Intraoperative therapeutic suggestions in day-case surgery: are there benefits for postoperative outcome?
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To determine if improved postoperative recovery in surgical inpatients receiving intraoperative therapeutic suggestions are applicable in an outpatient population, 70 consenting, unpremedicated adults undergoing elective outpatient hernia repair under general anaesthesia were allocated randomly to either a therapeutic tape (TT) or a comparison tape (CT) group. A standardized general anaesthetic technique was used with propofol, fentanyl or alfentanil, isoflurane and nitrous oxide in oxygen. Pain, and nausea and vomiting were assessed after operation at 30, 60 and 90 min and at 2, 6 and 24 h. The presence of other side effects, such as headache and muscular discomfort, in addition to recall of tape contents, were also evaluated after operation. Absorption ability was measured before operation. The groups were similar in patient characteristics, preoperative, surgical and anaesthetic characteristics, and level of absorption. There were no differences in pain ratings or need for analgesics administered at any time after operation. Nausea/vomiting was experienced significantly fewer times by patients in group TT compared with group CT over the first 90 min (group CT 15%, group TT 4%; P < 0.02), but not over the last three assessment times (group CT 10%, group TT 14%; P < 0.25). The therapeutic tape group experienced fewer side effects over the entire postoperative assessment period (P = 0.03), in particular less headaches (P = 0.03) and less muscular discomfort (P < 0.02). Use of intraoperative therapeutic suggestions could present mildly significant postoperative benefits in outpatients. (+info)
Postoperative pain after adenoidectomy in children.
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We have investigated if pain intensity or analgesic requirements in hospital predicted pain intensity, pain duration or analgesic requirements at home in 611 children, aged 1-7 yr, after day-case adenoidectomy. We also investigated if ketoprofen 0.3-3.0 mg kg-1, administered pre-emptively i.v. during operation, modified pain at home. In hospital, a prospective, randomized, double-blind, placebo-controlled study design was performed. A standard anaesthetic technique was used in all children and fentanyl i.v. was available for rescue analgesia. After discharge, the study design was open, experimental, prospective and longitudinal. On return home, children were prescribed ketoprofen tablets 5 mg kg-1 day-1. Parents were asked to complete an analgesia diary; non-responders were contacted by telephone. The response rate was 91%. The number of doses of fentanyl given in hospital correlated with pain intensity at home (P < 0.001). There were no other correlations and no pre-emptive effect of ketoprofen. (+info)
Protocol for ultrarapid immunostaining of frozen sections.
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Rapid immunostaining of frozen sections within a tolerable time span would be very helpful for intraoperative diagnosis. A protocol was therefore established using the enhanced polymer one-step staining (EPOS) system (Dako) with antibodies against leucocyte common antigen (LCA), cytokeratin (CK), and anti-melanoma (MEL). Best results with reliable and specific immunostaining and a labelling intensity comparable to standard immunostaining protocols were achieved with fixation of samples in 100% acetone for 20 seconds (CK, LCA) or two minutes (MEL), followed by incubation of the primary antibody and development of the chromogen reaction with 3,3'diaminobenzidine (DAB) for three and five minutes at 37 degrees C, respectively. The total procedure takes only 12 minutes, thus enabling rapid immunostaining on intraoperative frozen sections. Apart from its use in tumour classification, this method is especially useful in detecting tumour cells in sentinel lymph nodes. (+info)
Intraoperative microvascular Doppler ultrasonography in cerebral aneurysm surgery.
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OBJECTIVES: Outcome of surgical treatment of cerebral aneurysms may be severely compromised by local cerebral ischaemia or infarction resulting from the inadvertent occlusion of an adjacent vessel by the aneurysm clip, or by incomplete aneurysm closure. It is therefore mandatory to optimise clip placement in situ to reduce the complication rate. The present study was performed to investigate the reliability of intraoperative microvascular Doppler ultrasonography (MDU) in cerebral aneurysm surgery, and to assess the impact of this method on the surgical procedure itself. METHODS: Seventy five patients (19 men, 56 women, mean age 54.8 years, range 22-84 years) with 90 saccular cerebral aneurysms were evaluated. Blood flow velocities in the aneurysmal sac and in the adjacent vessels were determined by MDU before and after aneurysm clipping. The findings of MDU were analysed and compared with those of visual inspection of the surgical site and of postoperative angiography. Analysis was also made of the cases in which the clip was repositioned due to MDU findings. RESULTS: A relevant stenosis of an adjacent vessel induced by clip positioning that had escaped detection by visual inspection was identified by Doppler ultrasonography in 17 out of 90 (18.9%) aneurysms. In addition, Doppler ultrasound demonstrated a primarily unoccluded aneurysm in 11 out of 90 (12.2%) patients. The aneurysm clip was repositioned on the basis of the MDU findings in 26 out of 90 (28.8%) cases. In middle cerebral artery (MCA) aneurysms, the MDU results were relevant to the surgical procedure in 17 out of 44 (38.6%) cases. Whereas with aneurysms of the anterior cerebral artery significant findings occurred in only five of 32 cases (15.6%; p<0.05). The clip was repositioned on the basis of the MDU results in 18 out of 50 (36%) aneurysms in patients with subarachnoid haemorrhage (SAH) grade I-V compared with only eight out of 40 (20%) aneurysms in patients without SAH (p<0.05). CONCLUSIONS: MDU should be used routinely in cerebral aneurysm surgery, especially in cases of MCA aneurysms and after SAH. Present data show that a postoperative angiography becomes superfluous whenever there is good visualisation of the "working site" and MDU findings are clear. (+info)
Visual experience during phacoemulsification cataract surgery under topical anaesthesia.
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BACKGROUND/AIMS: Visual awareness during phacoemulsification cataract surgery is an important determinant of patient satisfaction with any anaesthetic technique. Topical anaesthesia could be associated with significant visual awareness because it does not affect optic nerve function. METHODS: The visual experience during phacoemulsification cataract surgery under topical anaesthesia (without sedation) was assessed for 106 consecutive unselected patients. Patients were interviewed immediately after surgery using a standardised questionnaire that explored specific aspects of their visual experience. RESULTS: Four patients were excluded because they had poor recollection of their visual experience. The visual awareness of the remaining 102 patients comprised operating microscope light (99), colours (73), flashes of light (7), vague movements (19), surgical instruments or other objects (12), change in light brightness during surgery (49), change in colours during surgery (30), and transient visual alteration during corneal irrigation (25). No patient found their visual experience during surgery unpleasant, though the operating microscope light was uncomfortably bright for two patients. Six patients lost light perception for a short interval during surgery. There was no association between the various visual phenomena reported and patients' age, sex, preoperative visual acuity, cataract morphology, coexisting ocular pathology, or previous experience of cataract surgery under local anaesthesia (p>0.05). CONCLUSIONS: Patients experience a wide variety of visual sensations during phacoemulsification cataract surgery under topical anaesthesia. Topical anaesthesia does not, however, appear to result in greater visual awareness than regional anaesthesia. Preoperative patient counselling should include information about the visual experience during surgery. (+info)
Lack of renoprotective effects of dopamine and furosemide during cardiac surgery.
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Because development of acute renal failure is one of the most potent predictors of outcome in cardiac surgery patients, the prevention of renal dysfunction is of utmost importance in perioperative care. In a double-blind randomized controlled trial, the effectiveness of dopamine or furosemide in prevention of renal impairment after cardiac surgery was evaluated. A total of 126 patients with preoperatively normal renal function undergoing elective cardiac surgery received a continuous infusion of either "renal-dose" dopamine (2 microg/kg per min) (group D), furosemide (0.5 microg/kg per min) (group F), or isotonic sodium chloride as placebo (group P), starting at the beginning of surgery and continuing for 48 h or until discharge from the intensive care unit, whichever came first. Renal function parameters and the maximal increase of serum creatinine above baseline value within 48 h (deltaCrea(max)) were determined. The increase in plasma creatinine was twice as high in group F as in groups D and P (P < 0.01). Acute renal injury (defined as deltaCreamax) >0.5 mg/dl) occurred more frequently in group F (six of 41 patients) than in group D (one of 42) and group P (zero of 40) (P < 0.01). (The difference between group D and group P was not significant.) Creatinine clearance was lower in group F (P < 0.05). Two patients in group F required renal replacement therapy. The mean volume of infused fluids, blood urea nitrogen, serum sodium, serum potassium, and osmolar- and free-water clearance was similar in all groups. It was shown that continuous infusion of dopamine for renal protection was ineffective and was not superior to placebo in preventing postoperative dysfunction after cardiac surgery. In contrast, continuous infusion of furosemide was associated with the highest rate of renal impairment. Thus, renaldose dopamine is ineffective and furosemide is even detrimental in the protection of renal dysfunction after cardiac surgery. (+info)
Evaluation of three gamma detectors for intraoperative detection of tumors using 111In-labeled radiopharmaceuticals.
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Attempts to detect tumors with intraoperative scintillation using tumor-binding radiopharmaceuticals have intensified recently. In some cases previously unknown lesions were found, but in most cases no additional lesions were detected. In this study the physical characteristics of three detector systems and their ability to detect tumors through accumulation of an 111In-labeled radiopharmaceutical were investigated. The first was a sodium iodide (NaI[TI]) detector; the second, a cesium iodide (CsI[TI]) detector; and the third, a cadmium telluride (CdTe) detector. METHODS: A body phantom and tumor phantoms (diameter 5-20 mm) made of water, agarose gel or epoxy with a density and attenuation coefficient similar to those of soft tissue were used to simulate a clinical situation. The activity concentration in the body phantom was based on reported values of 111In-octreotide in normal tissue in humans. The 111In activity concentration in the tumor phantoms varied from 3 to 80 times the 111In activity concentration in the body phantom. Data were processed to determine tumor detection levels. RESULTS: The NaI(TI) detector showed the lowest values for full width at half maximum because this detector had the best collimation, leading to a high ratio between counts from tumor and counts from background, i.e., small tumors could be detected. Because of high efficiency, the CsI(TI) detector sometimes required a somewhat shorter acquisition time to produce a statistically significant difference between tumor phantom and background. For deep-lying tumors the NaI(TI) detector was superior, whereas the CdTe detector was best suited for superficial tumors with a high activity concentration in the underlying tissue. CONCLUSION: At a maximum acquisition time of 30 s, almost all superficial tumors with a diameter of 10 mm or larger were detected if the ratio between the 111In concentration in the tumor and the 111In concentration in the background exceeded 3. However, in clinical situations, biologic variations in the uptake of 111In-octreotide in tumors and in normal tissue makes difficult the determination of a distinct detection level. For such clinical conditions, the NaI(TI) detector is the best choice because it has good resolution despite a lower efficiency. Documentation of detector characteristics is important so that clinicians can make an adequate device in relation to tumor location and receptor expression. (+info)
Hematogenous dissemination of hepatocytes and tumor cells after surgical resection of hepatocellular carcinoma: a quantitative analysis.
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The only hope of long-term survival for patients with hepatocellular carcinoma (HCC) is surgical resection or liver transplantation. However, recurrence or metastasis formation is common after surgery. We aim to assess whether surgical resection leads to hematogenous dissemination of malignant and nontumor hepatocytes and determine the quantity and timing of hepatocyte shedding into the circulation. Using semiquantitative reverse transcription-PCR for alpha-fetoprotein (afp) and albumin (alb) mRNAs, we measured the mass of malignant and nontumor hepatocytes in 53 peripheral blood samples collected preoperatively, intraoperatively, and postoperatively from 13 HCC patients. We compared these data with those in 54 control samples collected from 24 healthy subjects and patients with chronic hepatitis/cirrhosis and 10 hepatocellular adenoma patients who underwent resection. Clinicopathological information of HCC patients was obtained during 3-year follow-up. In 100% (23 of 23) of HCC and adenoma patients, alb mRNA levels increased 10-10(6)-fold intraoperatively and then markedly declined within 8 weeks after operation. Levels of afp mRNA increased 5-7600-fold preoperatively in 8% (1 of 13) and postoperatively in 70% (9 of 13) of HCC patients. All five HCC patients with persistently elevated afp mRNA levels died from intrahepatic/extrahepatic metastasis, liver recurrence, or persistent HCC within 1 year after surgery. The absence/clearance of afp mRNA in 75 % (six of eight) of survivors was strongly associated with the absence of metastasis/recurrence (P = 0.02). We present evidence that alb-expressing hepatocytes are released intraoperatively into the circulation, and afp-expressing tumor cells are disseminated mostly postoperatively that may potentially be the source of recurrence or metastasis. Sequential quantification of both alb and afp mRNAs may provide insights for risk assessment and prognostic indication. (+info)