The management of temperature during hypothermic cardiopulmonary bypass: II--Effect of prolonged hypothermia

In animals mild hypothermia (32-35 degrees C) reduces ischaemic brain injury, but this has not been investigated in humans. During hypothermic cardiopulmonary bypass (CPB) patients are made hypothermic (usually to 30-32 degrees C) but are then rewarmed at a time when they are still at risk of ischaemic brain injury. We investigated the feasibility and safety of maintaining mild hypothermia throughout the CPB period. Thirty adult cardiac surgical patients were randomized to either rewarming to 36-37 degrees C or to maintaining temperature at 34 degrees C without rewarming. On arrival in the recovery room, patients in the hypothermic group had a mean bladder temperature of 33.8 +/- 0.45 degrees C compared with 35.4 +/- 0.58 degrees C (mean +/- SD, P < 0.05) in the rewarmed patients. There were no differences between groups in intra- or postoperative blood loss or blood use, inotrope use, dysrhythmias, or myocardial infarction. The hypothermic group received more muscle relaxant for the treatment of shivering postoperatively. Our results suggest that mild hypothermia following CPB did not increase morbidity although larger studies are needed for confirmation.

Patient-controlled analgesia with epidural meperidine after elective cesarean section

BACKGROUND AND OBJECTIVES

We report the first controlled analysis of the use of patient-controlled epidural meperidine. This randomized, prospective study compares the efficacy and safety of patient-controlled epidural meperidine to conventional intramuscular meperidine for the management of postoperative pain after elective cesarean delivery.

METHODS

After delivery, 60 patients were randomly assigned to receive either conventional intramuscular meperidine therapy or epidural meperidine by a patient-controlled analgesia pump, which was programmed to deliver bolus doses in addition to a continuous background infusion.

RESULTS

Patients in the patient-controlled epidural analgesia group used significantly less meperidine in the first 24 hours after surgery (p < 0.05) and had significantly lower visual analog pain scores (p < 0.05) from three hours postoperatively until study completion at 24 hours. Patients in the patient-controlled epidural analgesia group ambulated sooner (19 +/- 7.8 versus 29.2 +/- 2.2 hours, p < 0.005) and cared for their infants earlier (4.6 +/- 0.9 versus 8.1 +/- 6.8 hours, p < 0.05) than patients receiving intramuscular meperidine. One patient developed a respiratory rate of four breaths per minute, 25 minutes after receiving 75 mg epidural meperidine in the operating room. This was treated with intravenous naloxone. No other serious side effects occurred in either group. Both groups were similar with regard to minor intraoperative and postoperative side effects.

CONCLUSIONS

Patient-controlled epidural meperidine after cesarean delivery more effectively manages postoperative pain than conventional intramuscular use. The technique is preferred by both patients and nursing staff and can be used in the ward setting with appropriate organization and education. Respiratory depression, if it occurs, should present early after epidural bolus administration.

[Neuropsychological catamnesis in cases of intracranial aneurysm]

The authors analyzed the results of neuropsychological examinations in 30 cases in which a single intracranial aneurysm had been excluded from circulation. The neuropsychological assessment of the higher mental functions was carried out using a set of tests of A. R. Luria in all cases and repeated thrice, comparing the results with those of neurological examination and EEG. The condition of the patients was evaluated using a three-grade scale. In the group of cases with aneurysms of the anterior communicating artery a divergence was observed between the results of neuropsychological examination and neurological examination. The patients achieved not infrequently, very good and good Grades in neurological examination and unsatisfactory in neuropsychological examination and unsatisfactory in neuropsychological examination. A similar divergence was observed also when the aneurysm was situated in other cerebral arteries. On the other hand, considerable similarities were found between the neuropsychological assessment and the result of EEG (with regard to the location, of disturbances and their intensity). Neuropsychological examination made possible detection and determination of the dynamic development of defects in the functions of higher psychic activities inaccessible for routine neurological examination, but having a very important effect on the everyday functions of the patient.