia (VAP) occurrence and respiratory support (RS) time after major cardiac surgery.. In retrospective-prospective study we investigated the respiratory support time and VAP occurrence in group of 47 patients with remifentanil/propofol and 35 patients with fentanil/midazolam anesthesia after major cardiac surgery in period June 2009-December 2011. Groups are divided in subgroups depending of who underwent cardiac surgery with or without cardiopulmonary by pass (CPB).. The time of respiratory support (RS) was the shortest in remifentanil group without CPB (R/Off 63min ± 44.3 vs R/On 94min ± 49.2 p=0,22), but was longer in fentanil group (F/Off 142 min ± 102.2 vs F/On 212 min ± 102.2 p=0.0014). The duration of RS of ON pump remifentanil group was shorter than in ON pump fentanil group (R/On 94 min vs F/On 212 min p=0.0011). The time of RS of OFF pump remifentanil group was lower than in Off pump entangle group (R/Off 63min ± 44,3 vs F/Off 142min ± 102.2 p=0,021) with statistically significance. Ventilator-associated pneumonia was detected in 7 patients (8.5 %). Six patients (17.1%) were from entangle group and one patient (2.1%) from remifentanil group. The most common isolates were Pseudomonas aeruginosa in all patients and both Pseudomonas aeruginosa and Klebsiella pneumonia in one patient.. The remifentanil anesthesia regimen in cardiac surgery decreases length of respiratory support duration and can prevent development of VAP. The role of remifentanil anesthesia in preventing VAP, as one of the most important risk factor of in-hospital mortality after cardiac surgery is still incompletely understood and should be investigated further.

Topics: Aged; Anesthesia, Intravenous; Bosnia and Herzegovina; Cardiac Surgical Procedures; Female; Humans; Male; Middle Aged; Piperidines; Pneumonia, Ventilator-Associated; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Respiration, Artificial; Retrospective Studies; Time Factors

Topics: Humans; Ileus; Piperidines; Postoperative Complications

Postoperative ileus, a temporary cessation in bowel motility, is a common and significant complication of major surgery. Consequences of postoperative ileus include increased patient discomfort, delayed time to adequate nutrition, prolonged length of stay, and increased cost to the patient and healthcare system. The traditional, multi-modal approach to the resolution of postoperative ileus includes opioid minimization, early ambulation, and early feeding. Newer medications, such as methlynaltrexone and alvimopan (which are peripherally acting mu opioid receptor antagonists), have become available and have proven beneficial for use with postoperative ileus.

Topics: Combined Modality Therapy; Exercise Therapy; Gastrointestinal Agents; Humans; Ileus; Naltrexone; Narcotic Antagonists; Piperidines; Postoperative Complications; Quaternary Ammonium Compounds

To evaluate in-hospital clinical outcomes after open and laparoscopic bowel resection (BR) with or without alvimopan treatment.. Delayed return of gastrointestinal function after BR may be associated with greater postoperative morbidity and increased hospital length of stay (LOS). In clinical trials, alvimopan--a peripherally acting μ-opioid receptor antagonist--accelerated gastrointestinal recovery after open BR.. A retrospective matched-cohort study (NCT01150760) was conducted using a national inpatient database. Each alvimopan patient was exact matched (surgical procedure, surgeon specialty) and propensity score matched (baseline characteristics) to a nonalvimopan BR patient. Outcomes included gastrointestinal and other morbidity (cardiovascular, pulmonary, infection, cerebrovascular, thromboembolic); mortality; readmission rate; and intensive care unit (ICU) stay (intent-to-treat [ITT] population). Postoperative LOS and estimated cost were also compared (modified ITT population).. Each cohort included 3525 ITT patients with similar baseline characteristics. Gastrointestinal (29.8% vs 35.7%) and other morbidity (cardiovascular [19.4% vs 24.0%], pulmonary [7.3% vs 10.5%], infectious [9.6% vs 11.8%], thromboembolic [1.2% vs 2.1%]), mortality (0.4% vs 1.0%), and mean ICU stay (0.3 vs 0.6 days) were lower in the alvimopan group (P ≤ 0.003 for each). Postoperative LOS and estimated direct cost were lower for all alvimopan patients and after laparoscopic and open BR (LOS: -1.1, -0.8, and -1.8 days respectively; cost: -$2345, -$1382, and -$3218, respectively; P ≤ 0.0008 for each).. On average, alvimopan-treated patients had a lower incidence of mortality and most incidents of morbidities. Length of stay, ICU use, and estimated cost were also lower with comparable readmissions. These results in patients outside the clinical trial setting include laparoscopic colectomy and demonstrate a potential association between acceleration of gastrointestinal recovery and improved early postoperative outcomes.

Topics: Adult; Aged; Anastomosis, Surgical; Cohort Studies; Digestive System Surgical Procedures; Female; Gastrointestinal Agents; Hospital Costs; Humans; Intensive Care Units; Intestines; Laparoscopy; Length of Stay; Logistic Models; Male; Middle Aged; Patient Readmission; Piperidines; Postoperative Complications; Propensity Score; Recovery of Function; Retrospective Studies; Treatment Outcome

To determine whether alvimopan for prevention of postoperative ileus in patients undergoing small- or large-bowel resection by laparotomy is associated with lower total costs compared with standard care.. Pharmacoeconomic analysis using a formal decision model.. Four phase III clinical trials, two pooled analyses, and one meta-analysis.. A cohort of patients who underwent bowel resection with primary anastomosis by laparotomy and received either standardized, accelerated postoperative care (usual care) or usual care plus alvimopan.. Clinical outcomes, obtained from pooled analyses of published studies, were time to discharge order written, postoperative nasogastric tube insertion, postoperative ileus-related readmission within 7 days, and occurrence of nausea and vomiting. Cost inputs included drugs, nursing labor, readmissions, and hospitalizations. Costs were assessed by determining the net cost of alvimopan use and subsequent reduction in length of stay. Sensitivity and scenario analyses were conducted. Costs for alvimopan were $570 based on an average of 9.5 doses. Given the 18.4-hour mean reduction in time to discharge order written, use of alvimopan reduced hospitalization costs by $2021. Mean difference in overall cost of care, as determined by Monte Carlo simulation, was $1168 (95% certainty interval -$437 to $5879), favoring the use of alvimopan. In the sensitivity analysis, association of alvimopan with lower costs was robust to several changes in key parameters including cost and number of doses of alvimopan, time to discharge order written, readmission rates, and hospitalization cost. In the scenario analyses, alvimopan use yielded a net cost of $226 when no difference in time to discharge order written was assumed. In the scenario analysis using data from a study that did not enforce opioid use, alvimopan resulted in a cost saving of $65/patient.. Alvimopan was cost saving for prevention of postoperative ileus in patients undergoing bowel resection by laparotomy, although these potential cost savings were highly dependent on a difference in time to discharge order written. This finding is not applicable to the less-invasive laparoscopic surgical approach for which quality data on alvimopan use are lacking. Limitations of this analysis included use of time to discharge order written as a proxy for length of stay and difficulty interpreting study results due to inconsistent reporting and conduct of the clinical trials evaluating alvimopan. More research is needed to determine the cost-effectiveness of alvimopan.

Topics: Cohort Studies; Cost-Benefit Analysis; Decision Support Techniques; Disease Management; Economics, Pharmaceutical; Humans; Ileus; Piperidines; Postoperative Complications; Randomized Controlled Trials as Topic; Statistics as Topic

The aim of this study was to evaluate the recovery complications following the use of 2 anesthetic protocols in orthognathic surgery, namely, propofol with remifentanil and isoflurane with remifentanil. Sixty-two patients with American Society of Anesthesiologists physical status I were selected. All underwent bimaxillary orthognathic surgery. Propofol with remifentanil was used as an anesthesia in group 1 (n = 32), and isoflurane with remifentanil was used in the patients in group 2 (n = 30). Early recovery complications consisting of pain, postoperative nausea and vomiting (PONV), shivering, and agitation were evaluated and documented. The length of the operation and duration of recovery were documented for all patients. Analysis of the data demonstrated no relationship between age and recovery time (P > 0.05). Analysis of data with χ(2) and independent t-tests did not show any difference between the 2 groups with regard to pain, agitation, PONV, and shivering (P > 0.05). Logistic regression was used to evaluate the effect of the operation time on recovery complications. The analysis showed that pain and PONV were significantly higher in those who experienced a longer operation time. With increasing operation time longer than 165 minutes, 64% of patients experienced pain, and 89% of them had PONV. General anesthesia can be provided via intravenously administered medications and/or inhaled volatile anesthetics. No significant difference in early recovery time was found in patients when either isoflurane or propofol was used to maintain the anesthesia. However, the length of the operation played a major role in increasing early recovery complications.

Topics: Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Chi-Square Distribution; Female; Humans; Isoflurane; Logistic Models; Male; Orthognathic Surgery; Pain Measurement; Piperidines; Postoperative Complications; Postoperative Nausea and Vomiting; Propofol; Prospective Studies; Psychomotor Agitation; Remifentanil; Shivering; Statistics, Nonparametric; Young Adult

To investigate the efficacy and safety of propofol-remifentanil total intravenous anesthesia (TIVA) and spontaneous ventilation for foreign body (FB) removal in pediatric patients with preoperative respiratory impairment.. We carried out a prospective observational clinical study of FB removal using a rigid bronchoscope under propofol-remifentanil TIVA and spontaneous ventilation in 65 pediatric patients who presented with preoperative respiratory impairment. Heart rate, blood pressure, pulse oxygen saturation (SpO(2)), respiratory rate, endtidal CO(2) (ETCO(2))(ETCO2), induction time, and remifentanil rate were recorded. Adverse events, the intervention for these events, and the duration of postoperative care were also of interest.. Sixty children completed the study. The mean induction time was 12.3 min. During the procedure, the maximum remifentanil rate was 0.14 μg · kg(-1) · min(-1). Light breath holding occurred in 16 (26.7%) patients. No severe breath holding or body movements were observed. An SpO(2) below 90% occurred in 10 (16.7%) cases. No progressive desaturation was observed. The mean ETCO(2) at the end of the procedures was 7.91 KPa and returned to normal 5 min after the procedure. In the postanesthesia care unit (PACU), no hypoxemia was observed and the mean recovery time was 23.4 min. No laryngospasm, pneumothorax, or arrhythmias were observed.. Propofol-remifentanil TIVA and spontaneous ventilation are effective and safe techniques to manage anesthesia during airway FB removal in children with preoperative respiratory impairment.

Topics: Anesthesia, Intravenous; Anesthetics, Intravenous; Blood Pressure; Bronchoscopy; Carbon Dioxide; Child, Preschool; Cough; Female; Foreign Bodies; Heart Rate; Humans; Infant; Male; Monitoring, Intraoperative; Muscle Relaxants, Central; Piperidines; Postoperative Complications; Propofol; Remifentanil; Respiration Disorders

The long-lasting post-surgical changes in nociceptive thresholds in mice, indicative of latent pain sensitization, were studied. The contribution of kappa opioid and N-methyl-d-aspartate (NMDA) receptors was assessed by the administration of nor-binaltorphimine or MK-801; dynorphin levels in the spinal cord were also determined. Animals underwent a plantar incision and/or a subcutaneous infusion of remifentanil (80μg/kg), and mechanical thresholds (von Frey) were evaluated at different times. On day 21, after complete recovery of mechanical thresholds and healing of the wound, one of the following drugs was administered subcutaneously: (-)-naloxone (1mg/kg), (+)-naloxone (1mg/kg), naloxone-methiodide (3mg/kg), or nor-binaltorphimine (5mg/kg). Another group received subcutaneous MK-801 (0.15mg/kg) before nor-binaltorphimine administration. Dynorphin on day 21 was determined in the spinal cord by immunoassay. In mice receiving remifentanil during surgery, the administration of (-)-naloxone or nor-binaltorphimine induced significant hyperalgesia even 5months after manipulation. Nociceptive thresholds remained unaltered after (+)-naloxone or naloxone-methiodide. On day 21 after manipulation, the administration of MK-801 prevented nor-binaltorphimine-induced hyperalgesia. No changes in dynorphin levels were observed before or after opioid antagonist administration. In conclusion, surgery produced latent pain sensitization evidenced by opioid antagonist-precipitated hyperalgesia. The effect was stereospecific, centrally originated, and mediated by kappa opioid receptors. The blockade of nor-binaltorphimine-induced hyperalgesia by MK-801, suggests that NMDA receptors are also involved. Our results show for the first time that surgery induces latent, long-lasting changes in the processing of nociceptive information that can be induced by non-nociceptive stimuli such as the administration of opioid antagonists.

Topics: Animals; Dizocilpine Maleate; Dynorphins; Hyperalgesia; Male; Mice; Naloxone; Naltrexone; Narcotic Antagonists; Pain; Pain Threshold; Piperidines; Postoperative Complications; Reaction Time; Receptors, N-Methyl-D-Aspartate; Receptors, Opioid, kappa; Remifentanil; Spinal Cord

Remifentanil may be beneficial in patients undergoing cardiac surgery, by attenuating the neurohumoral stress response to surgical stimulation and inflammation evoked by cardiopulmonary bypass (CPB).. We retrospectively examined blood glucose monitored every 30 minutes during CPB and insulin dose in patients during CPB under remifentanil anesthesia (remifentanil group) and those under low dose fentanyl anesthesia (fentanyl group) in adult cardiac surgery. Furthermore we also investigated incidence of atrial fibrillation within 72 hours after surgery in both groups.. There were 35 patients in remifentanil group and 22 patients in fentanyl group. Although blood glucose at the beginning and the end of CPB in both groups were not different, remifentanil group showed lower maximum blood glucose (median 172 mg x dl(-1), interquatile range 156-205 mg x dl(-1)) during CPB than in fentanyl group (197 mg x dl(-1), 176-219 mg x dl(-1); P = 0.009). Significantly less insulin was administered during CPB in remifentanil group than in fentanyl group. Incidence of postoperative atrial fibrillation was similar between the groups.. Maximum blood glucose was lower and less insulin was administered during CPB in remifentanil group. These data may suggest that remifentanil reduce stress response to surgical stimulation in cardiac surgery.

Topics: Aged; Anesthetics, Intravenous; Atrial Fibrillation; Blood Glucose; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Female; Fentanyl; Humans; Insulin; Male; Middle Aged; Piperidines; Postoperative Complications; Remifentanil; Retrospective Studies

Alvimopan, a peripherally acting μ-opioid receptor antagonist, was recently approved for the reduction of postoperative ileus after open colectomy. No data are available regarding the use of alvimopan following laparoscopic segmental colectomy.. This study was designed to evaluate the effectiveness of alvimopan in patients undergoing laparoscopic segmental colectomy.. A retrospective review of segmental laparoscopic colectomy was conducted in a population of patients using an accelerated postcolectomy care pathway. Patients that received alvimopan were identified from an institutional review board-approved database and matched with nonalvimopan patients for age, sex, procedure, and diagnosis. Patients with a diverting ileostomy or with contraindications for alvimopam were excluded.. One hundred patients undergoing laparoscopic colectomy received alvimopan perioperatively and were matched with a similar group of nonalvimopan patients. Although patients on alvimopan were significantly less likely to develop postoperative ileus (4% vs 12%; P = .04), there was no difference in length of hospital stay (3.63 days in the alvimopan group vs 3.78 in the nonalvimopan group; P = .84) or 30-day readmission rate (4.0% vs 4.2%; P = .95).. As the cost of providing health care continues to increase, reductions in perioperative complications and hospital stay are important to hospital efficiency and patient care. Alvimopan effectively reduces the incidence of postoperative ileus in patients undergoing open colectomy; however, hospital stay and readmission rates were not altered in this laparoscopic group. Further study is required before alvimopan can be routinely used in patients undergoing laparoscopic colectomy.

Topics: Analysis of Variance; Chi-Square Distribution; Colectomy; Female; Gastrointestinal Agents; Humans; Ileus; Laparoscopy; Male; Middle Aged; Piperidines; Postoperative Complications; Retrospective Studies; Treatment Outcome

We investigated the effects of the beach-chair position and induced hypotension on regional cerebral oxygen saturation (rSO(2)) in patients undergoing arthroscopic shoulder surgery by using near-infrared spectroscopy.. Twenty-eight patients scheduled for arthroscopic shoulder surgery were enrolled prospectively. After induction of anesthesia, mechanical ventilation was controlled to maintain Paco(2) at 35 to 40 mm Hg. Anesthesia was maintained with sevoflurane and remifentanil. After radial artery cannulation, mean arterial pressure (MAP) was measured at the external auditory meatus level and maintained between 60 and 65 mm Hg. The rSO(2) was measured by use of near-infrared spectroscopy. MAP and rSO(2) were recorded at the following times: before induction (T(0)), immediately after induction (T(1) [baseline]), after beach-chair position (T(2)), immediately after induced hypotension (T(3)), 1 hour after induced hypotension (T(4)), and after supine position at the end of surgery (T(5)). Cerebral desaturation was defined as a reduction in rSO(2) to less than 80% of baseline value for 15 seconds or greater.. A total of 27 patients were evaluated until the end of this study. The MAP at T(2) was significantly lower than that at T(1). The MAP values at T(3) and T(4) were significantly lower than those at T(1) and T(2). The rSO(2) at T(2) was significantly lower than that at T(1). Unlike the pattern of change in the MAP, there was no additional decrease in rSO(2) at T(3) and T(4). There were 2 patients who had an episode of cerebral desaturation.. The beach-chair position combined with induced hypotension significantly decreases rSO(2) in patients undergoing shoulder arthroscopic surgery under general anesthesia.. Level IV, study of nonconsecutive patients without consistently applied reference gold standard.

Topics: Aged; Anesthesia, General; Arthroscopy; Blood Pressure; Cerebrovascular Circulation; Cognition; Female; Humans; Hypotension; Male; Middle Aged; Oxygen; Piperidines; Postoperative Complications; Postoperative Period; Posture; Preoperative Period; Prospective Studies; Remifentanil; Shoulder; Spectroscopy, Near-Infrared

Cholinesterase inhibitors (ChEIs) may interact with muscle relaxants given during general anesthesia (GA), increasing the risk of postoperative complications. We evaluated the effects of ChEIs on the postoperative outcomes of older adults who underwent hip fracture surgery.. Population-based cohort study using linked administrative databases.. All individuals with dementia age 66 years or older, who underwent hip fracture surgery between April 1, 2003, and December 31, 2007, in Ontario, Canada.. Use of any ChEI (donepezil, rivastigmine, or galantamine) before surgery.. The primary composite outcome included any of the following: 30-day postoperative mortality; intensive care unit admissions; or in-hospital resuscitation. Secondary outcomes included postoperative respiratory failure and pneumonia.. We stratified the study sample on the basis of residence (community or long-term care [LTC]) and type of anesthetic (general or regional) to create four residence/anesthesia groups. We used propensity scores to match users and nonusers of ChEIs within the residence/anesthesia strata. We then calculated the relative risks (RR) and 95% confidence intervals (CI) for outcomes associated with ChEIs in the matched groups.. A total of 624 pairs of individuals from the community and 725 pairs from LTC were created among individuals who received GA. High rates of postoperative mortality and complications were observed in both ChEI users and nonusers. The RR of the primary outcome associated with ChEI use for individuals receiving GA was 0.88 (95% CI: 0.68-1.16; χ2 = 0.93; df = 1; p = 0.34) and 0.82 (95% CI: 0.63-1.04; χ2 = 2.59; df = 1; p = 0.11) in the community and LTC groups, respectively. In addition, ChEIs were not associated with any significant increased risk of postoperative respiratory complications.. ChEI use was not associated with an increased risk of postoperative complications among older adults with dementia who underwent hip fracture surgery. However, the poor postoperative outcomes overall reinforced the need to prevent fractures and improve outcomes in this population.

Topics: Aged; Aged, 80 and over; Anesthesia, General; Cholinesterase Inhibitors; Cohort Studies; Critical Care; Dementia; Donepezil; Female; Galantamine; Hip Fractures; Humans; Indans; Male; Outcome and Process Assessment, Health Care; Phenylcarbamates; Piperidines; Pneumonia; Postoperative Complications; Respiratory Insufficiency; Resuscitation; Risk; Rivastigmine

We prospectively evaluated safety and efficacy from our six-year results of general anesthesia (GA) using remifentanil conscious sedation in carotid endarterectomy (CEA).. From January 2005 to December 2010, 625 consecutive CEAs were performed on 545 patients (male/female 336/209, age 75 ± 7 years). After a superficial plexus block with ropavacaine, GA was induced with an intravenous infusion of propofol, using local lidocaine during tracheal intubation and a high-dose of remifentanil, in all cases reducing and then stopping the remifentanil infusion at the clamping time so that the patient would be awake and collaborating within a few minutes, as in local anesthesia. Data on postoperative morbidity and mortality, neurological complications, shunt insertions and the responses to one-day and three-month questionnaires on satisfaction were collected for all patients.. The 30-day mortality was 0.32% (two patients). Only one major stroke (0.16%) and two minor strokes (0.32%) occurred. A shunt was deployed in 83 cases (13.3%). Eight patients (1.28%) reported cranial nerve injuries, and surgical drainage for postoperative hematoma was performed in 11 patients (1.8%). Thirty-one patients (4.6%) suffered postoperative nausea/vomiting. Almost all patients were satisfied at the 24-h (94.6%) and three-month (>98%) follow-up questionnaire.. The six-year results for GA using remifentanil conscious sedation were very satisfactory and highlighted the advantages of both GA (hemodynamic stability and excellent control of ventilation) and local anesthesia (ease of evaluation of neurological status) in a calm and relaxed environment for both patient and surgeon.

Topics: Aged; Aged, 80 and over; Anesthesia, General; Carotid Artery Diseases; Conscious Sedation; Endarterectomy, Carotid; Female; Humans; Hypnotics and Sedatives; Intubation, Intratracheal; Italy; Male; Middle Aged; Patient Satisfaction; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Surveys and Questionnaires; Time Factors; Treatment Outcome

Neuroplastic changes involved in latent pain sensitization after surgery are poorly defined. We assessed temporal changes in glucose brain metabolism in a postoperative rat model using positron emission tomography. We also investigated brain metabolism after naloxone administration.. Rats were given remifentanil anesthetic and underwent a plantar incision, with 1 mg/kg of (-)-naloxone subcutaneously administered on postoperative days 20 and 21. Using the von Frey test, mechanical thresholds were measured pre- and postoperatively at different time points in awake animals during F-fluorodeoxyglucose (F-FDG) uptake. Brain images were also obtained the day before mechanical testing, using a positron emission tomography R4 scanner (Concorde Microsystems, Siemens, Knoxville, TN). Differences in brain activity were assessed utilizing a statistical parametric mapping.. Surgery induced minor changes in F-FDG uptake in the cerebellum, hippocampus, and posterior cortex, which extended to the thalamus, hypothalamus, and brainstem on days 6 and 7. Changes were still present on day 21. Maximal postoperative hypersensitivity was observed on day 2. The administration of (-)-naloxone on day 21 induced significant hypersensitivity, greatly enhancing the effect on F-FDG uptake. In sham-operated rats, naloxone induced changes limited to the striatum and the cerebellum. Nonnociceptive stimulation with von Frey filaments had no effect on F-FDG uptake.. Surgery, remifentanil, and their combination induced long-lasting and significant metabolic changes in the pain brain matrix, with a positive correlation with hypersensitivity after naloxone. Changes in brain F-FDG precipitated by naloxone suggest that surgery under remifentanil anesthetic induces the greatest neuroplastic brain adaptations in opioid-related pathways involved in nociceptive processing and long-lasting pain sensitization.

Topics: Animals; Brain; Fluorodeoxyglucose F18; Glucose; Male; Naloxone; Pain; Pain Threshold; Piperidines; Positron-Emission Tomography; Postoperative Complications; Radiopharmaceuticals; Rats; Rats, Sprague-Dawley; Remifentanil

Postoperative stress produces an inflammatory response. Recent studies have shown that narcotic analgesics suppress the immune system. Nutritional management during perioperative care has also been reported to affect inflammation. We therefore examined whether remifentanil or glucose administration could ameliorate postsurgical inflammatory responses using a rat model of surgical stress.. We divided male Wistar rats randomly into five groups: (1) control, (2) sevoflurane+lactated Ringer's solution, (3) sevoflurane+lactated Ringer's solution with 1% glucose, (4) sevoflurane+remifentanil+lactated Ringer's solution, and (5) sevoflurane+remifentanil+ lactated Ringer's solution with 1% glucose. In all groups, serum samples were obtained at various time points after surgery, and secreted cytokine concentrations were determined. In addition, we assessed the activation of protein kinase B (Akt) and forkhead/winged helix box class O (FOXO3), which play a role in gluconeogenesis/stress responses.. Surgical stress increased the serum concentrations of tumor necrosis factor-α and interleukin-6. Groups receiving remifentanil with anesthesia showed an attenuated inflammatory response. The inflammatory response was also reduced by administering 1% glucose. Furthermore, 1% glucose induced Akt and FOXO3 phosphorylation in the quadriceps femoris muscle 12 h after surgery.. Anesthesia based on remifentanil and perioperative administration of lactated Ringer's solution containing 1% glucose may be able to control inflammatory responses caused by surgical stress.

Topics: Anesthetics, Inhalation; Animals; Blood Glucose; Forkhead Box Protein O3; Forkhead Transcription Factors; Glucose; Hypnotics and Sedatives; Inflammation; Interleukin-6; Isotonic Solutions; Male; Methyl Ethers; Models, Animal; Phosphorylation; Piperidines; Postoperative Complications; Proto-Oncogene Proteins c-akt; Quadriceps Muscle; Rats; Rats, Wistar; Remifentanil; Ringer's Lactate; Sevoflurane; Stress, Physiological; Tumor Necrosis Factor-alpha

The need to compromise between surgical and anesthetic access in airway surgery is an important clinical problem. We wanted to determine the feasibility of performing upper airway surgery under awake anesthesia and spontaneous respiration.. This was a prospective, clinical feasibility study. Patients with upper tracheal stenosis were managed through cervical epidural anesthesia and conscious sedation, and atomized local anesthetic. No intraoperative intubation or jet ventilation was required. Outcome measures were ease of surgery, observer-rated functional result, early (less than 30 days) complications, and patient-reported satisfaction.. Twenty consecutive patients with idiopathic (n = 4) or postintubation (n = 16) complete (n = 3) or severe (>80%, n = 17) subglottic (n = 12) or upper trachea (n = 8) stenosis were enrolled. Operations included 12 subglottic and 8 segmental resections with primary anastomosis. Permissive hypercapnia was well tolerated. Median length of resection was 4.5 cm (range, 2 to 6 cm), and 12 releases (8 thyrohyoid, 4 suprahyoid) were required. One patient required a nasotracheal tube for 36 hours. All but 1 were able to cough and talk immediately, and to swallow fluids and solids, and were fully mobilized at 6 hours. There were no early complications. Median hospitalization was 3.1 days (range, 2 to 15). Patients had excellent (n = 16) or good (n = 4) functional (n = 20) outcomes, with no early relapse of stenosis. Median self-reported satisfaction at median 12 months was 9.5 +/- 1.0 (scale, 0 to 10). All patients indicated that they would be happy to repeat the procedure.. Awake and tubeless upper airway surgery is feasible and safe, and has a high level of patient satisfaction. If supported by randomized controlled trial, this method will change the way airway stenosis surgery is approached by both surgeons and anesthesiologist.

Topics: Adult; Aerosols; Analgesics, Opioid; Anastomosis, Surgical; Anesthesia, Epidural; Anesthetics, Local; Conscious Sedation; Early Ambulation; Feasibility Studies; Female; Follow-Up Studies; High-Frequency Jet Ventilation; Humans; Intubation, Intratracheal; Larynx; Length of Stay; Lidocaine; Male; Middle Aged; Patient Satisfaction; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Trachea; Tracheal Stenosis

Topics: Adult; Androstanols; Anesthesia, Intravenous; Cholecystectomy, Laparoscopic; Cholelithiasis; Contraindications; Diabetes Mellitus, Type 2; Fentanyl; Humans; Intraoperative Complications; Male; MELAS Syndrome; Neuromuscular Nondepolarizing Agents; Oxygen; Piperidines; Postoperative Complications; Preanesthetic Medication; Preoperative Care; Propofol; Remifentanil; Rocuronium; Succinylcholine

Adenosine-induced transient flow arrest has been used to facilitate clip ligation of intracranial aneurysms. However, the starting dose that is most likely to produce an adequate duration of profound hypotension remains unclear. We reviewed our experience to determine the dose-response relationship and apparent perioperative safety profile of adenosine in intracranial aneurysm patients.. This case series describes 24 aneurysm clip ligation procedures performed under an anesthetic consisting of remifentanil, low-dose volatile anesthetic, and propofol in which adenosine was used. The report focuses on the doses administered; duration of systolic blood pressure <60 mm Hg (SBP(<60 mm Hg)); and any cardiovascular, neurologic, or pulmonary complications observed in the perioperative period.. A median dose of 0.34 mg/kg ideal body weight (range: 0.29-0.44 mg/kg) resulted in a SBP(<60 mm Hg) for a median of 57 seconds (range: 26-105 seconds). There was a linear relationship between the log-transformed dose of adenosine and the duration of a SBP(<60 mm Hg) (R(2) = 0.38). Two patients developed transient, hemodynamically stable atrial fibrillation, 2 had postoperative troponin levels >0.03 ng/mL without any evidence of cardiac dysfunction, and 3 had postoperative neurologic changes.. For intracranial aneurysms in which temporary occlusion is impractical or difficult, adenosine is capable of providing brief periods of profound systemic hypotension with low perioperative morbidity. On the basis of these data, a dose of 0.3 to 0.4 mg/kg ideal body weight may be the recommended starting dose to achieve approximately 45 seconds of profound systemic hypotension during a remifentanil/low-dose volatile anesthetic with propofol induced burst suppression.

Topics: Adenosine; Adult; Aged; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Atrial Fibrillation; Cardiovascular Diseases; Cerebrovascular Circulation; Dose-Response Relationship, Drug; Female; Humans; Intracranial Aneurysm; Ligation; Male; Middle Aged; Nervous System Diseases; Neurosurgical Procedures; Piperidines; Postoperative Complications; Propofol; Remifentanil; Vasodilator Agents

Topics: Adolescent; Anesthesia Recovery Period; Anesthetics, Intravenous; Ankle Joint; Humans; Piperidines; Postoperative Complications; Propofol; Reflex; Remifentanil; Scoliosis; Spinal Cord Injuries; Young Adult

Our objective was to determine whether coating the amniotic membrane with halofuginone, a type 1 collagen synthase inhibitor, with or without the hemostasis-inducing substance chitosan, reduced the number and severity of adhesions in the rat uterine horn injury model. Sixty retired breeder Sprague-Dawley rats underwent midline laparotomy and a zone of ischemia was created in the left uterine horn of each animal. Rats were randomized to one of six treatment groups: (1) untreated control, (2) oxidized regenerated cellulose (Interceed®) (ORC), (3) plain amnion, (4) amnion coated on both sides with 0.5% solution of halofuginone (HAH), (5) amnion coated on one side with 0.5% halofuginone and on the other side with chitosan (CAH), or (6) amnion coated on both sides with chitosan (CAC). The zone of ischemia in each left uterine horn was wrapped in each treatment. Rats were sacrificed 2 weeks after laparotomy, and adhesions were counted and scored for severity. Data were analyzed using Chi square and a p < 0.05 was considered significant. Our results showed that there were no differences in the percentage of animals with adhesions in the untreated, ORC, plain amnion, or CAC groups. No adhesions formed in any animal in the HAH group and only 14% of the animals developed adhesions to the uterine horn in the CAH group (p < 0.05). The percentage of animals with moderate and severe adhesions did not differ between untreated controls and the ORC groups, but were significantly reduced in all four of the amnion groups: plain amnion, HAH, CAH, and CAC (p < 0.05). Amnion coated with halofuginone alone or in combination with chitosan reduced the percentage of animals with adhesions, as well as the percentage of animals with moderate and severe adhesions compared to untreated controls and the ORC group in the rat uterine horn injury model. Amnion alone or coated with chitosan reduced the percentage of rats with moderate and severe adhesions, but not the percentage of rats with adhesions of any type compared to both untreated controls and the ORC group in the rat uterine horn injury model.

Topics: Abdomen; Amnion; Angiogenesis Inhibitors; Animals; Cellulose, Oxidized; Chitosan; Female; Ischemia; Laparotomy; Piperidines; Postoperative Complications; Quinazolinones; Random Allocation; Rats; Rats, Sprague-Dawley; Tissue Adhesions; Treatment Outcome; Uterine Diseases; Uterus

A 54-year-old man had emergency laparoscopic chelecystectomy for acute cholecystitis. General inflammatory change (CRP 26.6 mg x dl(-1), WBC 26,800) was noted preoperatively. Anesthesia was induced with propofol and remifentanil and maintained with sevoflurane in oxygen and remifentanil. Operation was performed uneventfully within 128 min. At the end of the surgery, 0.1 mg of fentanyl was administrated. After confirming adequate respiration and oxygenation, endotracheal tube was removed. At that period, hypertension (SBP 220 mmHg) and tachycardia (HR 122 beats x min(-1)) developed. Soon thereafter, he became agitated and complained of dyspnea with desaturation (Spo2 < 70%). After reintubation, massive pinkish babbly secretion flowed out from the endotracheal tube. Chest X-ray revealed diffuse bilateral infiltration of the lungs without cardiomegaly. He was transferred to the intensive care unit for mechanical ventilation. His condition improved progressively and was extubated on the POD 6. The cause of pulmonary edema is thought to be profound centralization of circulating volume associated with catecholamine-induced vasoconstriction due to rapid disappearance of remifentanil effect. Adequate analgesia is necessary during remifentanil-based anesthesia especially in patients suffering from general inflammatory changes.

Topics: Aged; Anesthesia; Anesthesia Recovery Period; Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Humans; Hypertension; Intubation, Intratracheal; Male; Perioperative Care; Piperidines; Postoperative Complications; Pulmonary Edema; Remifentanil

A 12-year-old girl with severe scoliosis underwent an operative procedure for correction of her spine deformity. Spinal cord injury is one of the most feared complications of scoliosis surgery. Therefore, it is necessary to detect spinal injury as early as possible. Intraoperative wake-up test is used to monitor spinal cord function during surgery. We used an intraoperative wake-up test with the concept of target-controlled infusion and total intravenous anesthesia (propofol and remifentanil). The use of Bispectral Index monitoring as a measure of depth of anesthesia enabled the patient to awake rapidly and consequently we did an immediate evaluation of muscle strength of lower extremities.

Topics: Anesthesia, General; Anesthesia, Intravenous; Child; Female; Humans; Intraoperative Complications; Monitoring, Intraoperative; Perioperative Care; Piperidines; Postoperative Complications; Propofol; Remifentanil; Scoliosis; Spinal Cord; Spinal Cord Injuries; Treatment Outcome; Wakefulness

To determine the outcome of immediate suture adjustment in adjustable suture strabismus surgery using a general anaesthetic technique.. Adjustable suture strabismus surgery was performed in 69 patients using a target-controlled infusion of propofol-remifentanil. Sutures were adjusted immediately following surgery and patient satisfaction and ocular alignment were assessed at 3 months postoperatively.. Preoperatively, 71% (49/69) of patients were divergent (group 1) and 29% (20/69) were convergent (group 2). Following surgery, the mean deviation in group 1 was 3.5 +/- 13.08 Delta exodeviation for near and 0.8 +/- 10.66 Delta exodeviation for distance. The mean postoperative deviation in group 2 was 2.6 +/- 9.1 Delta esodeviation for near and 2 +/- 9.0 Delta esodeviation for distance. Overall, 80% (45/69) were within 10 Delta of orthotropia.. Single-stage adjustable suture strabismus surgery produces good results and is well suited to day case surgery.

Topics: Adolescent; Adult; Aged; Ambulatory Surgical Procedures; Anesthesia; Anesthetics, Intravenous; Humans; Middle Aged; Patient Satisfaction; Piperidines; Postoperative Complications; Postoperative Period; Propofol; Remifentanil; Retrospective Studies; Strabismus; Suture Techniques; Young Adult

Anesthetic goals for procedures involving resections close to the motor cortex include immobility, analgesia, and a level of consciousness that allows for the ability to follow motor commands. Remifentanil as a single agent is an attractive choice, particularly when ventilation is controlled. The successful use of large-dose remifentanil infusion during an awake craniotomy in a 16 year-old man and the subsequent severe acute opioid tolerance is presented.

Topics: Adolescent; Analgesics, Opioid; Anesthesia; Consciousness; Craniotomy; Drug Tolerance; Epilepsy; Fentanyl; Hematoma, Epidural, Cranial; Humans; Male; Morphine; Motor Cortex; Pain, Postoperative; Piperidines; Postoperative Complications; Remifentanil; Wakefulness

Topics: Humans; Ileus; Piperidines; Postoperative Complications

Topics: Analgesics, Opioid; Anesthetics; Gastrointestinal Agents; Humans; Intestinal Pseudo-Obstruction; Intubation, Gastrointestinal; Naltrexone; Piperidines; Postoperative Complications; Preoperative Care; Quaternary Ammonium Compounds

A 21-year-old man was scheduled to undergo posterior cruciate ligament reconstruction under arthroscopic control. The patient did not have a previous history of thyroid disease. Low blood cholesterol was revealed in the laboratory data. On arriving at the operating room, he showed sinus tachycardia of 130 beats x min(-1). Anesthesia was induced with remifentanil and propofol intravenously followed by sevoflurane inhalation, and maintained with remifentanil at a rate of 0.3 microg x kg(-1) x min(-1) and 2% sevoflurane. Heart rate was stable around 70-90 beats x min(-1) during the operation. After remifentanil and sevoflurane were discontinued following surgery, his heart rate increased and paroxysmal atrial fibrillation occurred. Although verapamil was administered intravenously, atrial fibrillation and tachycardia persisted. Further investigations revealed an elevated serum free thyroxin level and suppressed thyroid-stimulating hormone (TSH). Serum TSH receptor antibody concentration was elevated. Upon postoperative examination, goiter and the protuberance of the eyes were noticed. We conclude that he was suffering from Basedow disease. Although he had no subjective symptoms in the preoperative period, the possibility of hyperthyroidism should have been predicted from the laboratory data such as hypolipidemia and by conducting a careful medical examination. It seems that remifentanil suppresses sympathetic activity, and is useful for patients with hyperthyroidism.

Topics: Anesthesia Recovery Period; Anesthesia, General; Atrial Fibrillation; Humans; Hyperthyroidism; Male; Piperidines; Plastic Surgery Procedures; Posterior Cruciate Ligament; Postoperative Complications; Remifentanil; Young Adult

To compare the incidence of laryngospasm by using halothane-fentanyl anaesthesia and midazolam-remifentanil anaesthesia in paediatric patients undergoing eye surgery.. We enrolled 120 ASA physical status I children aged 7-12 years scheduled for eye surgery from March 2004 to February 2006 in this prospective clinical trial study. Children suffering from any medical condition that could affect airway reflexes such as active upper respiratory infection, symptomatic asthma, obesity, patients with predicted difficulty in tracheal intubation were not included in the study. Patients with prolonged or difficult intubation or those who received another drug before extubation were excluded from the study. Using a random numbers table, participants were allocated to two equal groups. After induction of anaesthesia, in one group Halothane 1% was administered for the maintenance of anaesthesia in addition with intravenous fentanyl 1.5 microg kg(-1), and for the patients of the other group midazolam with a dose of 0.1 mg kg(-1) and remifentanil infusion by a dose of 0.1 microg kg(-1) min(-1) was administered. The patients were extubated in a unique plan of anaesthesia, using the sign of swallowing as a clinical indicator for extubation of patients.. The incidence of laryngospasm was lower in midazolam-remifentanil group (0%) in comparison with halothane-fentanyl group (6.6%).. The results of our study suggest that remifentanil combined with midazolam in children undergoing eye surgery provided a better condition for extubation of the patients.

Topics: Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Drug Therapy, Combination; Fentanyl; Halothane; Humans; Incidence; Laryngismus; Midazolam; Ophthalmologic Surgical Procedures; Piperidines; Postoperative Complications; Postoperative Period; Remifentanil; Risk Factors

An 82-year-old woman with amyotrophic lateral sclerosis (ALS) with bulbar paralysis, respiratory muscle paralysis, and arteriosclerosis obliterans (ASO) of the lower extremities, underwent uneventful general anesthesia with remifentanil and sevoflurane for bilateral below-knee amputation. Remifentanil is a potent ultra short-acting opioid analgesic drug, undergoes rapid metabolism by non-specific tissue and plasma esterases, and does not accumulate to any clinically important degrees. Furthermore, when remifentanil is used together with propofol during anesthetic induction, successful tracheal intubation can be accomplished without muscle relaxants. These features of remifentanil make it an ideal agent for use in patients with neuromuscular diseases, including ALS, with higher risks of postoperative opioid-induced respiratory depression.

Topics: Aged, 80 and over; Amputation, Surgical; Amyotrophic Lateral Sclerosis; Anesthesia, General; Arteriosclerosis Obliterans; Female; Humans; Leg; Methyl Ethers; Piperidines; Postoperative Complications; Remifentanil; Respiratory Distress Syndrome; Sevoflurane

The Tako-Tsubo syndrome (or transient left ventricular apical balloning) is a new clinical entity, very similar to acute myocardial infarction, but different by its excellent short-term prognosis. It has been reported after a physical or an emotional stress, and it is diagnosed by a coronary angiogram and a left ventriculography. We report here a case of Tako-Tsubo syndrome related to an anaphylactic shock caused by succinylcholine during general anaesthesia of a female patient, wearing an unadjustable gastric band.

Topics: Anaphylaxis; Anesthesia, General; Anesthesia, Intravenous; Diabetes Mellitus, Type 2; Female; Gastroplasty; Heart Arrest; Humans; Intraoperative Complications; Laparoscopy; Middle Aged; Neuromuscular Depolarizing Agents; Obesity; Pelvic Floor; Piperidines; Postoperative Complications; Propofol; Pulmonary Edema; Remifentanil; Succinylcholine; Takotsubo Cardiomyopathy; Ventricular Fibrillation

To investigate whether esmolol is effective in attenuating postoperative hemodynamic changes related to sympathetic overdrive.. Clinical study.. Operating room of a university hospital.. 60 ASA physical status I, II, and III patients, age 18 to 65 years, scheduled for elective craniotomy for supratentorial neurosurgery.. Patients were given total intravenous anesthesia (TIVA) during emergence from anesthesia and up to 60 minutes after extubation. Those patients who had hypertension (defined as an increase in systolic blood pressure >20% from baseline values) and tachycardia (defined as an increase >20% in heart rate from baseline) received a loading dose of 500 microg/kg esmolol in one minute, followed by an infusion titrated stepwise (50, 100, 200, and 300 microg/kg per min) every two minutes.. The mean dose and duration of esmolol therapy were measured.. Of 60 patients, 49 (82%) who received propofol-remifentanil TIVA developed significant tachycardia and hypertension soon after extubation. Treatment with esmolol (500 microg/kg in bolus maintained at a mean rate of 200 +/- 50 microg/kg per min) effectively controlled hypertension and tachycardia in 45 of 49 patients (92%; P < 0.05) within a mean 4.30 +/- 2.20 minutes. After extubation, mean esmolol infusion time was 29 +/- 8 minutes.. In patients undergoing elective neurosurgery with propofol-remifentanil TIVA, a relatively small esmolol dose and short infusion time effectively blunts early postoperative arterial hypertension and tachycardia.

Topics: Adolescent; Adrenergic beta-Antagonists; Adult; Aged; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Blood Pressure; Craniotomy; Elective Surgical Procedures; Female; Heart Rate; Humans; Male; Middle Aged; Pain Measurement; Piperidines; Postoperative Complications; Propanolamines; Propofol; Prospective Studies; Remifentanil; Young Adult

Topics: Drug Discovery; Gastrointestinal Agents; Humans; Ileus; Piperidines; Postoperative Complications; Randomized Controlled Trials as Topic

Our objective was to investigate the therapeutic potential of peripheral opioid antagonism with alvimopan and anti-inflammatory cyclooxygenase 2 (COX-2) inhibition in an animal model of postoperative ileus with pain management. Intestinal manipulation was conducted in mice and rats with or without postoperative morphine injection. Rodents were orally fed non-digestible fluorescein (FITC)-labelled dextran and transit measured after a period of 90 min. The immunomodulatory effects of morphine and alvimopan were determined on nitric oxide released from the organ cultured muscularis externa. Surgical manipulation of the intestine resulted in a delay in gastrointestinal transit after 24 h that worsened with exogenous morphine. Alvimopan did not significantly alter transit of control or manipulated animals, but significantly antagonized the transit delaying effects of morphine. However, when the inflammatory component was robust enough to obscure a further opioid induced delay in gastrointestinal transit, alvimopan ceased to be effective in improving postoperative intestinal function. Cyclooxygenase 2 inhibition significantly diminished the inflammatory component of postoperative ileus. Surgical manipulation resulted in an increased release of nitric oxide from the inflamed isolated muscularis externa in 24-h organ culture which was not altered by morphine or alvimopan. Two distinct mechanisms exist which participate in postoperative bowel dysfunction: a local inflammatory response which is antagonized by COX-2 inhibition, and a morphine-induced alteration in neural function which can be blocked with alvimopan.

Topics: Analgesics, Opioid; Animals; Cyclooxygenase 2 Inhibitors; Ileus; Inflammation Mediators; Male; Mice; Mice, Inbred C57BL; Organ Culture Techniques; Piperidines; Postoperative Complications; Rats; Rats, Sprague-Dawley; Receptors, Opioid, mu

Surgical resection of brain tissue is associated with tissue damage at the resection margin. Studies of ischemic brain injury in rodents have shown that administration of L-histidine and thioperamide reduces ischemic tissue loss, in part by inhibition of apoptotic cell death. In this study we tested administration of L-histidine and thioperamide in surgical brain injury in mice. Mice were randomized to one of three groups: Sham surgery (n=18), surgical brain injury without treatment (SBI) (n=33), and surgical brain injury with combined l-histidine and thioperamide treatment (SBI+H) (n=29). Surgical brain injury was induced via right frontal craniotomy with resection of the right frontal lobe. L-histidine (1000 mg/kg) and thioperamide (5 mg/kg) were administered to the SBI+H group immediately following surgical resection. Postoperative assessment included neurobehavioral scores, Evans blue measurement of blood-brain barrier breakdown, brain water content, Nissl histology, and immunohistochemistry for IgG and cleaved caspase 3. Postoperative findings included equivalent neurobehavioral outcomes at 24 and 72 h in the SBI and SBI+H groups, similar histological outcomes between SBI and SBI+H, and similar qualitative staining for cleaved caspase 3. SBI+H had increased BBB breakdown on Evans blue analysis and a trend towards increased brain edema which was significant at 72 h. We conclude that combined treatment with l-histidine and thioperamide leads to increased BBB breakdown and brain edema in surgical brain injury.

Topics: Animals; Apoptosis; Blood-Brain Barrier; Body Water; Brain Chemistry; Brain Injuries; Coloring Agents; Evans Blue; Functional Laterality; Histamine; Histamine Antagonists; Histidine; Immunohistochemistry; Male; Mice; Neurosurgical Procedures; Physical Stimulation; Piperidines; Postoperative Complications; Vibrissae; Walking

Topics: Anesthetics, Inhalation; Anesthetics, Intravenous; Anticonvulsants; Cerebral Cortex; Combined Modality Therapy; Deep Brain Stimulation; Drug Resistance; Electrodes, Implanted; Electroencephalography; Entropy; Epilepsy, Generalized; Humans; Intraoperative Complications; Methyl Ethers; Monitoring, Intraoperative; Neurosurgical Procedures; Piperidines; Postoperative Complications; Propofol; Remifentanil; Sevoflurane; Vagus Nerve

Topics: Adult; Airway Obstruction; Analgesia, Obstetrical; Anesthesia, Epidural; Anesthesia, Intravenous; Anesthesia, Obstetrical; Anesthetics, Intravenous; Delivery, Obstetric; Female; Fetal Diseases; Fetoscopy; Fetus; Gestational Age; Humans; Hysterotomy; Pain; Perception; Piperidines; Postoperative Complications; Pregnancy; Remifentanil

A young, healthy adult man exhibited naloxone-reversible, prolonged apnea after a 4-hour infusion of remifentanil, which was used as the opioid component of a general endotracheal anesthetic. Clinical experience and pharmacokinetic simulations indicate that the apnea was clearly atypical.

Topics: Adult; Analgesics, Opioid; Anesthesia, General; Apnea; Craniotomy; Humans; Male; Naloxone; Narcotic Antagonists; Piperidines; Postoperative Complications; Remifentanil; Time Factors

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Local; Antiemetics; Carotid Artery, Internal; Dexamethasone; Granisetron; Humans; Intracranial Aneurysm; Intubation, Intratracheal; Lidocaine; Male; Middle Aged; Piperidines; Postoperative Complications; Remifentanil; Subarachnoid Hemorrhage; Surgical Mesh; Time Factors

This prospective study was performed to compare the incidence of complications occurring after neurosurgical procedures in patients anesthetized with either sevoflurane-fentanyl or propofol-remifentanil anesthesia. We enrolled 162 American Society of Anesthesiologists (ASA) I to III patients (82 females and 80 males, Glasgow 15) undergoing elective neurosurgical procedures. Anesthesia was conducted using either propofol-remifentanil (T group; n=80 patients) or sevoflurane-fentanyl (S group; n=82 patients). All patients were monitored in the postanesthesia care unit for 6 hours after extubation. We analyzed and compared in both groups the incidence of high severity complications such as respiratory events (PaO2 <90 mm Hg; PaCO2 >45 mm Hg) and neurologic events (seizures, new motor or sensory deficit, unexpected delay of awakening) and the incidence of low severity complications such as hypertension (mean arterial pressure increase above 30% of baseline), hypotension (mean arterial pressure decrease below 30% of baseline), pain, shivering, nausea, and vomiting. A total of 162 complications occurred in 92 patients (57%) with 50 patients (31%) having had 1, 26 patients (16%) having had 2, and 16 patients (10%) having had 3 or more events. The most frequent complication was respiratory impairment (28%) which was frequently reported only in the first postoperative hour. Out of the total number of complicating events, 77 (48 %) were found in group S, and 85 (52%) in group T (P=ns). Severe complications were rarely reported and evenly distributed in the 2 anesthetic groups. Similarly, no difference could be demonstrated in the composite incidence of less serious complications between the 2 anesthetic regimens tested in this study. This study confirms that the recovery period after neurosurgical procedures remains a time of great potential danger to patients given the high incidence of postoperative complicating events independently from the anesthetic strategy.

Topics: Adult; Aged; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Brain; Brain Neoplasms; Endpoint Determination; Female; Fentanyl; Humans; Intracranial Aneurysm; Intracranial Arteriovenous Malformations; Male; Methyl Ethers; Middle Aged; Neurosurgical Procedures; Piperidines; Postoperative Care; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Respiratory Mechanics; Sevoflurane

Postoperative ileus (PI) is a common surgical complication treated mainly with supportive measures. Tachykinins control gastrointestinal motility and modulate somatic and visceral pain sensation; therefore, the effect of tachykinin receptor antagonists in a rat model of PI using NK(1-3) antagonists, SR140333, SR48968, and SR142801, was investigated.. Intestinal transit was measured as Evans blue migration after varied nociceptive stimuli: skin incision (SI), laparotomy (LAP), or laparotomy plus gut manipulation (L + M) in anesthetized rats.. Diethyl ether anesthesia and SI did not influence the intestinal transit of the dye in comparison to untreated animals--UN: 61.17 +/- 5.47, 62.10 +/- 8.30, and 56.70 +/- 4.10 cm, respectively. In contrast LAP and L + M have significantly reduced intestinal motility to 26.40 +/- 2.07 and 9.70 +/- 1.15 cm, respectively. SR140333 (3-30 microg/kg), SR48968 (1-30 microg/kg), and SR142801 (3-10 microg/kg) reversed the additional inhibitory effects of gut manipulation subsequent to LAP dose-dependently, the dye transit returning with the use of the most effective antagonist doses up to 25.28 +/- 1.08, 21.70 +/- 0.19, and 25.0 +/- 1.34 cm. The combinations of submaximal doses of NK(1) and NK(3), NK(2) and NK(3) and NK(1), and NK(2) and NK(3) antagonists were not more effective than a single-agent regimen. On the other hand SR140333 and SR48968 (NK(1) + NK(2) antagonists) acted additively, the intestinal transit reaching 26.60 +/- 0.85 cm. SR140333, SR48968, and SR142801 have not affected the intestinal passage in UN rats or those undergoing SI or LAP.. SR140333, SR48968, and SR142801 exert a salutary action on suppressed gut motility following surgical manipulation of the gut, the combination of NK(1) and NK(2) antagonists being most beneficial.

Topics: Anesthetics, Inhalation; Animals; Antipsychotic Agents; Benzamides; Disease Models, Animal; Ether; Gastrointestinal Motility; Ileus; Male; Neurokinin-1 Receptor Antagonists; Piperidines; Postoperative Complications; Quinuclidines; Rats; Rats, Wistar; Receptors, Neurokinin-2; Receptors, Neurokinin-3; Receptors, Tachykinin

This was a prospective audit to assess the incidence and characteristics of early postoperative complications in the recovery room in extubated patients after elective neurosurgical procedures using propofol and remifentanil-based total intravenous anaesthesia.. Vital signs (temperature, conscious level, respiratory rate, oxygen saturation, pulse and blood pressure) and postoperative complications (shivering, nausea, vomiting and cardiorespiratory) were analysed in 145 adult patients over a 1-yr period.. The overall shivering, postoperative nausea and vomiting and postoperative hypertension (systolic blood pressure more than 25% of the preoperative value) incidences were 30.3%, 16.6% and 35.2%, respectively. Fifty-one percent of the patients had at least one of the above complications. The complication rates were found to be widely different among various types of neurosurgery. The surgical procedures were divided into five groups: supratentorial craniotomy, posterior fossa craniotomy, intracranial vascular procedures, transphenoidal hypophysectomy and extracranial procedures. Median extubation time was similar in all groups and patients were fully conscious with no hypoxia in the recovery room. The intracranial vascular group had the highest shivering and postoperative nausea and vomiting rates (58.8% and 29.4%, respectively). In the supratentorial craniotomy group, 46% of the patients had hypertension. The overall complication rate (presence of any complications) was highest in the supratentfial craniotomy (55.4%), posterior fossa craniotomy (75%) and intracranial vascular (76.5%) groups. Shivering and overall complication rate was significantly related to the anaesthetic time (P

Topics: Anesthesia, Intravenous; Humans; Medical Audit; Neurosurgical Procedures; Piperidines; Postoperative Complications; Propofol; Recovery Room; Remifentanil; Time Factors

Postoperative ileus (POI) is often exacerbated by opioid analgesic use during and following surgery, since mu opioid receptor activation results in a further delay of gastrointestinal (GI) transit. The effects of alvimopan, a novel, selective, and peripherally acting mu opioid receptor antagonist, and the reference compound methylnaltrexone, upon POI were investigated in rats. Under isoflurane anesthesia, POI was induced by laparotomy with intestinal manipulation. Immediately after the surgery, the rats received (51)Cr by gavage. Three hours after the surgery, the rats were sacrificed and GI transit was estimated using the geometric center (GC) of (51)Cr. Alvimopan (0.1-3 mg/kg) or methylnaltrexone (100 mg/kg) were administered by gavage either before or after the surgery, with or without morphine administration (1 mg/kg). GI transit was delayed by intestinal manipulation (GC = 2.92 +/- 0.17). Alvimopan (1 and 3 mg/kg) significantly reversed this delayed GI transit when administered 45 min prior to surgery. However, the effects of alvimopan were less pronounced when administered following surgery. Morphine administration further delayed GI transit induced by intestinal manipulation (GC = 1.97 +/- 0.11). Under these conditions, alvimopan (1 and 3 mg/kg) also significantly improved delayed GI transit when administered before surgery. Methylnaltrexone was inactive under all experimental conditions. These data suggest that mu opioid receptors play a role in the pathogenesis of POI, and that the clinical benefit reported to be afforded by alvimopan may be in part mediated via inhibition of an endogenous opioid release as well as blockade of the unwanted GI actions of analgesic agents.

Topics: Analgesics, Opioid; Analysis of Variance; Animals; Disease Models, Animal; Dose-Response Relationship, Drug; Gastrointestinal Transit; Ileus; Laparotomy; Male; Naltrexone; Narcotic Antagonists; Piperidines; Postoperative Complications; Quaternary Ammonium Compounds; Rats; Rats, Sprague-Dawley

Topics: Abdomen; Clinical Trials as Topic; Constipation; Digestive System Surgical Procedures; Humans; Ileus; Irritable Bowel Syndrome; Narcotic Antagonists; Piperidines; Postoperative Complications; Receptors, Opioid, mu

Eisenmenger's syndrome consists of high pulmonary vascular resistance with reversed or bidirectional shunt at aortopulmonary, ventricular or atrial level. We describe the anaesthetic management of two adult females with Eisenmenger's syndrome admitted for laparoscopic cholecystectomy. One patient suffered post-operative complications, but the other case was uncomplicated. We used sevoflurane and total intravenous anaesthesia to provide general anaesthesia. Both techniques were tolerated.

Topics: Adult; Analgesics; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Cholecystectomy, Laparoscopic; Echocardiography; Eisenmenger Complex; Female; Fentanyl; Humans; Intermittent Positive-Pressure Ventilation; Intubation, Intratracheal; Ketamine; Methyl Ethers; Piperidines; Postoperative Complications; Propofol; Remifentanil; Sevoflurane; Shock

Small-intestinal submucosa (SIS) has been successful as an onlay graft in ureteral repair, but tubularized segment interposition of SIS has been unsuccessful. Our objective was to evaluate whether a type I collagen inhibitor, halofuginone, would prevent stricture formation in tubularized SIS interposition.. We performed either laparoscopic partial ureteral excision followed by an SIS onlay graft (N = 5) or complete laparoscopic ureteral excision followed by an SIS interposition graft (N = 7) in domestic pigs. Animals received either no (N = 3), low-dose (N = 5), or high-dose (N = 4) halofuginone. Animals had ureteral stenting for 2 weeks after surgery and were permitted to survive for 6 or 9 weeks. An intravenous urogram (IVU) was performed prior to sacrifice. Kidneys were examined grossly and histologically.. One animal that received an onlay graft died of an unrelated illness. The remaining four ureteral onlay animals, including one control and two low-dose and one high-dose pig, had grossly normal kidneys at harvest. The IVU was normal in the control and high-dose animal but showed delayed excretion with mild hydroureteronephrosis in the low-dose animals. Pathologic examination of the SIS site revealed circumferential reepithelialization with inflammation and mild fibrosis. All seven tubularized interposition graft kidneys demonstrated either severe hydroureteronephrosis (N = 5) or renal atrophy (N = 2), and all had complete obstruction on IVU. Pathologic examination revealed a stenotic ureteral lumen with extensive surrounding inflammation and fibrosis.. An SIS onlay graft was successful in the porcine model of ureteral injury. Halofuginone, a type I collagen inhibitor, did not demonstrate a significant beneficial effect in this technique. Ureteral tubularized interpositions with SIS are unsuccessful and not improved by halofuginone.

Topics: Animals; Collagen Type I; Female; Intestinal Mucosa; Intestine, Small; Piperidines; Postoperative Complications; Protein Synthesis Inhibitors; Quinazolines; Quinazolinones; Swine; Ureter; Ureteral Obstruction

A severe intractable delirium caused by the basal forebrain vascular lesion and its dramatic recovery after donepezil administration were reported. A 68-year-old man had suffered for a month from delirium of mixed type caused by the right basal forebrain vascular lesion after surgery for craniopharyngioma. Magnetic resonance imaging (MRI) showed hemorrhagic infarcts in the head of the right caudate nucleus and the right basal forebrain of the medial septal nucleus, diagonal band of Broca and nucleus basalis of Meynert. He had been treated with anti-psychotics, anti-depressants and hypnotics, which resulted in little improvement. Donepezil administration dramatically improved his intractable delirium at the 19th post-donepezil administration day, but this was followed by amnestic symptoms. Clinical correlates of delirium with the basal forebrain lesion and efficacy of donepezil support the hypocholinergic theory of delirium.

Topics: Aged; Basal Ganglia Cerebrovascular Disease; Basal Nucleus of Meynert; Craniopharyngioma; Delirium; Donepezil; Humans; Indans; Magnetic Resonance Imaging; Male; Nootropic Agents; Piperidines; Pituitary Neoplasms; Postoperative Complications; Prosencephalon; Sleep Wake Disorders; Vision Disorders

A 13-year-old girl presented with right ventricular failure secondary to Ebstein's malformation (downward displacement of the tricuspid valve leaflets with adherence to the right ventricular muscle and redundancy or dysplasia of the tricuspid valve leaflets). She subsequently required a heart transplant but developed rhabdomyolysis early in the postoperative period and required ventilatory support for more than 3 weeks. A variety of causes were considered, but her condition improved only when cyclosporin was eliminated from the immunosuppression regimen. We believe it is likely that the rhabdomyolysis has been caused by cyclosporin. If so, this has occurred both earlier in the clinical course and at lower serum concentrations than previously described.

Topics: Acute Disease; Adolescent; Anesthetics, Intravenous; Creatinine; Cyclosporine; Female; Heart Transplantation; Humans; Immunosuppressive Agents; Piperidines; Postoperative Complications; Propofol; Remifentanil; Rhabdomyolysis

Topics: Abdomen; Humans; Intestinal Obstruction; Narcotic Antagonists; Piperidines; Postoperative Complications

Opiates such as remifentanil have the potential to reduce time to extubation (TTE), shorten length of stay (LOS) and lower hospital costs, because of a short duration of action. However, the cost of remifentanil is approximately ten times higher than longer-acting opiates like fentanyl.. The objective of this analysis was to compare TTE, LOS and total hospital costs between patients who received remifentanil and fentanyl during off-pump bypass surgery.. The study was prospective and observational in design. Consecutive patients who underwent off-pump cardiac bypass surgery and received either remifentanil or fentanyl from September 1998 to August 1999 were screened for study entry. Patient bills and charges were converted to costs using hospital cost-to-charge ratios. The percent of patients' extubated in the operating room (OR), LOS and hospital costs were compared between the groups.. The baseline demographics (age: 66 +/- 12 years mean +/- SD; female 36%) and intraoperative variables were similar between the remifentanil (n=39) and fentanyl (n=20) groups. Patients given remifentanil during surgery were significantly more likely to be extubated in the OR than patients given fentanyl (15 vs. 64%; P < 0.001). Mean LOS was similar in both groups (7.3 +/- 3.1 vs. 8.3 +/- 2.7 days; P=0.27). Patients who received remifentanil incurred lower pulmonary function testing ($0 +/- 0 vs. $34 +/- 103; P=0.045), recovery room ($31 +/- 40 vs. $65 +/- 33; P=0.002) and lower ward costs ($3973 +/- 1719 vs. $4808 +/- 1794; P=0.09) than patients who received fentanyl. Anesthesia costs were higher among patients who received remifentanil ($476 +/- 102 vs. $416 +/- 130; P=0.06). Medical and surgical supplies, OR, intensive care unit, laboratory, respiratory therapy, pharmacy, radiology and transfusion costs were similar between the two groups. The total cost was $15 272 +/- 5556 and $15 616 +/- 4169 in the remifentanil and fentanyl groups, respectively (P=0.81).. Remifentanil, when used in off-pump bypass surgery, is associated with an increased likelihood of extubation in the OR. However, LOS and total hospital costs remain unchanged.

Topics: Aged; Analgesics, Opioid; Anesthesia, General; Coronary Artery Bypass; Costs and Cost Analysis; Female; Fentanyl; Hospital Costs; Humans; Intubation, Intratracheal; Length of Stay; Male; Middle Aged; Piperidines; Postoperative Complications; Remifentanil

Topics: Digestive System; Humans; Hysterectomy; Intestinal Obstruction; Narcotic Antagonists; Piperidines; Postoperative Complications

Carotid endarterectomy can be performed under general or locoregional anesthesia. If locoregional anesthesia is chosen, the state of awareness of the patient allows for direct viewing of the effect of vascular clamping of the corresponding neurological territory. We present the results of an anesthetic procedure using only an analgesic in patients who were intubated and ventilated but with a level of consciousness that allowed us to view the effect of carotid clamping on motor functions.. Forty-eight patients, ASA II-III, underwent surgical carotid endarterectomy. The anesthetic protocol began with preoxygenation for 2 min; induction with remifentanil 0.75-1 microgram kg-1 for 2 min., followed by perfusion of 1 microgram/kg-1.min-1 of remifentanil and propofol 1 microgram/kg-1; and orotracheal intubation by local anesthesia of the glottis with 5% lidocaine spray. Ventilation was with FiO2 100%, FR 12 min. and VT 8 ml. kg-1. For maintenance the dose of remifentanil was regulated to obtain a coordinated motor response (maximum 1.5 microgram/kg-1.min-1, minimum 0.35 microgram/kg-1. min-1). For all patients we monitored hemodynamics continuously and non-invasively, including aortic output by the transesophageal Doppler echocardiography.. The objective of anesthesia was reached in all the patients. The most common hemodynamic alterations were bradycardia (28), arterial hypotension (25), elevated blood pressure (3) and altered aortic output. All changes were corrected quickly with the treatment used, guided by the evolution of hemodynamic parameters. Postanesthetic recovery came in less than 4 min. The only episodes of hyper -and hypotension consisted of a few episodes of mild hyper- (12) and hypotension (1), which were soon corrected. No alterations attributable to hemodynamic instability occurred. During surgery, an intracarotid shunt was necessary in only one patient. Three suffered surgically-related neurological complications after the operations. No complications could be attributed to anesthesia.. An advantage of this technique is that the duration of anesthesia is not limited, with adequate ventilation and maintenance of an adequate state of consciousness for clinical evaluation of the repercussions of carotid clamping. Hemodynamic monitoring detected the appearance of imbalances requiring therapeutic intervention. The procedure is interesting provided it is performed according to a strict protocol, with continuous clinical and instrumental monitoring of the patient's status.

Topics: Aged; Aged, 80 and over; Alprazolam; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Bradycardia; Cardiac Output; Endarterectomy, Carotid; Female; Hemodynamics; Humans; Hydroxyzine; Hypnotics and Sedatives; Hypotension; Intraoperative Complications; Male; Middle Aged; Monitoring, Intraoperative; Piperidines; Postoperative Complications; Preanesthetic Medication; Propofol; Remifentanil; Treatment Outcome

Topics: Aged; Alzheimer Disease; Delirium; Donepezil; Geriatric Assessment; Humans; Indans; Male; Nootropic Agents; Piperidines; Postoperative Complications; Time Factors

We report a case of postoperative apnoea in the recovery room, 25 minutes after tracheal extubation, in a fully awake patient. This event occurred after flushing of an obstructed IV line into which remifentanil had been injected through a 3-way stopcock during anaesthesia. The means for prevention of such an adverse event are discussed.

Topics: Adult; Anesthesia, General; Anesthetics, Intravenous; Apnea; Female; Humans; Intubation, Intratracheal; Piperidines; Postoperative Complications; Recovery Room; Remifentanil

To evaluate the effects of halofuginone, a specific inhibitor of collagen type I synthesis, on the postoperative formation of abdominal adhesions in rats.. Postoperative adhesions remain the leading cause of small bowel obstruction in the Western world. Surgical trauma causes the release of a serosanguineous exudate that forms a fibrinous bridge between two organs. This becomes ingrown with fibroblasts, and subsequent collagen deposition leads to the formation of a permanent adhesion. Most of the drugs used have been clinically ineffective, and none has been specific to a particular extracellular matrix molecule. Therefore, there are serious concerns about the toxic consequences of interfering with the biosynthesis of other collagens, other matrix proteins, or vital collagen-like molecules.. Adhesions were induced by scraping the cecum until capillary bleeding occurred. The adhesions were scored 21 days later. Halofuginone was either injected intraperitoneally (1 microg/25 g body weight) every day, starting on the day of operation, or added orally at concentrations of 5 or 10 mg/kg, starting 4 days before the operation. Collagen alpha1(I) gene expression was evaluated by in situ hybridization, total collagen was estimated by Sirius red staining, and collagen type III was detected by immunohistochemistry.. The adhesions formed between the intestinal walls were composed of collagen and were populated with cells expressing the collagen alpha1(I) gene. Regardless of the administration procedure, halofuginone significantly reduced the number and severity of the adhesions. Halofuginone prevented the increase in collagen alpha1(I) gene expression observed in the operated rats, thus reducing collagen content to the control level. In fibroblasts derived from abdominal adhesions, halofuginone induced dose-dependent inhibition of collagen alpha1(I) gene expression and collagen synthesis. Collagen type III levels were not altered by adhesion induction or by halofuginone treatment.. Upregulation of collagen synthesis appears to have a critical role in the pathophysiology of postoperative adhesions. Halofuginone, an inhibitor of collagen type I synthesis, could be used as an important tool in understanding the role of collagen in adhesion formation, and it may become a novel and promising antifibrotic agent for preventing postoperative adhesion formation.

Topics: Abdomen; Animals; Collagen; Histocytochemistry; In Situ Hybridization; Piperidines; Postoperative Complications; Protein Synthesis Inhibitors; Quinazolines; Quinazolinones; Rats; Rats, Sprague-Dawley; Tissue Adhesions

The relationship between intestinal motor activity and the influence of prostaglandin F2alpha (PGF) and cisapride were investigated during the early postoperative period in 26 patients who underwent abdominal surgery. Records of intestinal motility were made using an infusion catheter. PGF, 0.4 microg/kg per minute, given intravenously over 60 min, and cisapride, 5 mg, given intraintestinally, were administered to 13 patients each, first immediately after the operation, and then after the migrating motor complexes (MMCs) had reappeared following a period of intestinal quiescence. The MMCs were reestablished within the first postoperative day. Both PGF and cisapride stimulated irregular, high-amplitude contractions; however, the MMCs reappeared following these induced contractions only if the drugs were administered just after the postoperative MMCs became evident. These prokinetic drugs did not affect gastrointestinal hormone concentrations, but induced contractile activity even in the early postoperative period. Although the findings of this study demonstrate that these drugs may be useful as prokinetic agents to promote recovery from postoperative ileus just after the reappearance of MMCs in the early postoperative period, their precise mode of action has not been established.

Topics: Abdomen; Cisapride; Dinoprost; Female; Gastrointestinal Agents; Gastrointestinal Motility; Humans; Infusions, Intravenous; Intestinal Obstruction; Male; Middle Aged; Piperidines; Postoperative Complications; Surgical Procedures, Operative

Long-term follow-up examination with esophagogastroduodenoscopy was performed on seven patients who had undergone successful delayed anastomosis for isolated esophageal atresia. The follow-up period ranged from 1.2 to 11.3 years (mean, 5.3). All patients had undergone fundoplication because of symptomatic gastroesophageal reflux (GER). Three anastomotic strictures had to be resected. At the time of the last follow-up examination, the subjective results were excellent for five patients and good for two. The last endoscopy showed macroscopic esophagitis in three and normal mucosa in four. The fundoplication was partly disrupted in two patients. In three patients the fundoplication was competent but partly intrathoracic. Histological examination showed moderate esophagitis in one, mild esophagitis in one, and normal mucosa in five patients; however, four patients were on continuous medication for esophagitis. In conclusion, the subjective results of patients with isolated esophageal atresia treated with esophageal anastomosis are good. However, long-term complications caused by GER are common in these patients. Therefore, active search and treatment of reflux is necessary for these patients.

Topics: Anastomosis, Surgical; Anti-Ulcer Agents; Cisapride; Constriction, Pathologic; Endoscopy, Digestive System; Esophageal Atresia; Esophageal Diseases; Esophagitis; Follow-Up Studies; Fundoplication; Gastroesophageal Reflux; Gastrointestinal Agents; Humans; Infant; Piperidines; Postoperative Complications; Sucralfate

After Roux-en-Y gastrojejunostomy patients frequently complain of upper abdominal pain, fullness, nausea, and vomiting. This Roux-en-Y syndrome is caused by slow gastric emptying, Roux-limb stasis, or both. Treatment of this syndrome is cumbersome. We evaluated the effect of cisapride on complaints and on transit through gastric remnant and Roux limb in 24 such patients. Thirteen of them had slow gastric emptying and 13 had stasis in the Roux limb (two patients had both). Symptoms and transit were evaluated before and after three weeks of treatment using a questionnaire and scintigraphy. Responding subjects continued therapy and were interviewed again after six months. Seven patients with slow gastric emptying and three patients with Roux-limb stasis had enduring symptomatic relief; all exhibited accelerated transit during therapy: mean half gastric emptying time in the seven patients with slow gastric emptying was 204 +/- 89 min before and 111 +/- 59 min during cisapride (P less than 0.05); mean percentage of radioactivity, emptied from the gastric remnant, which remained in the Roux limb at 60 min in the three patients with Roux limb stasis was 74 +/- 4% before and 25 +/- 10% during cisapride (P less than 0.05). In patients without symptomatic response, transit did not improve.. with cisapride long-lasting symptomatic relief and improved transit is achieved in about 40% of patients with the Roux-en-Y syndrome.

Topics: Adult; Aged; Anastomosis, Roux-en-Y; Cisapride; Female; Gastric Emptying; Humans; Jejunum; Male; Middle Aged; Piperidines; Postoperative Complications; Radionuclide Imaging; Serotonin Antagonists; Stomach; Syndrome

We report on one patient in whom segmental colic intestinal pseudo-obstruction (IPO) following the surgical treatment of a grade III necrotising enterocolitis (NEC) was responsible for a severe failure to thrive. Further intestinal resection in an already short gut was avoided by using Cisapride, a new intestinal prokinetic agent (1 mg/kg/d in 4 doses, orally), which dramatically improved the symptoms and allowed weight gain and intestinal adaptation. After 6 months, Cisapride was withdrawn. IPO did not recur after 2 years of follow-up, although proximal distention persisted.

Topics: Cisapride; Colonic Pseudo-Obstruction; Enteral Nutrition; Enterocolitis, Pseudomembranous; Follow-Up Studies; Humans; Ileostomy; Infant; Infant, Newborn; Infant, Premature, Diseases; Male; Piperidines; Postoperative Complications; Serotonin Antagonists

Attempts have previously been made to reduce adhesion formation by promoting early intestinal motility. The prokinetic agent Cisapride was used in an animal model of end-to-end large bowel anastomoses. Twenty Wistar rats receiving Cisapride 1 mg/kg subcutaneously (sc) twice daily for two days post-operatively were compared with 20 controls receiving saline 0.2 mL in a similar regimen. The points of adhesion of the anastomosis to the following structures were enumerated: tubal fat; mesentery; omentum; caecum; small bowel; and abdominal wall. The treatment group had significantly fewer adhesions: 2.8 +/- 0.9 v 4.3 +/- 1.0. This was mainly in the number of small bowel attachments, 3.8% compared with 37.8%. The study was repeated using small bowel anastomoses. Cisapride again reduced the number of adhesions compared with controls: 2.1 +/- 0.4 v 4.2 +/- 1.4. Cisapride therapy resulted in greater post-operative stool weights and food consumption: control, 3.87 +/- 1.1 stool, 17.04 +/- 4.3 g food; Cisapride 4.43 +/- 0.9 g stool, 19.8 +/- 4.7 g food. The enhanced motility did not affect the anastomotic strength of the small bowel; bursting pressures at a constant inflation rate of 1.1 mL/min were: control 212.8 +/- 56.0 mmHg; Cisapride, 215.8 +/- 58.9 mmHg (NS).

Topics: Administration, Cutaneous; Anastomosis, Surgical; Animals; Cisapride; Disease Models, Animal; Female; Intestinal Diseases; Intestinal Obstruction; Piperidines; Postoperative Complications; Random Allocation; Rats; Rats, Inbred Strains; Tissue Adhesions

Paralytic ileus and intestinal adhesions are common events following intra-abdominal surgery. The theoretical hypothesis 'that stimulation of the postoperative bowel will reduce intestinal adhesions' was studied in a rat model for intestinal adhesions in which postoperative bowel motility was pharmacologically manipulated. Immediate postoperative stimulation of gastrointestinal motility by the prokinetic agent, Cisapride, resulted in a significant reduction in both the number and extent of adhesions. Inhibition of postoperative intestinal motility with the anticholinergic agent, atropine, resulted in a greater number of more dense adhesions involving an increased length of bowel.

Topics: Animals; Cisapride; Female; Gastrointestinal Motility; Intestinal Diseases; Intestinal Pseudo-Obstruction; Piperidines; Postoperative Complications; Rats; Rats, Inbred Strains; Serotonin Antagonists; Tissue Adhesions

Topics: Acute Disease; Cisapride; Female; Humans; Middle Aged; Paralysis; Piperidines; Postoperative Complications; Stomach Diseases

One hundred and eighteen patients in whom postoperative gastrointestinal atony had lasted for 48-72 hours, were given one or two intravenous injections of different doses of cisapride (2, 4 or 8 mg), or vehicle. The first occurrence of flatus was taken to mark the cessation of ileus. There was no significant difference in remission of ileus between the groups in the first hour following injection. All patients not responding to treatment in the first hour were given a repeat dosage and observed for the following 3 hours. Among this group, there was a significant remission of ileus in patients who had received 2 X 8 mg, which was particularly marked in those who had undergone intraperitoneal surgery. This study suggests that cisapride in repeated dosage may be of value in inducing remission in prolonged surgical ileus, particularly in patients who have undergone intraperitoneal operations.

Topics: Cisapride; Digestive System; Dose-Response Relationship, Drug; Female; Gastrointestinal Diseases; Gastrointestinal Motility; Humans; Intestinal Obstruction; Male; Piperidines; Postoperative Complications

Postoperative hypertension following coronary artery bypass grafting is usually treated with vasodilating agents like nitroprusside. In recent studies ketanserin, a 5-hydroxytryptamine type 2 antagonist, appeared to be effective in the treatment of this clinical syndrome. In 20 patients, divided into two comparable groups, nitroprusside and ketanserin were compared with respect to their haemodynamic and ventilatory profiles. The study showed that both agents were equally effective in decreasing the raised systolic blood pressure, but that ketanserin was more advantageous with respect to the absence of reflex tachycardia and the unchanged shunt fraction.

Topics: Blood Pressure; Coronary Artery Bypass; Female; Ferricyanides; Heart Rate; Humans; Hypertension; Ketanserin; Male; Middle Aged; Nitroprusside; Piperidines; Postoperative Complications; Pulmonary Artery; Vascular Resistance

The effect of loperamide on faecal control after Stephens rectoplasty for high imperforate anus was studied in eight patients more than 8 years after surgery. Clinical assessment and anorectal manometry were performed before and after administration of loperamide for 6 to 8 weeks. Decreased faecal soiling was noted in seven of the eight cases. Obstipation forced two patients to stop the medication. The improved faecal control was verified by an increase in squeeze pressure at anorectal manometry in four patients. When incontinence persists after Stephens rectoplasty, loperamide can improve the faecal control in some cases.

Topics: Adolescent; Anal Canal; Anus, Imperforate; Child; Fecal Incontinence; Follow-Up Studies; Humans; Loperamide; Manometry; Piperidines; Postoperative Complications; Pressure; Rectum

Research was conducted into post-operative pain and possible means for its control. A total of 66 patients subdivided into 3 groups were studied. In order to document analgesic effectiveness, pain was measured by two subjective methods--Huskisson's Visual Analogue and the "SCORE" index. Patients' anxiety was assessed pre-operatively by a suitably modified tourniquet test. The groups of patients were subdivided according to the analgesic agent used: 1st group (herniectomies, appendicectomies) Baralgina f. 1; 2nd group (cholecystectomies, hysterectomies) Talwin f. 1; 3rd group (cholecystectomies, hysterectomies) Baralgina f. 1 + Talwin f. 1. The latter combination proved to be satisfactory and guaranteed a sufficiently calm post-operative period. On the basis of the data obtained, it is recommended that anaesthesiological procedures include analgesic cover that exploits the action of Phentanyl as an analgesic agent and neurovegetative stabilizer and is to be used at the start of the operation. For operations lasting more than 60 minutes, a combination of Baralgina and Talwin or Buprenorfina may be administered during the post-operative period.

Topics: Adolescent; Adult; Aged; Analgesia; Appendectomy; Benzophenones; Child; Cholecystectomy; Dipyrone; Drug Combinations; Female; Herniorrhaphy; Humans; Hysterectomy; Male; Middle Aged; Pain; Pentazocine; Piperidines; Postoperative Complications

Topics: Arrhythmias, Cardiac; Child, Preschool; Follow-Up Studies; Humans; Infant; Infant, Newborn; Metaproterenol; Methods; Piperidines; Postoperative Complications; Prognosis; Transposition of Great Vessels

Peri-aneurysmal CSF was obtained at operation from 13 patients with subarachnoid haemorrhage from ruptured intracranial aneurysms. The 5-hydroxytryptamine antagonist ketanserin inhibited contractions of isolated human intracranial arteries, elicited by this CSF. The presence of 5-HT in CSF was confirmed by high performance liquid chromatography. The use of ketanserin in the therapy of postoperative cerebral vasospasm is discussed.

Topics: Adult; Aged; Animals; Female; Humans; Hydroxyindoleacetic Acid; Intracranial Aneurysm; Intraoperative Complications; Ischemic Attack, Transient; Ketanserin; Male; Middle Aged; Piperidines; Postoperative Complications; Rats; Rupture, Spontaneous; Serotonin; Serotonin Antagonists; Subarachnoid Hemorrhage; Vasoconstriction

In patients developing hypertension following coronary artery bypass surgery (CABG) the possible role of 5-hydroxytryptamine (5-HT; serotonin) was investigated by injecting ketanserin, a specific 5-HT2-receptor antagonist. Ketanserin was administered intravenously when intraarterial systolic blood pressure (SAP) exceeded 150 mm Hg either as a 10-mg bolus (group 1, N = 15), or as a 10-mg bolus followed by infusion of 4 mg/h for either 2.5 h (group 2, N = 15) or for 1 h (group 3, N = 10). In 33 patients (82.5%), SAP and diastolic arterial pressure decreased significantly within 5 min after the 10-mg bolus. In group 1, SAP gradually increased after 30-50 min but in groups 2 and 3 SAP remained normal. The triple index (TI) decreased significantly in all groups. Heart rate decreased slightly but significantly in groups 2 and 3. Central venous and left atrial pressures did not change substantially in any of the three groups. Cardiac output increased significantly (0.51 +/- 0.158 L/min); hence, systemic vascular resistance (SVR) decreased significantly (452.1 +/- 50.57 dyn . s . cm-5--group 3). No rebound increase in SAP occurred after terminating the infusions (groups 2 and 3). These findings indicate that 5-HT plays a role in the majority of patients who develop hypertension following CABG. The decrease of SVR without reflex tachycardia is a favorable effect of ketanserin.

Topics: Coronary Artery Bypass; Female; Heart Rate; Hemodynamics; Humans; Hypertension; Infusions, Parenteral; Injections, Intravenous; Ketanserin; Male; Middle Aged; Piperidines; Postoperative Complications; Serotonin Antagonists

The possible role of 5-hydroxytryptamine (serotonin) in patients developing hypertension following coronary artery bypass surgery was investigated by intravenous administration of ketanserin, a specific 5-hydroxytryptamine-receptor antagonist. Our findings in the preliminary study indicate that 5-hydroxytryptamine might not play a role in the hypertension seen after coronary artery bypass surgery.

Topics: Adult; Aged; Antihypertensive Agents; Blood Pressure; Coronary Artery Bypass; Humans; Hypertension; Ketanserin; Middle Aged; Piperidines; Postoperative Care; Postoperative Complications

Eleven patients undergoing coronary or aortic valve surgery received ketanserin (3 X 10 mg i.v.). When surgery was finished hemodynamic measurements were performed prior to and after cessation of nitrous oxide. The results were compared with those of a control group (n = 30), reported in a previous study. At the end of operation the ketanserin treated patients had significantly lower heart rate (84 +/- 16 vs. 96 +/- 14 min-1; Mean +/- S.D.), lower mean arterial pressure (75 +/- 12 vs. 84 +/- 10 mmHg) and higher skin temperature (31.9 +/- 1.3 vs. 27.7 +/- 2.3 degrees C). However, postoperative hypertension after the withdrawal of nitrous oxide was not prevented: similarly as in the control group blood pressure rose and systemic vascular resistance increased. As the last dose of ketanserin was given 60 minutes before the end of anesthesia it is likely that the effect of ketanserin had already worn off.

Topics: Adult; Aged; Anesthesia; Aortic Valve; Coronary Artery Bypass; Heart Valve Prosthesis; Hemodynamics; Humans; Hypertension; Injections, Intravenous; Ketanserin; Middle Aged; Nitrous Oxide; Piperidines; Postoperative Complications; Serotonin Antagonists

Ketanserin (R 41468) blocks selectively the 5HT2 receptors. We studied the effects of 10 mg of Ketanserin i.v. in 11 patients after cardiopulmonary by-pass. A sudden decrease in arterial blood pressure and in filling pressures way observed. The heart rate stayed unchanged and the rate pressure product decreased significantly. Cardiac output increased. The observed effects were essentially those of vasodilation without increases in heart rate. This pilot study showed that the 5HT2 receptors blockade may be of clinical value in the quick reversal of hemodynamic instability after cardiopulmonary by-pass.

Topics: Aged; Cardiopulmonary Bypass; Female; Hemodynamics; Humans; Ketanserin; Male; Middle Aged; Pilot Projects; Piperidines; Postoperative Complications; Serotonin Antagonists

This paper reports a case of fatal perhexiline maleate liver injury. A 62-year-old man had received perhexiline maleate for 18 months before death. Hepatic failure developed after a routine surgical procedure. The clinical course and histological findings are presented.

Topics: Angina Pectoris; Chemical and Drug Induced Liver Injury; Humans; Liver; Liver Cirrhosis, Alcoholic; Liver Diseases; Male; Middle Aged; Osteoarthritis; Perhexiline; Piperidines; Postoperative Complications; Transaminases

The result of our examinations was that instillagel has a desinfecting effect in the urethra. This result is mathematically secured by means of the 2 I-test and highly significant. 95% of the preoperatively infected urethras were germ-free immediately after operation. This effect could not be proved in nifucin-gel-medicain as well as in urocomb. Using these lubricants all preoperatively infected urethras were also infected immediately after operation.

Topics: Anti-Infective Agents, Urinary; Bacterial Infections; Chlorhexidine; Drug Combinations; Electrosurgery; Humans; Lidocaine; Lubrication; Male; Nitrofurazone; Piperidines; Postoperative Complications; Propiophenones; Prostatic Hyperplasia; Prostatic Neoplasms; Tetracaine; Urethra; Urinary Bladder Neoplasms; Urinary Tract Infections

Topics: Cholestyramine Resin; Drug Interactions; Humans; Ileostomy; Intestinal Absorption; Loperamide; Male; Middle Aged; Piperidines; Postoperative Complications

The effect of domperidone (R 33 812), a new antiemetic, was studied in 27 patients presenting with postoperative vomiting and staying for at least six hours in a recovery room. All patients received 4 mg domperidone intravenously because of the vomiting. Nineteen patients were fully protected during the subsequent 6 hours observation period, 8 patients required a second 4 mg-dose: only one of these 8 patients was not protected at all. No side-effects were observed.

Topics: Adult; Aged; Anesthesia; Antiemetics; Benzimidazoles; Drug Evaluation; Female; Humans; Male; Middle Aged; Piperidines; Postoperative Complications; Vomiting

Topics: Doxapram; Drug Evaluation; Drug Therapy, Combination; Female; Humans; Injections, Intravenous; Lung Diseases; Male; Middle Aged; Piperidines; Postoperative Complications

Topics: Androstanes; Anesthesia, Inhalation; Aortic Aneurysm; Atropine; Autopsy; Blood Pressure; Calcium; Carbon Dioxide; Cerebrospinal Fluid Proteins; Gluconates; Glucose; Hematocrit; Humans; Male; Middle Aged; Neuromuscular Nondepolarizing Agents; Nitrous Oxide; Oxygen; Oxygen Consumption; Phenytoin; Piperidines; Postoperative Complications; Potassium; Respiration, Artificial; Seizures; Sodium; Thiopental; Urea

Topics: Abdomen; Adult; Analgesics; Anesthesia, Endotracheal; Bronchitis; Female; Humans; Lung Diseases; Piperidines; Postoperative Complications; Tracheal Diseases

Topics: Analgesics; Anesthesia, Endotracheal; Anesthetics; Atropine; Diphenhydramine; Ethyl Ethers; Humans; Male; Morpholines; Nitrous Oxide; Phenobarbital; Piperidines; Postoperative Complications; Respiratory Tract Diseases; Thiopental; Tranquilizing Agents

Topics: Anesthesia, Intravenous; Blood Glucose; Blood Pressure; Female; Humans; Male; Phencyclidine; Piperidines; Postoperative Complications; Preanesthetic Medication; Tachycardia

Topics: Digestive System Abnormalities; Duodenum; Esophagus; Female; Gastrointestinal Motility; Humans; Infant; Infant, Newborn; Infant, Newborn, Diseases; Intestinal Absorption; Intestinal Obstruction; Malabsorption Syndromes; Male; Megacolon; Piperidines; Postoperative Complications

Topics: Adolescent; Adult; Aged; Aminopyrine; Benzilates; Child; Drug Synergism; Female; Humans; Male; Middle Aged; Muscles; Pain; Piperidines; Postoperative Complications

Topics: Aminopyrine; Analgesics; Humans; Pain; Piperidines; Postoperative Care; Postoperative Complications; Sulfonic Acids

Topics: Biomedical Research; Colchicine; Colectomy; Colitis; Colitis, Ulcerative; Colonic Diseases; Colonic Diseases, Functional; Crohn Disease; Diabetic Neuropathies; Diarrhea; Diphenoxylate; Diverticulitis; Diverticulitis, Colonic; Drug Therapy; Dysentery; Dysentery, Amebic; Enteritis; Gastroenteritis; Humans; Piperidines; Postgastrectomy Syndromes; Postoperative Complications; Toxicology; Virus Diseases