thiopental and Cerebrovascular-Disorders

Changes in middle cerebral arterial flow velocity (MCAV) during rapid intravenous induction and awake intubation using transcranial Doppler sonography were investigated. The study involved 20 patients without disorders of the central nervous or cardiovascular systems who were scheduled for maxillofacial surgery. In the intravenous induction group, anesthesia was induced with sodium thiopental, and orotracheal or nasotracheal intubation was facilitated with succinylcholine chloride or alcuronium chloride. In the awake intubation group, orotracheal or nasotracheal intubation was performed under intravenous sedation with diazepam and topical anesthesia with 4% lidocaine. Arterial blood pressures, heart rate, and MCAV were monitored at specific intervals. During intravenous induction, blood pressures decreased after the administration of thiopental and muscle relaxants and increased during endotracheal intubation. MCAV was remarkably slowed after the administration of thiopental and during mask ventilation. During awake intubation, blood pressures were increased by endotracheal intubation. MCAV was decreased from the administration of diazepam to the transtracheal injection of lidocaine, but returned to the control value from endotracheal spray to endotracheal intubation. These results suggest that smooth awake intubation may be the safest method of induction for patients with cerebrovascular disorders.

Topics: Alcuronium; Anesthesia, Dental; Anesthesia, General; Blood Flow Velocity; Blood Pressure; Cerebrovascular Circulation; Cerebrovascular Disorders; Dental Care for Chronically Ill; Diazepam; Heart Rate; Humans; Injections, Intravenous; Intubation, Intratracheal; Succinylcholine; Thiopental; Ultrasonography, Doppler, Transcranial; Wakefulness

To determine if thiopental reduces the incidence of neurologic sequelae after coronary artery surgery, we prospectively studied 300 patients undergoing coronary artery bypass grafting. Patients who had no history of neurologic or psychiatric illness were randomly assigned to receive either a thiopental infusion or a saline placebo infusion beginning with the administration of heparin and ending just after aortic decannulation. The patients received an opioid-relaxant anesthetic administered by an anesthesiologist who was not involved in this investigation and who was blinded to the test infusion. One of the investigators infused either saline or thiopental to produce an isoelectric electroencephalogram with 30-45 s between bursts. Standardized neurologic examinations were performed preoperatively and on the 2nd and 5th postoperative days by one of the blinded investigators. The group of patients receiving thiopental required a longer time for awakening (6.4 +/- 3.9 vs. 4.0 +/- 2.4 h, mean +/- SD, P less than 0.05) and for tracheal extubation (22.4 +/- 18.4 vs. 17.4 +/- 9.6 h, P less than 0.05), and a greater number of these patients were lethargic on the 2nd postoperative day. More patients receiving thiopental required vasoconstrictors during the thiopental loading and cardiopulmonary bypass (CPB) periods, while a greater number of patients receiving placebo required vasodilators. A greater number of patients receiving thiopental required inotropic drugs during separation from CPB. Despite the above differences, only 2 of the 151 patients in the placebo group (1.3%) and 5 of the 149 patients in the thiopental group (3.3%) experienced strokes (P = 0.2535).(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adult; Aged; Cerebrovascular Disorders; Coronary Artery Bypass; Female; Humans; Male; Middle Aged; Postoperative Complications; Prospective Studies; Thiopental

Topics: Adolescent; Adult; Aged; Anesthesia, General; Brain Diseases; Brain Neoplasms; Carbon Dioxide; Cerebral Angiography; Cerebrovascular Disorders; Child; Child, Preschool; Craniocerebral Trauma; Droperidol; Female; Fentanyl; Humans; Male; Middle Aged; Neuroleptanalgesia; Nitrous Oxide; Partial Pressure; Thiopental

Serial serum thiopentone concentrations were measured during and following completion of an intravenous infusion of thiopentone in 20 patients with neurosurgical emergencies. The concentration data from a further 55 patients who had had some such measurements were reviewed retrospectively. The patients received an infusion for longer than 24 hours at a rate adjusted to maintain EEG burst suppression. The data were interpreted in terms of thiopentone pharmacokinetics and used to produce statistical models relating to clinical outcomes. In these patients, the one-month mortality rate following commencement of thiopentone treatment was 20%; the mean durations of pupillary and motor unresponsiveness following cessation of an infusion were 22 and 91 hours, respectively. Predictors of a prolonged duration of motor unresponsiveness included a prolonged duration of pupillary unresponsiveness, a low thiopentone clearance and a high maximum serum concentration of thiopentone. From pooled logistic regression, median effective serum thiopentone concentrations (EC50) were found to be 50 mg x l(-1) for recovery of pupillary responsiveness and 12 mg x l(-1) for the recovery of motor responsiveness. Because prolonged high-dose thiopentone leads to prolonged residual serum concentrations, it is difficult to distinguish the residual pharmacological effects of thiopentone from the clinical condition. This study suggests that, based on EC50 values for responses, monitoring of post-infusion serum thiopentone concentrations may help determine whether a patient's clinical state is due to residual thiopentone pharmacological effects.

Topics: Adult; Brain Injuries; Cerebrovascular Disorders; Chromatography, High Pressure Liquid; Drug Monitoring; Electroencephalography; Emergencies; Female; Humans; Hypnotics and Sedatives; Infusions, Intravenous; Intracranial Hypertension; Intracranial Pressure; Logistic Models; Male; Middle Aged; Muscle Contraction; Neuroprotective Agents; Prospective Studies; Reflex, Pupillary; Retrospective Studies; Thiopental

The results of carotid endarterectomy can be improved by reducing the perioperative embolic and hemodynamic risks. Electrophysiologic monitoring, although reliable, cannot provide full information. In this study, we report on the combined use of transcranial Doppler (TCD) and electrophysiologic monitoring in 153 patients undergoing 166 carotid endarterectomy procedures. TCD monitoring confirmed the low incidence of intolerance to cross-clamp (1.8%), showing a good correlation with electrophysiologic monitoring. In addition, it frequently showed embolic signals immediately after clamp release, but never during carotid dissection or in the final operative phases. Furthermore, TCD allowed the detection of hyperperfusional flow patterns in four cases, making immediate and aggressive control of arterial pressure possible.

Topics: Aged; Aged, 80 and over; Anesthesia, General; Carotid Stenosis; Cerebrovascular Disorders; Electroencephalography; Endarterectomy, Carotid; Female; Follow-Up Studies; Hemodynamics; Humans; Incidence; Intraoperative Complications; Isoflurane; Male; Middle Aged; Monitoring, Intraoperative; Nitrous Oxide; Postoperative Complications; Succinylcholine; Thiopental; Ultrasonography, Doppler, Transcranial

The purpose of this study was to validate the commonly accepted indicators of risk of ischemic stroke that indicate the necessity for cerebral protection during carotid endarterectomy (CEA), and to examine the efficacy of high-dose thiopentone sodium (thiopental) as a cerebral protection method in patients who are at high risk of intraoperative ischemic stroke.. In a prospective study of 37 CEAs performed for symptomatic stenosis > 70%, functional and clinical indicators of risk of ischemic stroke during carotid cross-clamping were identified. Functional indicators of risk were the development of ischemic electro-encephalogram (EEG) changes and stump pressure < 25 mm Hg. Clinical indicators of risk were previous ischemic hemispheric stroke and severe bilateral disease. These indicators were correlated in all patients, some of whom had two or three coexisting indicators of risk. The EEG and stump pressure were monitored continuously during carotid occlusion in all operations. Carotid occlusion times were recorded. Intraluminal shunting was eliminated in favor of high-dose thiopental cerebral protection in all patients. Neurologic outcome was deemed to measure the efficacy of thiopental protection in patients who are identified to be at risk and, hence, in need of cerebral protection. The validity of the indicators used to identify risk of ischemic stroke during CEA was assessed.. The absolute stroke risk was found to be 29.7% for the whole group (37 patients) and 57.9% in 19 patients who had commonly accepted indications for protective shunting. The correlation of ischemic EEG changes with stump pressure < 25 mm Hg was only 27.3%, whereas the expected correlation based on well-documented reports in the literature was 100%. The lack of correlation may have been related to the prevention of ischemic EEG changes by thiopental. There were no neurologic deficits in the series.. The absence of neurologic deficit in the study indicated that thiopental protection was effective in preventing ischemic stroke in high-risk patients and safely replaced intraluminal shunting.

Topics: Aged; Aged, 80 and over; Blood Pressure; Brain Ischemia; Carotid Arteries; Carotid Stenosis; Cerebrovascular Circulation; Cerebrovascular Disorders; Constriction; Electroencephalography; Endarterectomy, Carotid; Female; Hemodynamics; Humans; Intraoperative Complications; Male; Middle Aged; Monitoring, Intraoperative; Neurologic Examination; Neuroprotective Agents; Prospective Studies; Reproducibility of Results; Risk Assessment; Risk Factors; Thiopental; Time Factors; Treatment Outcome

Intraoperative monitoring of brain function may influence the outcome of carotid endarterectomy (CEA).. We performed transcranial Doppler (TCD) monitoring of middle cerebral artery blood flow velocities (VMCAs) and eight-channel electroencephalographic (EEG) recording simultaneously in 82 patients undergoing CEA. Thiopental narcosis limited EEG interpretation in 11 patients, thus allowing direct comparison of both methods in 71 patients.. There was a significant correlation between VMCA decrease and the frequency of EEG changes after carotid clamping (P < .001). Eight patients (11%) showed a VMCA decrease exceeding 60%, accompanied by EEG changes in 7 patients. Altogether, 16 patients (22%) showed severe or moderate EEG changes. Stenosis or occlusion of the contralateral carotid artery led to an increase of abnormal findings with both monitoring methods, which was, however, significant only for TCD (P < .05). Four patients (4.8%) suffered intraoperative transient ischemic attacks. In 3 of these patients, there were no abnormal findings with either of the methods. The events were thus unpredictable and probably of embolic origin. The fourth patient showed VMCA decrease to 0 and severe EEG changes. Nine patients had severe or moderate EEG changes without significant VMCA decrease and without complications. EEG monitoring alone in these would have led to unnecessary use of a shunt with the increased risk of embolism.. EEG and TCD monitoring are complementary techniques. Their results showed a good overall correlation but with marked differences in the individual patient. TCD monitoring alone was sensitive enough to prevent ischemic intraoperative complications. EEG findings are of limited value when barbiturates are used.

Topics: Aged; Aged, 80 and over; Blood Flow Velocity; Brain Ischemia; Carotid Stenosis; Cerebral Arteries; Cerebrovascular Circulation; Cerebrovascular Disorders; Electroencephalography; Endarterectomy, Carotid; Female; Humans; Hypnotics and Sedatives; Ischemic Attack, Transient; Male; Middle Aged; Monitoring, Intraoperative; Postoperative Complications; Predictive Value of Tests; Retrospective Studies; Thiopental; Treatment Outcome; Ultrasonography, Doppler, Transcranial

High-dose thiopentone has been reported to reduce the incidence of neurological dysfunction after open-chamber cardiac surgery. However, this technique delays tracheal extubation and increases requirements for inotropic support after cardiopulmonary bypass. As a quality assurance measure to determine the safety of high-dose thiopentone, we reviewed the records of all patients undergoing elective, open-chamber surgery at our institution between 1st March, 1987 and 31st Dec, 1989.. The charts of 236 patients were reviewed retrospectively, and 227 met our inclusion criteria. The perioperative characteristics of patients anaesthetized with thiopentone (Group T, n = 80) were compared with those of patients anaesthetized with opioids (Group O, n = 147).. Anaesthetic technique was chosen by the attending anaesthetist. in Group T (n = 80) thiopentone 38.1 +/- 11.8 mg.kg-1 was infused to produce electroencephalographic burst-suppression during bypass. Moderate hypothermia and arterial line filtration were used during bypass. The groups did not differ with respect to demographics, type of surgery, or conduct of bypass. There were no strokes in Group T and 4 in Group O (P = NS). The time to extubation was prolonged in Group T compared with Group O (39 +/- 51 vs 27 +/- 24 h, P = 0.014), as was the duration of stay in intensive care (66 +/- 56 vs 51 +/- 29 h, P = 0.010). Thiopentone did not increase the need for inotropic or mechanical support after bypass. In-hospital mortality was lower in Group T than in Group O (1.2% vs 9.5%, P = 0.034).. High-dose thiopentone delays extubation after open-chamber procedures. However, the technique appears safe, and further prospective investigation is justifiable.

Topics: Anesthesia, Intravenous; Anesthetics, Intravenous; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Cardiotonic Agents; Cerebrovascular Disorders; Critical Care; Elective Surgical Procedures; Electroencephalography; Female; Humans; Incidence; Intubation, Intratracheal; Length of Stay; Male; Middle Aged; Narcotics; Neuroprotective Agents; Quality Assurance, Health Care; Retrospective Studies; Safety; Survival Rate; Thiopental

Topics: Cerebrovascular Disorders; Coronary Artery Bypass; Humans; Postoperative Complications; Thiopental

This study compared the technique of general and regional cervical block anesthesia for carotid endarterectomy. Three hundred sixty-eight patients undergoing 399 carotid endarterectomies were administered one of these alternative anesthetics as selected preoperatively by each patient and his or her physician. In 242 cases general anesthesia was used. The other 157 cases were done under regional cervical block anesthesia. Perioperative mortality was 1.0%. Nonfatal strokes occurred in 1.25%. There were significantly more strokes in the general anesthesia group. Perioperative blood pressure was unstable for a significantly longer period of time after general anesthesia (mean, 24.6 hours) as compared with regional cervical block anesthesia (mean, 2.1 hours). Furthermore, vasoactive drugs were required for significantly longer periods of time in the general anesthesia group.

Topics: Adult; Aged; Aged, 80 and over; Anesthesia, General; Anesthesia, Spinal; Anesthetics; Blood Pressure; Bupivacaine; Carotid Artery, Internal; Cerebrovascular Disorders; Endarterectomy; Female; Humans; Isoflurane; Male; Middle Aged; Nitrous Oxide; Postoperative Complications; Thiopental

Topics: Animals; Brain Damage, Chronic; Brain Injuries; Cerebrovascular Disorders; Coma; Heart Arrest; Humans; Resuscitation; Thiopental

Three patients awoke in the operating theater with a neurologic deficit after carotid endarterectomy with shunt under general anesthesia with either upper or lower extremity paralysis or both and evidence of a patent carotid artery confirmed by Doppler ultrasonography, B-mode real-time ultrasonography, or surgery. After confirmation of patency of the carotid artery, patients were anesthetized with thiopental (3 to 4 mg/kg) for 48 hours, with respiratory maintenance by ventilator. The therapeutic effect of barbiturates was monitored by prevention of spontaneous respiration without hypotension. All patients awoke approximately 36 to 48 hours after discontinuing the thiopental without the previously noted postoperative neurologic deficit or any adverse neurologic sequelae. At last follow-up more than 1 year postoperatively they were asymptomatic. Results of this study indicate that patients who undergo carotid endarterectomy and awake with a neurologic deficit and a patent operated vessel should be considered for barbiturate induced coma as a therapeutic modality.

Topics: Aged; Carotid Arteries; Cerebrovascular Disorders; Endarterectomy; Female; Follow-Up Studies; Humans; Ischemic Attack, Transient; Male; Middle Aged; Postoperative Complications; Thiopental; Time Factors

Carotid endarterectomy was performed 28 times in 27 patients. All but one patient had symptomatic carotid artery disease, 59% had bilateral disease and 59% had associated intracranial disease. Barbiturate therapy was used as a means of cerebral protection during carotid artery cross-clamping. Neurological deficit occurred in two patients, being permanent in one patient (3.5%); both patients had bilateral carotid and intracranial disease and both had carotid stump pressures greater than 55 mmHg. No morbidity could be attributed to barbiturate usage.

Topics: Adult; Aged; Anticoagulants; Blood Pressure; Brain Diseases; Carotid Arteries; Carotid Artery Diseases; Cerebrovascular Disorders; Constriction; Endarterectomy; Female; Humans; Intraoperative Complications; Ischemic Attack, Transient; Male; Middle Aged; Postoperative Complications; Risk; Thiopental

Pharmacologic protection should be used cautiously. The author reviews its rationale, use, and recommendations in three clinical conditions associated with ischemic brain damage: stroke, cardiac arrest, and head trauma.

Topics: Adult; Animals; Arterial Occlusive Diseases; Barbiturates; Brain Injuries; Brain Ischemia; Cats; Cerebral Arteries; Cerebrovascular Disorders; Dogs; Female; Heart Arrest; Humans; Intracranial Pressure; Male; Middle Aged; Models, Biological; Papio; Phenobarbital; Saimiri; Thiopental

Topics: Cerebrovascular Disorders; Chromatography, High Pressure Liquid; Humans; Thiopental

Topics: Anesthetics; Angiotensin II; Animals; Autoradiography; Blood Flow Velocity; Blood Pressure; Blood-Brain Barrier; Brain; Carbon Radioisotopes; Cerebrovascular Circulation; Cerebrovascular Disorders; Disease Models, Animal; Hypertension; Methoxyflurane; Rabbits; Thiopental; Vasomotor System

Topics: Adolescent; Adult; Aged; Anesthesia, General; Atropine; Blood Pressure; Cerebrovascular Circulation; Cerebrovascular Disorders; Diazepam; Female; Fentanyl; Halothane; Humans; Hypotension; Male; Middle Aged; Nitrous Oxide; Preanesthetic Medication; Subclavian Steal Syndrome; Succinylcholine; Thiopental; Time Factors

Topics: Acidosis; Aged; Anesthesia, General; Blood Glucose; Cerebrovascular Disorders; Coma; Female; Humans; Hyperglycemia; Nitrous Oxide; Osmolar Concentration; Thiopental; Time Factors

Topics: Anesthesia, Inhalation; Apnea; Brain Neoplasms; Cerebral Angiography; Cerebrovascular Disorders; Halothane; Hypotension, Controlled; Nitrous Oxide; Oxygen; Punctures; Respiration, Artificial; Thiopental

Topics: Anesthesia; Anesthesia, Inhalation; Atmosphere; Bis-Trimethylammonium Compounds; Blood Flow Velocity; Blood Gas Analysis; Cerebral Infarction; Cerebrovascular Circulation; Cerebrovascular Disorders; Dogs; Halothane; Hyperbaric Oxygenation; Hypothermia; Hypothermia, Induced; Infarction; Neurosurgery; Oxygen; Research; Thiopental