Complications of Laparoscopic Adrenal Surgery
Kevin R. Loughlin in Complications of Urologic Surgery and Practice, 2007
Anesthetic agents need to be specifically tailored for pheophromocytoma patients. Preoperatively, patients are premedicated with hydroxyzine and alprazolam (46,52). Benzodiazepines are ideal anxiolytics as they decrease catecholamine release whereas opioids can cause histamine release which can stimulate catecholamine release (48). Propofol is a helpful induction agent as the vasodilation it causes can counteract the hypertensive response to endotracheal intubation (48). An anesthetic preference is a sufentanil, fentanyl, and/or propofol infusion combined with inhaled isoflurane (46,52). Fentanyl has the advantage of not causing histamine release (48,49). Vecuronium is the nondepolarizing muscle relaxing agent of choice as it does not release histamine and it does not induce sympathetic stimulation or muscular fasciculations (48,49). Isoflurane is an ideal inhalation agent as it does not sensitize the myocardium to catecholamines (48). Neuromuscular blockade reversal is accomplished with a combination of neostigmine (antimuscarinic effects) and glycopyrolate (cholinergic effects) (48).
Cardiac surgery
Brian J Pollard, Gareth Kitchen in Handbook of Clinical Anaesthesia, 2017
Probably the most commonly used induction technique in UK practice is a slow bolus of opioid (fentanyl 10–15 mcg kg−1) followed by a small dose of induction agent. Maintenance is usually provided by an opioid infusion (e.g. remifentanil 1–3 mcg kg−1 min−1 or alfentanil 50 mcg kg−1 h−1), combined with a low dose of either an inhalational or intravenous agent. Propofol by infusion can be used for maintenance at a rate of 5–6 mg kg−1 h−1 or as target controlled infusions (TCI) to achieve adequate serum levels during bypass. Of the inhalational agents, isoflurane has received much attention because its known vasodilator properties have been implicated in causing myocardial ischaemia through the coronary steal mechanism. However, this has been shown not to be of relevance at concentrations less than 1.5% and may even provide protection against myocardial ischaemia. Both enflurane and halothane have been and are still used for maintenance although halothane is not now available in the UK. Isoflurane is probably the most commonly used. If there is poor urine flow in the presence of an adequate circulating fluid volume and blood pressure consider furosemide (bolus or infusion). Any of the currently available muscle relaxants may be used. The cardiovascular side effects of pancuronium may be beneficial in counteracting the bradycardia caused by opioids. Rocuronium is associated with very little cardiovascular effect and is becoming the relaxant of choice. Vecuronium is associated with an increased incidence of bradycardia.
Neuromuscular care
Hemanshu Prabhakar, Charu Mahajan, Indu Kapoor in Essentials of Anesthesia for Neurotrauma, 2018
Steroidal compounds such as pancuronium, vecuronium, and rocuronium have little or minimal effect on CBF, CMRO2, or ICP. Pancuronium raises blood pressure and heart rate, which could be detrimental for certain patients, including those with hypertension, especially if they have disturbed autoregulation. In these patients, a substantial elevation of ICP can occur. Vecuronium doesn’t induce histamine release and doesn’t change blood pressure or heart rate, and may be preferable. Rocuronium, because of its rapid onset of action when compared to other non-depolarizing MRs and its lack of adverse activity, such as histamine release, may be preferable to succinylcholine during rapid induction of anesthesia.
Analgesic efficacy of dexmedetomidine versus fentanyl as an adjunct to thoracic epidural in patients undergoing upper abdominal surgery: a randomized controlled trial
Published in Southern African Journal of Anaesthesia and Analgesia, 2018
Neerja Bharti, Shweta N Pokale, Indu Bala, Vikas Gupta
Anaesthesia was induced with morphine 0.1 mg/kg followed by propofol 2–3 mg/kg until loss of verbal response. Muscle relaxation was achieved with vecuronium bromide 0.1 mg/kg and the patient’s trachea was intubated when train of four (TOF) count reached 0. Anaesthesia was maintained by isoflurane with 60% nitrous oxide in oxygen titrated to maintain a Bispectral index (BIS) value of 40–60. Muscle relaxation was maintained with top-ups of vecuronium bromide guided by neuromuscular monitoring. The lungs were ventilated with positive pressure ventilation to maintain end-tidal carbon dioxide (EtCO2) between 32 and 36 mmHg. The epidural drug was administered according to the group allocation immediately after intubation over a period of 10 minutes. Patients’ heart rate, electrocardiography (ECG), SpO2, BIS, nasopharyngeal temperature and EtCO2 were monitored continuously and blood pressure was taken at five-minute intervals. The data were recorded every 5 minutes for the first 30 minutes and then every 15 minutes till completion of surgery.
Regulation of cytochrome P450 enzyme activity and expression by nitric oxide in the context of inflammatory disease
Published in Drug Metabolism Reviews, 2020
Edward T. Morgan, Cene Skubic, Choon-myung Lee, Kaja Blagotinšek Cokan, Damjana Rozman
Hepatic heme-nitrosyl complexes have also been detected in the livers of mice treated with killed Corynebacterium parvum bacteria in the presence or absence of LPS (Chamulitrat et al. 1995). In rats treated with C. parvum, the clearance of vecuronium and antipyrine was reduced and this was partially reversed by NOS inhibition (Blobner et al. 1999). However, levels of P450 proteins were not measured. In a model of sterile inflammation caused by turpentine injection in rabbits, a NO-dependent reduction in the clearance of antipyrine was observed in the absence of changes in CYP1A2 (Barakat et al. 2001). Similarly, a NO-dependent reduction of antipyrine clearance in rats treated with type II Shiga-like toxin was not accompanied by changes in CYP2C11 and CYP3A2 proteins (Kitaichi et al. 2004). In a model of Type I allergy in mice, an NO scavenger blocked the observed decreases in Cyp1a2, Cyp2c, Cyp2e1 and Cyp3a activities, whereas there were no changes in Cyp protein levels (Tanino et al. 2016). On the other hand, decreases in P450-dependent activities in the livers of mice treated with polyinosinic. polycytidylic acid (a toll-like receptor 3 agonist) were not affected by NOS inhibition (Hodgson and Renton 1994).
Propofol post-conditioning after temporary clipping reverses oxidative stress in aneurysm surgery
Published in International Journal of Neuroscience, 2019
Di Guo, Yanli Li, Haiyun Wang, Xinyue Wang, Wei Hua, Qingkai Tang, Lumin Miao, Guolin Wang
Midazolam (0.03 mg/kg) was used as premedication for all patients. Induction of anesthesia in both groups was performed using intravenous propofol 1.5 mg/kg, fentanyl 5 µg/kg, and rocuronium 0.8 mg/kg. Patients were monitored throughout the duration of general anesthesia with electrocardiogram, peripheral oxygen saturation (SpO2), invasive arterial blood pressure, end-tidal CO2 (PETCO2), and bispectral index (BIS). After endotracheal intubation, mechanical ventilation was set to maintain a PETCO2 between 38 and 45 mmHg. Maintenance anesthesia differed between the two groups. For Group S, 0.5–2% sevoflurane was inhaled to keep the BIS value between 40 and 60. In Group P, 0.5–2% sevoflurane was administered prior to and during clipping of the parent artery. Immediately after clip removal, 1.2 µg/mL propofol (TCI, plasma target concentration) was given while the concentration of sevoflurane was simultaneously decreased to maintain a BIS value between 40 and 60 until the surgery was completed. Vecuronium was given as needed.
Related Knowledge Centers
- Hypotension
- Surgery
- Tracheal Intubation
- Paralysis
- General Anaesthesia
- Mechanical Ventilation
- Muscle Relaxant
- Suxamethonium Chloride
- Rocuronium Bromide
- Intravenous Therapy