一氧化二氮，俗稱笑氣，是現代臨床麻醉最為常用的一種麻醉劑。然而，關於一氧化二氮效能及安全性的研究至今仍存在爭議。近來，一個稱為ENIGMA的臨床研究項目對2,050個施行大手術的病人接受麻醉情況及術後併發癥進行了研究。研究發現手術中施行一氧化二氮麻醉的病人術後傷口感染率較之對照組上升了35%。另一方面，對423個ENIGMA病人的長期隨訪研究發現，在術中接受一氧化二氮麻醉的病人中慢性術後痛的發病率相對對照組降低了56%。 對於這些臨床發現的分子機制，目前知之甚少。 因此我們進行了一系列實驗來研究一氧化二氮導致術後感染以及預防慢性痛的分子機制。 / 一氧化二氮對基因穩定性的影響 / 在對93個接受直腸結腸大型外科手術的病人進行的隨機對照試驗中，我們比較了接受一氧化二氮麻醉及其對照組病人的外周白細胞脫氧核糖核酸（DNA）損傷情況和術後傷口感染率。通過單細胞凝膠電泳（彗星實驗），我們發現術中一氧化二氮麻醉顯著增加了手術24小時后病人的DNA損傷情況 （p < 0.001）。且這種變化是劑量依賴的，r = 0.33; p = 0.03。並且，在DNA損傷程度及術後傷口感染率間存在顯著相關。術後DNA損傷程度每增加十個單位，傷口感染率則隨之增加17%。 / 一氧化二氮對DNA損傷應答及修復的影響 / 利用大鼠模型，我們對一氧化二氮導致基因不穩定的機制進行了研究。Sprague Dawley大鼠暴露於一氧化二氮中2小時後，我們對其DNA損傷應答及修復基因的轉錄情況進行了檢測。脂多糖（LPS）注射大鼠模擬了圍手術期的炎癥反應。我們發現LPS刺激的白細胞經一氧化二氮處理后，其編碼DNA連接酶IV的LIG4基因的轉錄量顯著降低（p < 0.05）。LIG4基因的下調導致了一氧化二氮麻醉後圍手術期的免疫抑制效應。 / NMDA受體抑制在一氧化二氮預防性鎮痛中的作用 / 在大鼠慢性神經痛模型中，我們檢測了一氧化二氮鎮痛作用的機制。我們發現一氧化二氮處理組的機械痛覺過敏相較對照組顯著降低（p = 0.001）。一氧化二氮處理后，神經痛大鼠脊髓背角中的c-Fos表達量也顯著降低，這表明了一氧化二氮對神經元活性的影響。該影響可能是NMDA受體抑制的結果。另外，我們還觀察到一氧化二氮的鎮痛特徵與NMDA受體非競爭性拮抗劑MK-801的鎮痛效果相似。 / 基因表達改變在一氧化二氮預防性鎮痛中的作用 / 一氧化二氮鎮痛效果的遲發性和延續性提示了除受體拮抗之外的其他作用機制的存在。我們發現在大鼠坐骨神經壓迫損傷模型中，一氧化二氮處理顯著降低了同側脊髓背角組織中LIG4基因的轉錄及表達（p = 0.006）。同時一氧化二氮處理降低了星形膠質細胞在同側脊髓背角中的活化。我們的研究表示一氧化二氮影響DNA修復， 抑制脊髓背角基因的表達，從而起到預防性鎮痛的作用。 / 總而言之，一氧化二氮通過抑制鉀硫氨酸合成酶，削弱DNA修復和基因組穩定性，從而成為導致術后傷口感染的危險因素。另一方面，這一機制也阻止了脊髓背角中異常突觸的建立，從而預防了神經損傷導致的慢性神經痛的建立。另外，一氧化二氮的鎮痛機制也和NMDA受體抑制作用有關。 / Nitrous oxide is a commonly administered anesthetic and analgesic agent in contemporary clinical anesthesia. However, the efficacy and safety of nitrous oxide delivery remains a subject of debate. The recent Evaluation of Nitrous oxide In a Gas Mixture for Anaesthesia (ENIGMA) Trial found that nitrous oxide administration, in 2,050 patients undergoing major surgery, increased the incidence of wound infection by 35%. On the other hand, in a long term follow-up study of 423 ENIGMA patients in Hong Kong, the risk of chronic postsurgical pain was reduced by 56% in patients who received nitrous oxide in the index surgery. Little is known about the mechanisms associated with these clinical observations; we therefore conducted a series of experiments to determine the molecular changes after nitrous oxide administration leading to postoperative wound infection and preventive analgesia. / Genomic Instability after Nitrous Oxide Administration / In a randomized controlled trial of 93 patients undergoing major colorectal surgery, we compared the changes of deoxyribonucleic acid (DNA) damage in circulating leukocytes and rates of wound infection in patients who were exposed to nitrous oxide or not. Using single cell gel electrophoresis (CometAssay), we found that intraoperative nitrous oxide administration produced significant DNA damage, 24 hours after surgery, compared with controls, p < 0.001. The changes were dose-dependent, r = 0.33; p = 0.03. In addition, there was a significant correlation between DNA damage and postoperative wound infection. For every 10 units increase in the percentage of DNA in tail after surgery compared with baseline, there was 17% increase in the risk of wound infection. / DNA Damage Response and Repair / In a rat model, we explored the mechanism of genomic instability after nitrous oxide administration. In Sprague Dawley rats exposed to nitrous oxide anesthesia for 2 hours, we tested the transcription of an array of DNA damage response and repair genes. Lipopolysaccharide (LPS) was added to mimic postoperative inflammation. In the mRNA that were extracted and analyzed by real-time polymerase chain reaction (RT-PCR), we found the transcription of gene encoding for DNA Ligase IV (LIG4 gene) was significantly reduced after nitrous oxide administration in LPS-stimulated leukocytes (p < 0.05). The down regulation of LIG4 gene contributed to perioperative immunosuppression following nitrous oxide exposure. / Role of N-methyl-D-aspartate receptor (NMDAR) Blockade for Preventive Analgesia with Nitrous Oxide / Using a rat model of chronic neuropathic pain, we tested the mechanisms underlying nitrous oxide analgesia. In Sprague Dawley rats undergoing unilateral constrictive injury to the sciatic nerve, we found that mechanical hyperalgesia was significantly reduced with nitrous oxide compared with controls (p = 0.01). In addition, c-Fos expression was decreased in spinal dorsal horn suggesting that neuron excitability was reduced after nitrous oxide administration which could be caused by blockade of the NMDA receptor. Interestingly, the characteristics of analgesia were similar to that provided by MK-801, a noncompetitive antagonist of NMDA receptors. / Transcriptional Changes for Nitrous Oxide Analgesia / The onset of nitrous oxide analgesia was delayed and outlasted actual receptor antagonism. We therefore explored mechanisms, other than NMDA receptor blockade, for nitrous oxide analgesia. Specifically, in rats undergoing sciatic nerve constrictive injury, we found that transcription of LIG4 gene was down-regulated in the ipsilateral spinal dorsal horn after nitrous oxide administration (p = 0.006). There was a decrease in DNA ligase IV expression and a reduction in the activation of astrocytes. Our data suggested that regulation of DNA repair and suppression spinal dorsal horn gene transcription is one of the alternative mechanisms for nitrous oxide analgesia. / In summary, nitrous oxide administration is a risk factor for postoperative wound infection. This is related to irreversible inhibition of the enzyme methionine synthase, impaired DNA repair and genomic instability. The same mechanism however prevented aberrations of synaptic regeneration in the spinal dorsal horn and could therefore prevent the development of chronic neuropathic pain after direct nerve injury. Nitrous oxide analgesia was also related to NMDA receptor blockade. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Chen, Yan. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 126-157). / Abstract also in Chinese. / Declaration of origination --- p.I / Abstract: --- p.II / Acknowledgements --- p.VIII / Table of Contents --- p.X / List of Tables --- p.XV / List of Figures --- p.XVI / List of Abbreviations --- p.XVIII / Chapter Part I: --- Literature Review --- p.1 / Chapter Chapter 1 --- A review of nitrous oxide: Historical, clinical and mechanistic Perspectives --- p.2 / Chapter 1.1 --- History of Nitrous Oxide --- p.2 / Chapter 1.2 --- Clinical Pharmacology of Nitrous Oxide --- p.4 / Chapter 1.3 --- Evaluation of Nitrous oxide In the Gas Mixture for Anesthesia (ENIGMA) Trial --- p.9 / Chapter 1.4 --- Efficacy and Toxicity of Nitrous Oxide: Biochemical and Molecular Mechanisms --- p.14 / Chapter 1.4.1 --- Immunosuppression Following Nitrous Oxide Administration --- p.14 / Chapter 1.4.2 --- Analgesia with Nitrous Oxide - Molecular Mechanisms --- p.17 / Chapter 1.4.2.1 --- Direct molecular target --- p.17 / Chapter 1.4.2.2 --- Interaction with γ aminobutyric acid type A (GABAA) receptors --- p.19 / Chapter 1.4.2.3 --- Regulation of opioid system --- p.20 / Chapter 1.4.2.4 --- Regulation of noradrenergic neurons --- p.21 / Chapter 1.4.2.5 --- N-methyl-d-aspartate (NMDA) receptor inhibition --- p.22 / Chapter 1.4.2.6 --- Long-term Preventive Analgesia with Nitrous Oxide --- p.23 / Chapter 1.4.3 --- Summary --- p.24 / Chapter Part II: --- Experiments --- p.26 / Chapter Chapter 2 --- Study Hypothesis and Objectives --- p.27 / Chapter 2.1 --- Genomic Instability after Nitrous Oxide Administration --- p.27 / Chapter 2.2 --- DNA Damage Response and Repair --- p.28 / Chapter 2.3 --- NMDA Receptor Blockade for Preventive Analgesia with Nitrous Oxide --- p.28 / Chapter 2.4 --- Transcriptional Changes for Nitrous Oxide Analgesia --- p.28 / Chapter Chapter 3 --- Genomic Instability After Nitrous Oxide Administration: A Randomized Controlled Trial --- p.32 / Chapter 3.1 --- Introduction --- p.32 / Chapter 3.2 --- Methods and Materials --- p.36 / Chapter 3.2.1 --- Study Participants --- p.36 / Chapter 3.2.2 --- Study Procedures --- p.36 / Chapter 3.2.3 --- Randomization --- p.37 / Chapter 3.2.4 --- Anesthetic Care --- p.37 / Chapter 3.2.5 --- Postoperative Care --- p.38 / Chapter 3.2.6 --- Measurement of Genomic Instability --- p.44 / Chapter 3.2.7 --- Statistical Analysis --- p.47 / Chapter 3.2.8 --- Sample Size Calculation --- p.47 / Chapter 3.3 --- Results --- p.48 / Chapter 3.4 --- Discussion --- p.61 / Chapter 3.4.1 --- Principal Findings --- p.61 / Chapter 3.4.2 --- Comparison to Other Studies --- p.61 / Chapter 3.4.3 --- Strengths and Limitations --- p.63 / Chapter 3.4.4 --- Implications --- p.64 / Chapter 3.4.5 --- Conclusions --- p.64 / Chapter Chapter 4 --- DNA Damage Response and Repair After Nitrous Oxide Administration / Chapter 4.1 --- Introduction --- p.65 / Chapter 4.1.1 --- DNA Damage Response and Repair Pathways --- p.65 / Chapter 4.1.2 --- Nitrous oxide and DNA Damage Response and Repair --- p.69 / Chapter 4.2 --- Materials and Methods --- p.70 / Chapter 4.2.1 --- Animals --- p.70 / Chapter 4.2.2 --- Nitrous Oxide Administration --- p.70 / Chapter 4.2.3 --- Lipopolysaccharide-Induced Infection Model --- p.72 / Chapter 4.2.4 --- Sample Collection and Preparation --- p.72 / Chapter 4.2.5 --- Single Cell Gel Electrophoresis (CometAssay) --- p.72 / Chapter 4.2.6 --- RNA Extraction for Gene Transcription Study --- p.72 / Chapter 4.2.7 --- Reverse Transcription Polymerase Chain Reaction (RT PCR) --- p.73 / Chapter 4.2.8 --- Quantitative RT PCR --- p.74 / Chapter 4.2.9 --- Statistical Analysis --- p.76 / Chapter 4.3 --- Results --- p.76 / Chapter 4.3.1. --- Genome Instability in Rat Leukocytes after Nitrous Oxide Administration --- p.76 / Chapter 4.3.2. --- Effect of Nitrous Oxide on the Transcription of DNA Damage Response Genes --- p.78 / Chapter 4.3.3. --- Effects of Nitrous Oxide on DNA Damage Response Genes in Animals Treated with Lipopolysaccharide --- p.80 / Chapter 4.4 --- Discussion --- p.84 / Chapter 4.4.1 --- Principal Findings --- p.84 / Chapter 4.4.2 --- Implications --- p.84 / Chapter 4.4.3 --- Limitation of our Study --- p.85 / Chapter 4.4.4 --- Conclusions --- p.87 / Chapter Chapter 5 --- Preventive Analgesia with Nitrous Oxide: Role of NMDA Receptor Blockade / Chapter 5.1. --- Introduction --- p.88 / Chapter 5.1.1. --- The ENIGMA Trial: Long Term Follow-up --- p.89 / Chapter 5.1.2. --- Nitrous oxide prevents chronic postsurgical pain: putative mechanisms --- p.89 / Chapter 5.1.3. --- Hypothesis --- p.90 / Chapter 5.2. --- Materials and methods --- p.91 / Chapter 5.2.1. --- Animals --- p.91 / Chapter 5.2.2. --- Chronic constriction injury (CCI) to induce neuropathic pain --- p.91 / Chapter 5.2.3. --- Behavioral test --- p.93 / Chapter 5.2.4. --- Nitrous oxide administration --- p.93 / Chapter 5.2.5. --- Dizocilpine (MK-801) pretreatment --- p.94 / Chapter 5.2.6. --- Tissue Collection, Preparation and Western Blot --- p.94 / Chapter 5.2.7. --- Statistical Analysis --- p.96 / Chapter 5.3. --- Results --- p.96 / Chapter 5.3.1. --- Preventive Analgesia with Nitrous oxide --- p.96 / Chapter 5.3.2. --- Nitrous oxide analgesia via NMDA receptors block --- p.99 / Chapter 5.3.3. --- Preventive analgesia with NMDA receptors Blockade --- p.101 / Chapter 5.4. --- Discussion --- p.103 / Chapter 5.4.1 --- Principal Findings --- p.103 / Chapter 5.4.2 --- Our Findings compared with Other Studies --- p.103 / Chapter 5.4.3 --- Limitations of the Study --- p.104 / Chapter 5.4.4 --- Conclusions --- p.105 / Chapter Chapter 6 --- Transcriptional Changes for Nitrous Oxide Analgesia --- p.106 / Chapter 6.1 --- Introduction --- p.106 / Chapter 6.1.1 --- Neuro-immune Interactions in the Development of Chronic Neuropathic Pain --- p.106 / Chapter 6.1.2 --- Nitrous Oxide Interferes Astrocytes and Glial Responses --- p.107 / Chapter 6.2 --- Materials and methods --- p.109 / Chapter 6.2.1 --- Chronic Constriction Injury Pain Model and Nitrous Oxide Administration --- p.109 / Chapter 6.2.2 --- Lumbar Dorsal Horn Tissue Collection, Preparation and Immunoflurescence --- p.109 / Chapter 6.2.3 --- RNA Extraction and Quantitative RT PCR for Gene Transcription Study --- p.110 / Chapter 6.2.4 --- Protein Extraction and Western Blot for protein Expression Study --- p.110 / Chapter 6.2.5 --- Statistical Analysis --- p.111 / Chapter 6.3 --- Results --- p.112 / Chapter 6.3.1 --- Time Course of LIG4 Gene Transcription after Constrictive Nerve Injury --- p.112 / Chapter 6.3.2 --- Nitrous oxide reduced DNA ligase IV expression in spinal dorsal horn --- p.114 / Chapter 6.3.3 --- Nitrous oxide Reduced Astrocytes Activation in Spinal Dorsal Horn --- p.116 / Chapter 6.4 --- Discussions --- p.119 / Chapter 6.4.1 --- Principal Findings --- p.119 / Chapter 6.4.2 --- Our Findings in Relation to Other Studies --- p.119 / Chapter 6.4.3 --- Limitations of Our Study --- p.120 / Chapter 6.4.4 --- Conclusions --- p.120 / Chapter Part III: --- Conclusions --- p.122 / Chapter Chapter 7 --- Conclusions and Future Perspectives --- p.123 / Chapter 7.1 --- Conclusions --- p.123 / Chapter 7.2 --- Future Perspectives --- p.124 / Chapter Part IV --- References --- p.126

Emergence delirium (ED), also known as emergence agitation, is a postoperative condition characterized by aberrant cognitive and psychomotor behaviors following general anesthesia. The incidence of ED is 3 to 8 times higher in children 5 years of age or less. There is no standard of nursing practice for managing ED symptoms in the pediatric surgical population. The purpose of this quality improvement project was to address a gap in knowledge needed to inform clinical decision-making when managing ED in the postoperative setting. Using an educational presentation for post anesthesia care unit (PACU) nurses, this project introduced the use of non-pharmacological interventions to mitigate symptoms of ED in the pediatric population as inspired by The Green Star Initiative, an Army program at Fort Carson. The project aim was to describe the effectiveness of ED-specific interventions from the nursing perspective. Using tenets of the Iowa model, this quality improvement project included a needs assessment survey, PowerPoint presentation, parent education leaflet, ED cheat sheet, and a post-intervention survey. Applying the context, input, process, product model for evaluation, this project increased knowledge of ED-specific interventions used by nurses that demonstrates a change in clinical decision-making. PACU nurses rated the interventions 43% effective on pediatric patients. This project addressed the gap in practice by providing structured education on ED, inspiring the use of ED-specific interventions, and promoting readiness to care for the pediatric surgical population. Outcomes add to the nursing literature by introducing ED-specific interventions to manage pediatric ED in facilities nationwide. A social implication of this project is to improve the care of pediatric surgical patients.

Aim: The overall aim of the thesis was to describe the experiences of awake patients during surgery under regional anesthesia. In addition, the aim was to develop a model for intraoperative care that can support and enhance patients’ well-being during the intraoperative period.   Methods: Study I was a patient interview study guided by a reflective lifeworld approach. In study II a philosophical reflection of the findings from study I was carried out. In study III a hermeneutic approach inspired by Ricoeur and Gadamer was used in order to interpret video recorded material. In study IV a hermeneutic approach inspired by Gadamer was used to synthesize the findings in studies I-III transformed into an intraoperative caring model.  Overall main findings: The analysis shows that being awake during surgery can be compared with walking a tightrope because of ambiguous feelings. The proximity and presence of the nurse anesthetist (NA) anchors the patient in the present and strengthens the patient’s feeling of trust. The temporary disruption in the relationship between the body and the world due to regional anesthesia means that the patient’s being in the world is exposed to revolutionary experiences. Gaps between the patient’s experiences and the situation can be bridged over when the NA acts as the patient’s bodily extension and links the patient as a subject to the world in the intraoperative situation. From the patient’s perspective this calls for the NA’s proximity and genuine presence in the ‘intraoperative caring space’. When the NA’s performance of his/her professional duties clashes with the patient’s existential being in the intraoperative situation the need of present presence from the NA is crucial. Conclusions: The findings contribute to knowledge development about intraoperative care and raise awareness that care for the awake patient cannot be performed on formal routines that might disregard the uniqueness of each patient’s situation. The model can be used as a tool to encounter awake patients’ existential needs in the intraoperative situation and to further enlighten NAs about the possible impact of their proximity, interaction and communication behavior in the delivery of intraoperative nursing care.

Der heute noch gängige Einsatz von Injektionsanästhetika bei Laborratten basiert zum großen Teil auf empirischen Daten. Auf der Grundlage des deutschen Tierschutzgesetzes sind Wissenschaftler verpflichtet, das nach dem derzeitigen Kenntnisstand schonendste Betäubungsmittel zu verwenden. Die wissenschaftlichen Daten zur intra- und postoperativen Belastung bei vielen Anästhetika sind lückenhaft. Daher wurden in dieser Studie im Sinne des „Refinements“ von Tierversuchen verschiedene Injektionsnarkosen bei 69 männlichen und weiblichen 6-8 Wochen alten Sprague-Dawley-Ratten im Rahmen einer stereotaktischen Gehirnoperation (OP) verglichen, bei der zumeist Injektionsnarkosen Verwendung finden. Die Ratten wurden entweder mit Chloralhydrat (CH: 3,6 %, 430 mg/kg intraperitoneal [i.p.] KGW), mit der vollständig antagonisierbaren Anästhesie (Medetomidin 0,15 mg/kg Körpergewicht [KGW], Midazolam 2 mg/kg KGW, Fentanyl 0,005 mg/kg KGW intramuskulär [i.m]) ohne (VAA-Gruppe) bzw. mit Antagonisierung (sog. VAA+A-Gruppe) zum OP-Ende (Atipamezol 0,75 mg/kg, Flumazenil 0,2 mg/kg, Naloxon 0,12 mg/kg subcutan [s.c.]) anästhesiert und nach Erreichen des Stadiums der chirurgischen Toleranz (cT), gekennzeichnet durch den Ausfall des Zwischenzehenreflexes an des Hintergliedmaße (ZZR hi.), einer 60-minütigen OP unterzogen. Eine weitere Gruppe erhielt eine i.p.-Bolusinjektion Propofol in einer Dosis von 120 mg/kg KGW, die sich im Rahmen von Vorversuchen als geeignet herausgestellt hatte, um bei Ratten eine Hypnose zu bewirken. Anschließend wurde Propofol zu Erzeugung und Aufrechterhaltung einer cT per Dauerinfusion i.v. (4 - 6 mg/kg/h) verabreicht. Kontrolltiere erhielten eine Injektion mit isotoner Kochsalzlösung (i.p.) ohne OP. Die Erfassung des KGWs erfolgte 3 Tage vor bis 2 Tage nach der OP. Im Vorfeld wurde jedes Tier über 3 Tage an das Tragen eines Pulsoximeterclips am Hals gewöhnt. Dies diente der Ermittlung von Basiswerte für die Atemfrequenz (AF), Herzfrequenz (AF) und die periphere Sauerstoffsättigung (SpO2)am wachen, freibeweglichen Tier am Tag der Anästhesie mittels MouseOx®-Pulsoximeter. In Narkose wurden die Tiere mittels Pulsoximeter, Reflextests (ZZR hi., Lid- [LR] und Cornealreflex [CR]) und Rektalthermometer überwacht. Die externe Wärmezufuhr wurde über eine elektrische Wärmeplatte (37 °C) vorgenommen Zu zwei Zeitpunkten erfolgten Blutabnahmen zur Bestimmung der Adrenalin- (A) und Noradrenalinwerte (NA) mittels HPLC. Der Verlust der cT wurde anhand festgelegter Kriterien bestimmt (ZZR hi. positiv, Zuckungen, lautes Vokalisieren, Zähneknirschen) und die Tiere ggf. nachdosiert. Prä- und postoperativ wurde immunreaktives Corticosteron (iCS) mittels ELISA aus Kotproben ermittelt. Zudem wurde die prä- vs. postoperative Belastung durch Etablierung eines nummerischen Scoresystems und Videoüberwachung der Tiere bewertet. 48 h nach der OP wurden die Ratten euthanasiert und relevante Organe und Gewebe für die histopathologische und immunhistochemische Untersuchung entnommen, um mögliche Anästhetika bedingte Irritationen sowie eine stressinduzierte Aktivierung von c-Fos-Proteinen in schmerz-assoziierten Gehirnregionen zu analysieren. Eine weitere Gruppe erhielt eine Inhalationsnarkose mit 3 % Isofluran (ISO) ohne OP und diente der Ermittlung von A und NA Basiswerten. Die AF lag bei 104 ± 1,05 Atemzüge/min, die HF bei 396 ± 2,10 Herzschläge/min und die SpO2 bei 95,7 ± 0,09 % (Angaben als Mittelwerte ± Standardfehler). Die Verwendung des MouseOx®-Pulsoximeters erwies sich als geeignete Methode zur Ermittlung von Wachwerten bei freibeweglichen Ratten. Alle CH-anästhesierten Tiere erreichten das cT-Stadium. Die Dauer der cT lag bei 49,14 ± 4,48 min, die Narkosedauer bei 155,66 ± 8,21 min. Während der Narkose zeigten die Tiere Tachykardie, Tachypnoe sowie eine geringgradig erniedrigte SpO2 und eine leichte Hypothermie. Erhöhte A/NA-Spiegel wiesen auf eine deutlich höhere intraoperative Stressbelastung in der CH-Gruppe hin. Auch iCS war in der CH-Gruppe im Vergleich zu VAA/VAA+A signifikant erhöht. Vom Tag der Anästhesie/OP auf den Folgetag verloren CH-Tiere durchschnittlich 9,4 g KGW. Postoperativ waren bei den Tieren keine bis geringe Anzeichen für Schmerz und/oder Disstress zu erkennen. Histopathologisch zeigten alle Ratten eine Peritonitis und Perihepatitis, 44 % der Tiere multifokale, akute Lebernekrosen und 22 % eine Perisplenitis. 95 % der mittels VAA anästhesierten Tiere erreichten die cT mit einer Dauer von 47,83 ± 7,05 min (VAA) bzw. 44,77 ± 5,27 min (VAA+A). Bei VAA-Tieren betrug die gesamte Narkosedauer 182,23 ± 20,58 min. Bei der VAA-Anästhesie insgesamt waren signifikante geschlechtsspezifische Unterschiede in der Latenzzeit bis zum Erreichen der 1. cT, der cT-Dauer und der Narkosedauer festzustellen. Die VAA-Anästhesie führte zu einer mittelgradiger Atemdepression und milden Hypothermie bei signifikant niedrigeren A/NA-Werten im Vergleich zu CH. Eine Nachdosierung ging mit einem vorrübergehenden signifikanten Abfall der SpO2 einher. Tiere der VAA+A-Gruppe erwachten 3,05 ± 0,21 min nach der s.c. Antagonisierung aus der Narkose. Anschließend zeigten sie starke Aufregung und Unruhe und ein verändertes Aktivitätsmuster, eine Stunde später teils Piloerektion sowie Ataxien. Die Körperkerntemperatur (KT) der VAA+A-Tiere sank innerhalb 1. Stunde nach der Antagonisierung signifikant ab. Einige Tiere wiesen eine Myositis als Folge der i.m. Applikation auf. Nach PROP-Anästhesie erreichten nur 36 % der Tiere das cT. Im Narkoseverlauf kam es bei diesen Tieren zu einer starken Beeinträchtigung der Atemfunktion. PROP-Tiere wiesen einen signifikanten Abfall der KT und Anzeichen verlängerter Sedation nach Wiedererwachen sowie die höchsten iCS-Gehalte auf. Insgesamt verstarben 4 von 11 Tieren wegen starker Atemdepression intra- oder postoperativ. Interessanterweise waren die nach ISO-Anästhesie ermittelten A/NA-Konzentrationen signifikant höher gegenüber allen Injektionsanästhesie-Gruppen. Die Ergebnisse dieser Studie belegen, dass die CH-Anästhesie mit gesteigerter Stresshormonfreisetzung einherging. Die Verwendung 3,6 %iger CH-Lösungen ist insbesondere wegen der massiven histopathologischen Befunde abzulehnen, obwohl die Tiere subjektiv ein scheinbar gutes Wohlbefinden aufwiesen. Die i.p. Applikation von Propofol erzeugte nur eine oberflächliche Anästhesie. Aufgrund der starken postanästhetischen Exzitationen sollte sie nur bedingt für kurze, nicht schmerzhafte Manipulation verwendet werden. Die initiale i.p. Propofol-Gabe mit anschließender i.v.-Infusion ist der reinen i.v. Gabe unterlegen und nicht empfehlenswert. Die VAA-Anästhesie ist für Ratten für stereotaktische OPs hingegen gut geeignet. Dabei ist eine exogene Wärmezufuhr auch nach der Antagonisierung zwingend notwendig, da das Thermoregulations-vermögen nach Wiedererwachen nicht ausreichend wiedererlangt wurde. Auf eine Belastung durch die unerwünschten Wirkungen der Antagonisierung wie Aufregung und Unruhe sowie durch die postanästhetische Hypothermie konnte nur anhand subjektiver Kriterien geschlossen werden. Hier sind weitere Untersuchungen nötig. Sofern kein Anästhesienotfall besteht, kann allerdings auf die Antagonisierung verzichtet werden, da in der Nachschlafzeit unter externer Wärmezufuhr (37 - 38 °C) kein wesentliches Risiko einer lebensbedrohlichen Hypothermie bzw. Kreislauf- und Atemdepression besteht. / Injectable anesthetics are still commonly used today, but mainly this is based on empirical data. In line with the German Animal Welfare Act, researches have to choose the least stressful anesthetic. However, scientific data about pain and distress during and after anesthesia are rare. To contribute to the refinement of animal experiments, we therefore investigated the suitability of different injectable anesthetics during a stereotactic surgery, for which kind of surgery injectable anesthetics are mostly used, in 69 male and female, 6 - 8 weeks old Sprague-Dawley rats. Rats were anesthetized with either chloral hydrate (CH: 3.6 %, 430 mg/kg intraperitoneal [i.p.]), with a complete reversible anesthesia (medetomidine 0.15, midazolam 2, fentanyl 0.0005 mg/kg intramuscular [i.m]) without (MMF) and with reversal (MMF with reversal) at the end of surgery (atipamezole 0.75, flumazenile 0.2, naloxone 0.12 mg/kg subcutaneous [s.c.]) or with propofol (PROP). The PROP-group received an i.p. bolus injection of propofol (120 mg/kg), shown to generate hypnosis in proceedings, followed by constant intravenous infusion (4 - 6 mg/kg/h) to achieve and maintain surgical tolerance (st). After reaching surgical anesthesia, indicated by loss of the pedal withdrawal reflex of the hind limb, a 60 minute surgery was undertaken. Rats with saline injection and without surgery served as control. Body weight of each rat was assessed 3 days before the surgery until 2 days after surgery. Over 3 days prior anesthesia and surgery, rats were adapted to wear a collar clip for MouseOx® pulse oximeter, used to gain basal of respiratory rate (RR), heart rate (HR) and peripheral oxygen saturation (pO2) values in awake and freely moving rats. During narcosis, monitoring was conducted via pulse oximeter, reflex tests (pedal withdrawal reflex, corneal and palpebral reflex) and rectal thermometer. All animals were placed on an electrical heating pad (37 °C). Levels of adrenalin and noradrenalin (A/NA) were analyzed at two designated time points via HPLC. Movement of the body or the extremities, audible vocalizations and teeth grinding were classified as defined criteria for the loss of st. If animals lost st during surgery, they received an additional anesthetic dose. Immunoactive corticosteron (iCS) in feces was determined by ELISA immunoassay before and after surgery. Moreover, different signs of pain and distress were scored by using a numerical pain scale and including video recordings. Rats were sacrificed 48 h after surgery for histopathological and immunhistochemical examination to analyze potential irritation on abdominal organs and tissue as well as stress-induced activation of c-Fos-protein in brain regions associated with pain. Furthermore, 5 rats were deeply anesthetized with 3 % isoflurane (ISO) and immediately sacrificed for reference values of A and NA. The RR assessed by MouseOx® pulse oximeter was 104 ± 1.05 brpm with a HR of 396 ± 2.10 bpm and an pO2 of 95.7 ± 0.09 % (results present the mean ± standard error). The MouseOx® pulse oximeter was found in the present study to be suitable to measure accurate values for awake and freely moving rats. All rats undergoing CH anesthesia reached st. The duration of the st was 49.14 ± 4.48 min, duration of narcosis was 155.66 ± 8.21 min. During the whole narcosis animal showed tachypnoea, tachycardia as well as minimal depressed pO2-levels and a slightly hypothermia. Elevated levels of A/NA indicated a high intraoperative distress. In addition, iCS levels were significantly elevated in comparison to the MMF-group. CH-rats lost 9.4 g of bodyweight from day of surgery to the following day. Overall, post-surgical little or no signs of pain and distress were observed after awakening from anesthesia, but all CH-rats exhibited peritonitis and perihepatitis, 44 % acute multifocal liver necrosis and 22 % perisplenitis. 95 % in the MMF-group reached satisfactory surgical anesthesia with duration of 47.83 ± 7.05 min (MMF) or 44.77 ± 5.27 min (MMF with reversal). Without reversal, MMF anesthesia lasted 182.23 ± 20.58 min. Gender-differences were noted in the latency to st, duration of st as well as duration of narcosis. Rats undergoing MMF anesthesia showed moderate depression of respiratory function and mild hypothermia. The A/NA levels were lower than in the CH-rats. Rats that received additional doses of MMF to maintain st showed a transient significant decrease of pO2. Core body temperature decreased significantly during 1 h after reversal. Post-mortem examination revealed myositis in some of the MMF-rats. MMF-rats with reversal awaked from anesthesia after 3.05 ± 0.31 min. Afterwards the rats were restless and agitated. After 1 h some of the rats exhibited piloerection and ataxic movements. Only 36 % of PROP-rats reached sufficient surgical anesthesia, accompanied by a pronounced respiratory depression. PROP-rats exhibited a significant decrease of core body temperature and signs of prolonged sedation after awakening from anesthesia. 4 of 11 rats died from respiratory failure during or after surgery. Surprisingly, levels of A/NA after ISO inhalation anesthesia were significantly higher compared to the injection groups. The results of this study indicate that CH anesthesia is associated with an increased liberation of stress hormones. The use of a 3.6 % solution of CH has to be refused especially because of the pathohistological findings, despite animals showed subjectively a good well-being. Propofol administered as an i.p. bolus produced only hypnosis. Therefore, i.p. injections are marely useful for short and non-painful procedures. However, post-anesthetic excitations represent limitations. The initial i.p. propofol bolus followed by intravenous infusion is therefore less suitable than an absolute intravenous administration. Thus, i.p. injections cannot be recommended. The complete reversible combination MMF is considered as suitable for stereotactic surgeries of Sprague-Dawley rats. There is an urgent need to continue heating after awakening, because thermoregulation is insufficiently restored after reversal of MMF anesthesia. Distress through the undesirable effects of the reversal like agitation and restlessness and through hypothermia was presumed only by subjective criteria. Further investigations are needed here. If there is no emergency situation, reversal should be avoided. In case of permanent external heating (37 - 38 °C) there is no major risk of life-threatening hypothermia or depression of respiratory or cardiovascular function during sleeping time.

Diss. (sammanfattning) Linköping : Univ., 2003. / Härtill 4 uppsatser.

Introduktion: Hypotermi är en av de vanligaste komplikationerna till anestesi. Konsekvenserna av hypotermi är bland annat rubbningar på koagulationen med ökad blödningsrisk, sårinfektioner och kardiella komplikationer. Patienter har beskrivit hypotermi som den värsta upplevelsen under sjukhusvistelsen och värderar det högre än den kirurgiska smärtan. Syfte: Att beskriva anestesisjuksköterskors erfarenheter av att förebygga hypotermi i samband med anestesi Metod: Studien har en kvalitativ ansats. Tio anestesisjuksköterskor, verksamma på en operationsavdelning i Västra Götalands län och Region Västernorrland medverkade i studien. Sjukhusen som inkluderades i studien liknade varandra till storlek och i vilken typ av ingrepp som utfördes där. Kvalitativa semistrukturerade intervjuer användes för att samla data och intervjuerna analyserades med kvalitativ innehållsanalys. Resultat: Analysen resulterade i tre kategorier och visar att förebyggandet av hypotermi är viktigt enligt anestesisjuksköterskor och att medvetenheten kring hypotermi och hur det förebyggs har ökat. Samtidigt beskrevs att mer skulle kunna göras. Anestesisjuksköterskorna upplevde att det finns bra rutiner som ökar tryggheten i förebyggandet av hypotermi. Det beskrevs dock som svårt att hinna hålla sig uppdaterad och vara på framkant i det senaste kring forskning. För att öka förutsättningarna och för att kunna vidareutveckla personalgruppen, i hypotermiförebyggande åtgärder, behövs ett ansvarsområde kring hypotermi. Slutsats: Kunskap, erfarenhet, forskning och samarbete i operationslaget är grundläggande förutsättningar för att hypotermi ska förebyggas på bästa sätt. Anestesisjuksköterskorna upplever inte hypotermi som något vardagsproblem, men menar att mer skulle kunna göras. Det behövs mer forskning på hur stor nytta ett särskilt ansvarsområde inom hypotermiprevention skulle utgöra. / Background: Hypothermia is one of the most common complications of anesthesia. The consequences of hypothermia include disorders of coagulation with increased risk of bleeding, wound infections and cardiac complications. Patients have described hypothermia as the worst experience during hospitalization and value it higher than the surgical pain. Aim: The aim of this study was to describe the anesthesia nurse's experience in preventing hypothermia associated with anesthesia. Method: The study has a qualitative approach. Ten anesthesia nurses, active in an operations department in Västra Götaland county and the region of Västernorrland, participated in the study. The hospitals included in the study were similar in size and what type of surgery performed there. Qualitative semi- structured interviews were used to gather data and the interviews were analyzed with a qualitative content analysis. Results: The analysis resulted in three categories and shows that prevention of hypothermia is important according to the anesthesia nurses and that awareness about hypothermia and its prevention has increased. At the same time, it was described that more could be done. The anesthetic nurses felt that there are good practices that increase safety in the prevention of hypothermia. However, it was described as difficult to keep themselves up to date of the latest research. In order to increase the prerequisites and to further develop the staff group, in hypothermia prevention, a person responsible for hypothermia prevention is needed. Conclusion: Knowledge, experience, research and collaboration in the operations team are fundamental factors for preventing hypothermia in the patient, in the best possible way. The anesthetic nurses do not experience hypothermia as a daily problem but mean that more could be done, within that area. More research is needed regarding the usefulness of a person responsible for hypothermia prevention would represent.

Submitted by CAIO JOSÉ XAVIER ABIMUSSI null (caioabimussi@fmva.unesp.br) on 2016-01-17T16:54:36Z No. of bitstreams: 1 TESE_VERSÃO FINAL_CORRIGIDA.pdf: 2286468 bytes, checksum: 496c8f6ffc7595636c5c52c061679bc7 (MD5) / Approved for entry into archive by Juliano Benedito Ferreira (julianoferreira@reitoria.unesp.br) on 2016-01-18T15:52:49Z (GMT) No. of bitstreams: 1 abimussi_cjx_dr_araca.pdf: 2286468 bytes, checksum: 496c8f6ffc7595636c5c52c061679bc7 (MD5) / Made available in DSpace on 2016-01-18T15:52:49Z (GMT). No. of bitstreams: 1 abimussi_cjx_dr_araca.pdf: 2286468 bytes, checksum: 496c8f6ffc7595636c5c52c061679bc7 (MD5) Previous issue date: 2015-12-14 / Não recebi financiamento / Objetivou-se avaliar a anestesia raquidiana com ropivacaína em cães alterando a baricidade do anestésico local, investigando as alterações hemodinâmicas e complicações. Foram utilizados seis cães, Beagle, 4 anos, submetidos a anestesia inalatória com isofluorano e aos tratamentos: Ghipo = anestesia raquidiana hipobárica (0,5 mL NaCl 0,9% + 0,5 mL ropivacaína 0,75%); Giso = anestesia raquidiana isobárica (0,5 mL NaCl 1,53% + 0,5 mL ropivacaína 0,75%); Ghiper = anestesia raquidiana hiperbárica (0,5 mL glicose 10% + 0,5 mL ropivacaína 0,75%). Após indução anestésica e manutenção com isofluorano, os animais foram posicionados em decúbito lateral direito para a passagem de um cateter de artéria pulmonar pela veia jugular esquerda. Após esse procedimento, a punção subaracnóide foi realizada entre L5-L6 com uma agulha espinhal 22G, seguida da administração de 1 mL de anestésico local em 1 min. Os animais foram mantidos por 60 minutos anestesiados em decúbito ventral. A FC, f, PAM, DC, PAPm e TºC apresentaram aumento progressivo em todos os grupos enquanto que a PCPm, apenas no GHIPO, aumentou ao longo de todos os momentos. O IRPT no GISO apresentou valores significativamente superiores no M1, M5 e M10 comparado aos demais grupos, exceto no M5, em que o GISO diferiu somente do GHIPER. O IRVP no GISO aumentou no M5 em comparação ao MB. Foram observados efeitos adversos como déficit motor unilateral, atonia vesical, excitação, dor aguda e quemose. Conclui-se que as alterações hemodinâmicas não foram relevantes, embora a anestesia inalatória com isofluorano tenha influído sobre os resultados obtidos. / The aim of the study was to assess spinal anesthesia with ropivacaine in dogs altering the local anesthetic agent’s baricity in order to investigate hemodynamic changes and complications. Six beagle dogs aged 4 years old were anesthetized with isoflurane and subjected to the treatments: Ghypo = spinal anesthesia with hypobaric ropivacaine (0.5 mL of 0.9% NaCl + 0.5 mL ropivacaine at 0,75%); Giso = isobaric spinal anesthesia (0.5 mL of 0,906% NaCl + 0.5 mL ropivacaine at 0,75%); Ghyper = hyperbaric spinal anesthesia (0.5 mL of 10% glucose + 0.5 mL ropivacaine at 0.75%). After induction to anesthesia and maintenance with isoflurane, animals were positioned in right lateral recumbency for pulmonary artery catheterization through the left jugular vein. Rightafter, spinal anesthesia was performed between L5-L6 using a 22G Quincke tip needle, followed by administration of 1 mL of local anesthetic during 1 minute. Animals were maintained under anesthesia for 60 minutes in ventral recumbency. HR, FR, MAP, CO, mPAP and body temperature progressively increased in all groups. whereas PCWP increased only in GHYPO at all time points. The TPRI showed significantly higher values in GISO at M1, M5 and M10 compared to the other groups, except for M5, during which GISO differed only from GHYPER. The PVRI increased at M5 compared to MB in GISO. Side effects such as unilateral motor deficit, bladder atony, excitation, acute pain and chemosis were observed. In conclusion, the hemodynamic changes were not relevant, although inhalation anesthesia with isoflurane might have influenced the results.

Orientador: Carlos Augusto Araujo Valadão / Banca: Newton Nunes / Banca: Paulo Sérgio Patto dos Santos / Banca: Aury Nunes de Moraes / Banca: Nilson Oleskovicz / Resumo: A administração intravenosa de anestésicos voláteis halogenados pode ser considerada uma alternativa à aplicação pela via inalatória, e neste contexto, as formulações emulsificadas têm mostrado segurança, eficiência e bons planos anestésicos. Neste estudo, objetivou-se comparar os efeitos hemodinâmicos e respiratórios das administrações intravenosa e inalatória de isofluorano em cães, após a determinação da taxa de infusão intravenosa de 6,99 mL/kg/h deste halogenado em emulsão lipídica. Para tanto, foram utilizados oito cães, os quais formaram três grupos distintos: grupo IV - anestesia intravenosa por infusão de emulsão lipídica com isofluorano; grupo E - anestesia inalatória com isofluorano, associada à infusão intravenosa de emulsão lipídica sem o halogenado; e grupo IN - anestesia inalatória com isofluorano, associada à infusão intravenosa de solução de NaCl 0,9%. Foram evidenciadas diminuições da contratilidade cardíaca, índice cardíaco e pressão arterial sistêmica a partir de 10 e 40 minutos de anestesia, respectivamente, nos grupos IV e E. A hipotensão no grupo IV resultou em acidose metabólica, porém, hipoxemia não foi observada. O grupo IN apresentou manutenção do índice cardíaco, apesar de reduções do índice de resistência vascular sistêmica e pressão arterial. A taxa de infusão intravenosa determinada foi efetiva na manutenção de plano de anestesia cirúrgica em cães. As infusões intravenosas de isofluorano e emulsão lipídica causaram depressão cardíaca e hipotensão. Em relação à função respiratória, nenhum dos grupos mostrou efeitos deletérios. / Abstract: The intravenous administration of halogenated anesthetics can be considered an alternative to the application by the inhalation route, moreover, emulsified formulations have been showing safety, efficiency and appropriated anesthetic depth. The aim of this study was to compare the effects of isoflurane anesthesia by intravenous or inhalational route on hemodynamic and respiratory variables, after the determination of the intravenous infusion rate of 6.99 mL/kg/h of this anesthetic in lipid emulsion, in dogs. Therefore, eight dogs were distributed in three different protocols: IV group - intravenous anesthesia with emulsified isoflurane; E group - inhalational anesthesia with isoflurane associated to intravenous infusion of lipid emulsion; and IN group - inhalational anesthesia with isoflurane associated to intravenous infusion of 0.9% NaCl solution. The results regarding IV and EM groups revealed decreases of heart contractility, cardiac index and systemic blood pressure starting from 10 and 40 minutes of anesthesia, respectively. The hypotension in the IV group resulted in metabolic acidosis, however, hypoxemia was not observed. The IN group demonstrated maintenance of cardiac index, despite of reduction of the blood pressure and systemic vascular resistance index. The intravenous infusion rate determined was effective in the maintenance of an anesthetic depth of general anesthesia in dogs. The intravenous infusions of isoflurane and lipid emulsion caused cardiac depression and hypotension. In relation to respiratory function, the inhalational route and the intravenous infusions of isoflurane and lipid emulsion did not result in harmful effects. / Doutor

INTRODUÇÃO: A cetamina por via regional ou sistêmica melhora a analgesia pós-operatória. A hipótese testada nesse estudo foi a de que o uso profilático da cetamina S(+) por via peridural é melhor que a cetamina S(+) administrada por via venosa durante toda a anestesia, para o controle da dor pós-operatória em crianças submetidas a operações ortopédicas. MÉTODOS: 60 pacientes pediátricos foram aleatoriamente distribuídos em dois grupos de 30 pacientes. Os pacientes do grupo I receberam por via peridural 1 ml.kg-1 de ropivacaína a 0,2%, acrescida de 0,5 mg.kg-1 de cetamina S(+). Os pacientes do grupo II receberam por via peridural a mesma dose de ropivacaína, e antes da incisão cirúrgica receberam por via venosa infusão contínua de cetamina S(+) na dose de 0,2 mg.kg-1.h-1, interrompida ao final da sutura da pele. A mesma técnica anestésica geral complementar foi utilizada para os dois grupos. A dor foi avaliada pela escala Oucher de faces. Também foi avaliado o tempo para a primeira dose do analgésico de resgate e o consumo de morfina nas primeiras 24 h. Os resultados receberam tratamento estatístico pelo teste t de Student, não pareado, para comparação entre os dados demográficos dos grupos, tempo de duração do ato cirúrgico e tempo para recuperação, o teste do Qui quadrado e o teste exato de Fisher para análise de dados não paramétricos, e o teste de análise de variância, para comparar os valores da pressão arterial e da frequência cardíaca. RESULTADOS: Não foram encontradas diferenças estatísticas quanto à intensidade da dor, o tempo para a primeira dose de analgésico de resgate e o consumo de morfina entre os grupos. O valor da frequência cardíaca foi estatisticamente maior no grupo II do que no grupo I. CONCLUSÕES: A intensidade da dor pós-operatória, o tempo para a primeira dose de analgésico de resgate e o consumo de morfina foi semelhante com o uso da cetamina S(+) por via peridural ou sistêmica. A incidência de efeitos adversos foi semelhante com o uso da cetamina por via peridural ou sistêmica, com exceção da frequência cardíaca que foi estatisticamente maior no grupo em que a cetamina S(+) foi empregada em infusão contínua por via venosa. / INTRODUCTION: Ketamine by neuroaxial as well as intravenousroute could improve postoperative analgesia. The hypothesis to be tested here was that the prophylactic epidural use the S(+) ketamine, added to a local anesthetic solution, would improve postoperative pain control after orthopedic surgical procedures in pediatric patients, when compared to intravenous administration. METHODS: 60 pediatric patients were randomly assigned to one of two groups of 30 patients each named I, and II. Before the surgical incision the patients of group I, received by epidural route 1 ml.kg-1 0.2% ropivacaine and 0.5 mg. kg-1 S(+) ketamine. Patients of group II received by epidural route the same ropivacaine dose and 0.2 mg.kg-1h-1 S(+) ketamine IV infusion through all surgical procedure long suspended after the skin suture. The same complement anesthesia technique was provided to all patients. The pain was assessed by Oucher scale, time elicited to first rescue analgesia and 24 h morphine consumption. All data were statistically managed as follow: t test for demographics, surgical procedure duration and time to postoperative recovery; square CHI and Fisher test for nonparametric data and ANOVA for comparing the values of arterial pressure and heart rate. RESULTS: there were no statistical differences on time elicited to the first rescue analgesia, degree of pain complaint or morphine consumption when compared groups I and II. Mild tachycardia was observed for group II with statistical differences when compared to group I (P<0.05). CONCLUSION: the time elicited to the first rescue analgesia, degree of pain complaint and morphine consumption were similar with S(+) ketamine, by epidural and intravenous either. The adverse effects incidence was similar except for the heart rate statistically higher for the group where S(+) ketamine was employed by continuous intravenous route.

Introdução. A morbi-mortalidade durante e após anestesia para aneurismectomia de aorta abdominal é alta, pois esta doença acomete pacientes após a sétima década de vida e que possuem várias doenças concomitantes. Objetivos. Analisar e discutir as condutas anestésicas utilizadas nos períodos pré e intra-operatório no Serviço de Anestesiologia do HCFMRP-USP. Casuística e Método. Foram analisados os prontuários de 104 pacientes submetidos à aneurismectomia de aorta no tocante às condutas utilizadas pelos anestesiologistas para a condução destes casos. Resultados. Apenas um paciente possuía menos de 40 anos de idade, 76,80% estavam na sétima ou oitava década de vida e 88,46% eram do sexo masculino. A hipertensão arterial acometeu 70,19% dos pacientes e 26,92% possuíam coronariopatia. Pacientes com obesidade foram a minoria (26,92%). O ecocardiograma pré-operatório demonstrou que a grande maioria dos pacientes apresentava função ventricular normal. A cirurgia foi realizada em regime de urgência em 7,69% dos casos. A anestesia geral exclusiva foi realizada em 17 pacientes e associada com a peridural em 57 pacientes, com a raquianestesia em 11 e com a raqui-peri combinadas em 19. O tempo cirúrgico variou de 120 a 510 minutos enquanto que o tempo de clampeamento aórtico variou de 30 a 165 minutos. Houve um óbito no período intra-operatório e a causa foi choque hipovolêmico e 10 óbitos até o vigésimo dia pós-operatório. Sessenta e seis pacientes receberam concentrado de papa de hemácias durante o período intra-operatório, mas só em 43,27% desses casos a indicação esteve suportada por exame laboratorial. Oitenta pacientes foram extubados ainda na sala de cirurgia, enquanto que os demais (23) permaneceram intubados no período pós-operatório e 19 necessitaram de suporte ventilatório que teve tempo que variou de 3 a 96 horas com média de 42,31 horas. Apenas quatro pacientes fizeram pós-operatório imediato no Centro de Terapia Intensiva enquanto que os demais permaneceram na Sala de Recuperação Pós-Anestésica. Conclusão. Não existe um protocolo único para a realização de anestesia para aneurismectomia de aorta no HCFMRP-USP e a técnica anestésica utilizada não influenciou o morbi-mortalidade. / Introduction. The morbidity and mortality during and after anesthesia for aneurysmectomy of the abdominal aorta are high since this disease affects patients after the seventh decade of life who have several concomitant diseases. Objectives. To analyze and discuss the anesthetic conducts used during the preoperative and intra-operative periods at the Service of Anesthesiology of HCFMRP-USP. Cases and Method. The medical records of 104 patients submitted to aneurysmectomy of the aorta were analyzed regarding the conducts used by the anesthesiologists for the management of these cases. Results. Only one patient was less than 40 years old, 76.80% were in he seventh or eighth decade of life, and 88.46% were male. Arterial hypertension was present in 70.19% of the patients and 26.92% had coronary artery disease. Obese patients were a minority (26.92%). The preoperative echocardiogram demonstrated that most patients had normal ventricular function. Surgery was performed on an emergency basis in 7.69% of cases. Seventeen patients received exclusive general anesthesia, while general anesthesia was associated with peridural anesthesia in 57, with rachi-anesthesia in 11 and with combined rachi-peridural anesthesia in 19. Surgical time ranged from 120 to 510 minutes and time of aortic clamping ranged from 30 to 165 minutes. One death occurred intra-operatively due to hypovolemic shock and 10 patients died up to the 20th postoperative day. Sixty-six patients received a red blood cell concentrate intra-operatively, but this indication was supported by a laboratory exam in only 43.27% of these cases. Eighty patients were extubated while still in the operating room while the remaining 23 continued to be intubated during the postoperative period and 19 required ventilatory support lasting 3 to 96 hours (mean duration: 42.31 hours). Only four patients spent the immediate postoperative period in the Intensive Care Unit, while the remaining ones stayed in the Post-Anesthesia Recovery Room. Conclusion. There is no single protocol for the application of anesthesia for aneurysmectomy of the aorta at HCFMRP-USP and the anesthetic technique used did not influence morbidity-mortality.