Lateral positioning for spinal anaesthesia delays the onset of hypotension, while requiring smaller total doses of vasoconstrictors for blood pressure maintenance.
aparoscopic-assisted surgery has found many applications in the treatment of intraabdominal L and gynecologic pathology. Traumatic diaphragmatic rupture is a difficult clinical diagnosis, and diagnostic laparoscopy has been advocated in the management of this condition (1 ). However, insufflation of carbon dioxide to create a pneunoperitoneum when the diaphragm may not be intact is controversial. We report a case of laparoscopic-assisted repair of traumatic diaphragmatic rupture and the potential respiratory complications. Case ReportA 43-yr-old, 60-kg, previously healthy woman was admitted to our neurosurgical intensive care unit after being involved in a motor vehicle accident. Physical examination on admission revealed a comatose state (Glasgow coma scale 31, a heart rate of 64 bpm, and a supine arterial blood pressure (ABP) of 125/65 mm Hg. Chest radiograph showed blunting of the left costophrenic angle. Pao, and Paco, were 80 and 34 mm Hg, respectively, with a fractional inspired oxygen concentration (FIo,) of 0.4. Management included tracheal intubation and intermittent positive pressure ventilation (IPPV) with a minute volume of 12 L, a respiratory rate of 14 breaths/min, and an inspiratory to expiratory (IE) ratio of 1:2 (Siemens Elema Servo 900 C; Stockholm, Sweden). Minute ventilation was adjusted to maintain a Paco, in the range 34-40 mm Hg. Intracranial pressure was monitored with a subdural catheter, and values ranged from 3 to 14 mm Hg during the intensive care course. Midazolam 2-5 mg/h was administered intravenously (IV) for sedation.A chest radiograph obtained 5 days after admission showed the gastric fundus occupying the left hemithorax. The tip of the nasogastric tube was visible above the diaphragm. Nasogastric tube aspiration of 0.5 L of gastric contents resulted in the return of the chest radiograph to its appearance on admission. No pneumothorax or rib fractures were apparent. A presumptive diagnosis of traumatic ruptured diaphragm was made. The patient remained in a comatose state (Glasgow coma scale 5).The patient was scheduled to undergo a diagnostic laparoscopy to evaluate the integrity of the left hemidiaphragm.Preoperative laboratory investigation revealed hemoglobin 8.2 g/dL and hematocrit 0.26. Pao, and Paco, were 125 and 34 mm Hg, respectively, with a FIO, of 0.4. The preoperative electrocardiogram revealed sinus rhythm, normal ST segments, and T waves. The remainder of the hematologic assessment, coagulation screen, renal and liver function tests, and serum electrolytes were within normal limits. A decision was made not to insert a chest drain preoperatively because of the risk of perforation of the gastric fundal hernia and because there was no evidence of visceral pleural injury.In the operating room, routine monitors were placed. A 16-gauge, 70-cm, central venous catheter was placed via the left basilic vein, and a 14-gauge IV catheter was also inserted for intraoperative fluid administration. A 20-gauge catheter was in situ in the right radial artery. A heart rate of 86 bpm, A...
GENERAL ANESTHESIAPurpose: To assess the effects of intraoperative infusion of dopexamine (a DA-1 and B2 adrenoreceptor agonist) on hemodynamic function, tissue oxygen delivery and consumption, splanchnic perfusion and gut permeability following aortic cross-clamp and release.Methods: In a randomised double blind controlled trial 24 patients scheduled for elective infrarenal abdominal aortic aneurysm repair were studied in two centres and were assigned to one of two treatment groups. Group I received a dopexamine infusion starting at 0.5 µg·kg -1 ·min -1 increased to 2 µg·kg -1 ·min -1 maintaining a stable heart rate; Group II received a placebo infusion titrated in the same volumes following induction of anesthesia. Measured and derived hemodynamic data, tissue oxygen delivery and extraction and gut permeability were recorded at set time points throughout the procedure.Results: Dopexamine infusion (0.5 -2 µg·kg -1 ·min -1 ) was associated with enhanced hemodynamic function (MAP 65 ± 5.5 vs 92 ± 5.7 mm Hg, P =<0.05) only during the period of aortic cross clamping. However, during the most part of infrarenal abdominal aortic surgery, dopexamine did not reduce systemic vascular resistance index, mean arterial pressure nor oxygen extraction compared with the control group. The lactulose/ rhamnose permeation ratio was elevated above normal in both groups (0.22 and 0.29 in groups I and II respectively).Conclusions: Dopexamine infusion (0.5 -2 µg·kg -1 ·min -1 ) did not enhance hemodynamic function and tissue oxygenation values during elective infrarenal abdominal aortic aneurysm repair.Objectif : Évaluer les effets d'une perfusion peropératoire de dopexamine, un agoniste des adrénorécepteurs DA-1 et B2, sur l'hémodynamie, l'apport et la consommation d'oxygène tissulaire, la perfusion splanchnique et la perméabilité intestinale à la suite d'un clampage total de l'aorte et de son retrait. Méthode : Il s'agit d'un essai randomisé, contrôlé et à double insu auprès de 24 patients, provenant de deux centres et répartis en deux groupes, qui ont subi la réparation d'un anévrysme aortique abdominal sous-rénal. Le groupe I a reçu une perfusion de dopexamine amorcée à 0,5 µg·kg -1 ·min -1 , augmentée à 2 µg·kg -1 ·min -1 , maintenant une fréquence cardiaque stable; le groupe II a reçu une perfusion placebo de même volume après l'induction de l'anesthésie. Les données hémodynamiques mesurées et dérivées, l'apport et la consommation d'oxygène tissulaire et la perméabilité intestinale ont été notés à des moments de mesure déterminés au cours de l'intervention.Résultats : La perfusion de dopexamine (0,5 -2µg·kg -1 ·min -1 ) a stimulé la fonction hémodynamique (TAM 65 ± 5,5 vs 92 ± 5,7 mm Hg, P = <0,05) pendant le clampage aortique seulement. Cependant, pendant la majeure partie de l'intervention aortique abdominale sous-rénale, la dopexamine n'a pas réduit l'indice de résistance vasculaire générale, la tension artérielle moyenne ou la consommation d'oxygène, ces données étant comparées avec celles du groupe témoin. Le ratio de diss...
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