Max Bermann

The present study was designed to investigate the effect of propranolol on portal pressure of patients with alcoholic cirrhosis and portal hypertension and to correlate these effects with clinical and laboratory parameters. The mean baseline hepatic venous pressure gradient in the 50 patients studied was of 18.2 ± 4.1 mm Hg. It decreased significantly2 hr after the oral administration of 40 mg of propranolol to 15.7 ± 4.2 mm Hg (a mean reduction of 13.4 ± 17%). This reduction in hepatic venous pressure gradient resulted mainly from a decrease in mean wedged hepatic venous pressure. There was no correlation between the decrease in hepatic venous pressure gradient and the decrease in heart rate. When results were analyzed individually, only 15 (30%) showed a large decrease in hepatic venous pressure gradient (>20%), 15 (30%) showed a moderate decrease (10 to 19%), and in 20 patients (40%) there was no reduction or an increase in hepatic venous pressure gradient. Comparison of “responders” (those that reduced hepatic venous pressure gradient >10%) and “nonresponders” (hepatic venous pressure gradient reduction <10%) showed no significant differences in baseline laboratory and hemodynamic parameters, in the severity of the liver disease, in theheart rate and blood pressure response to propranolol, nor in the propranolol plasma levels achieved 2 hr after propranolol administration. Propranolol plasma levels correlated with the reduction in heart rate but not with the reduction in hepatic venous pressure gradient. Of 14 nonresponders to 40 mg of propranolol who received additional doses, six showed a reduction inhepatic venous pressure gradient. We conclude that, although propranolol reduces the mean portal pressure in patients with alcoholic cirrhosis and portal hypertension, this response is not uniform. Twenty percent of cirrhotic patients do not show any reduction in portal pressure even after maximal doses of propranolol. There is no clear explanation for this variable response; pharmacologic and/or hemodynamic factors may be involved. Neither the heart rate response to propranolol nor the propranolol plasma concentrations were found to be useful in assessing the portal pressure response to propranolol.

S250 INTRODUCTION: Epidural-PCA fentanyl for post c/s pain provides excellent analgesia but is sometimes associated with pruritus which may be distressing to patients. IV naloxone [1] resulted in a prompt relief of symptoms. Such patients in our institution have been treated by a floor nurse with incremental doses of IV 0.04 mg naloxone. To determine whether patient-administered IV naloxone enhanced patient control and decreased need for hospital staff intervention, we conducted, with IRB approval, a prospective, randomized study of 148 consenting patients who received epidural fentanyl for post c/s pain. METHODS: The patients were randomly allocated in PACU to two groups. Group I: (n=74) received patient administered IV naloxone via PCA device (Abbott Life-Care-Abbott Laboratories, Chicago, IL.), PCA dose 0.04 mg (5 ml) and a lockout time interval of 5 min. Group II: (n=74) upon request from a floor nurse were able to receive IV naloxone 0.04 mg bolus dose every 5 min. The patients were evaluated at 1, 2, and 4 hrs, then every 4 hrs for 24 hrs for: fentanyl and naloxone total doses, fentanyl side effects, VAS pain scores, itching score, overall satisfaction and satisfaction from naloxone treatment. RESULTS: There were no differences among the groups with respect to age, height, weight, and parity data, pain and itching scores, incidence of sedation, nausea, or vomiting, overall satisfaction and satisfaction from itching treatments. GI patients were more likely to complain of itching (79.7% vs. 68.9% of the controls, Chi square = 2.26, 1 df), to receive naloxone treatment (70.3% vs. 37.8% for controls, Chi square = 15.67, 1 df), used more naloxone in 24 hrs (2.4 mg vs. 0.22 mg for the controls, P=0.3), and received more boluses of fentanyl (6.5 ml vs. 4.6 for the controls, P=0.19). However, the total fentanyl administered was comparable between the groups (438.8 [micro sign]g vs. 422.4 [micro sign]g for controls). DISCUSSION: Patient-administered IV naloxone enhanced patient control of treatment of epidural fentanyl-induced itching and decreased need for hospital staff intervention. The significantly greater amount of naloxone used by the self-administered group is strongly suggestive of the need to treat itching in patients who receive epidural-PCA fentanyl for post c/s pain. We believe that giving these patients the ability to administer naloxone on demand makes them more aware of itching that otherwise might go untreated.