Anesthesiology 2001 Sep;95(3):814
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PMID: 11575569, UI: 21459390
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Anesthesiology 2001 Sep;95(3):801-3
Department of Anesthesiology, Orthopedic University Clinic of Zurich/Balgrist, Switzerland.
PMID: 11575560, UI: 21459381
Anesthesiology 2001 Sep;95(3):771-80
Department of Anesthesia & Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories. karmakar@cuhk.edu.hk
PMID: 11575553, UI: 21459374
Br J Anaesth 2001 Apr;86(4):598-9
PMID: 11573647, UI: 21457550
Br J Anaesth 2001 Apr;86(4):572-5
Department of Surgery and Anaesthesia, Central Hospital of Seinajoki, Finland.
We studied the analgesic efficacy of tramadol 2 mg kg(-1) for post-operative analgesia after day-case adenoidectomy in children aged 1-3 yr. Eighty children were allocated randomly to receive tramadol 2 mg kg(-1) i.v. or placebo immediately after induction of anaesthesia. Anaesthesia was induced with alfentanil 10 microg kg(-1) and propofol 4 mg kg(-1) followed by mivacurium 0.2 mg kg(-1) for tracheal intubation. Anaesthesia was continued with sevoflurane in nitrous oxide and oxygen. All children were given ibuprofen rectally at approximately 10 mg kg(-1) before the start of surgery. Post-operative pain and recovery assessments were performed by a nurse blinded to the analgesic treatment using the Aldrete recovery score, the pain/discomfort scale and measurement of recovery times. Rescue medication (pethidine in increments of 5 mg i.v.) was administered according to the pain scores. A post-operative questionnaire was used to evaluate the need for analgesia at home up to 24 h after operation. Rescue analgesic at home was rectal or oral ibuprofen 125 mg. Children in the tramadol group required fewer pethidine doses than those in the placebo group (P = 0.014). Forty-five per cent of children receiving tramadol did not require post-operative analgesia at all compared with 15% of children receiving placebo (P = 0.003). Recovery times and the incidence of adverse effects were similar in the two groups in the recovery room and at home. The requirement for rectal ibuprofen at home did not differ between groups.
PMID: 11573636, UI: 21457539
Br J Anaesth 2001 Apr;86(4):506-12
Nuffield Department of Anaesthetics, University of Oxford, UK.
The Oxford Record Linkage Study (ORLS; an epidemiological database) was used to examine relationships between intercurrent cardiovascular drug therapy and cardiac death within 30 days of elective or emergency/urgent surgery under general anaesthesia. Cases identified from the ORLS were paired with matched control patients. Clinical details were obtained from the patients' medical notes. In elective surgical patients, there was no effect of beta-adrenoceptor or calcium entry channel blockade, diuretics or digoxin on cardiac death after adjusting for confounding variables. Use of nitrates was associated with an odds ratio of 4.79 [95% confidence interval (CI) 1.01-22.72] for cardiac death after adjustment for confounding by a history of angina and residual age difference. In emergency/urgent patients, there were significant univariate associations with cardiac death for intercurrent use of angiotensin converting enzyme (ACE) inhibitors (odds ratio 1.18) and diuretics (odds ratio 4.95; 95% CI 1.82-13.46). However, neither maintained significance after adjustment for the confounding effect of cardiac failure. We conclude that, with the possible exception of the use of nitrates in elective surgical patients, chronic intercurrent drug treatment alone does not significantly affect the odds of cardiac death within 30 days of surgery.
PMID: 11573623, UI: 21457526
Br J Anaesth 2001 Apr;86(4):497-505
Institute of Anaesthesiology, University Hospital, Zurich, Switzerland.
Transoesophageal echocardiography (TOE) has gained widespread acceptance among cardiac anaesthetists as a tool to facilitate peri-operative decision-making. This observational study analyses the impact of TOE and its inter-observer variability on intra-operative patient management during cardiac and major vascular surgery. From June 1996 to December 1998, standardized reports were obtained from 11 anaesthetists in 1891 adult cardiac and vascular surgery patients undergoing routine biplane or multiplane TOE. Inter-observer variability and the difference between variables of interest were tested using the chi-squared test or factorial analysis of variance as appropriate. TOE examinations were performed before and after the operation; 1,673 (88.5%) patients underwent cardiopulmonary bypass (CPB), and 218 (11.5%) patients had surgery without CPB, including 42 (2.2%) coronary revascularizations. In 923 patients (49%), TOE provided additional information that influenced the patient's therapy. In 968 patients (51%), TOE had only minor or no impact on clinical decision-making. In two patients (0.10%) the scheduled operation was not performed, and in another two patients the TOE examination led to major complications. Observer-dependent variables were: implications of TOE for intraoperative decision-making (P<0.0001), estimation of image quality (P < 0.0001), pre-operative left ventricular fractional area change (FAC) (P = 0.0026), difference between pre-operative FAC and post-operative FAC (P = 0.033), and requests for supervision (P < 0.0001). There was no significant difference in the case mix between observers. TOE had an important impact on intraoperative patient management. Inter-observer variability was significant for several variables but not for the frequency of additional surgical procedures.
PMID: 11573622, UI: 21457525
Br J Anaesth 2001 Apr;86(4):469-73
PMID: 11573618, UI: 21457521
Br J Anaesth 2001 Jun;86(6):903
PMID: 11573614, UI: 21457517
Br J Anaesth 2001 Jun;86(6):901-2
PMID: 11573612, UI: 21457515
Br J Anaesth 2001 Jun;86(6):899-900
PMID: 11573610, UI: 21457513
Br J Anaesth 2001 Jun;86(6):891-3
Department of Anaesthesia, Barnsley District General Hospital NHS Trust, UK.
We describe the management of a 23-yr-old woman with extreme needle and mask phobia, presenting for an emergency Caesarean section for fetal distress. She also suffered from spina bifida cystica with no sensation from mid thigh. Regional anaesthesia, rapid sequence induction, and gaseous induction were not possible. She was managed successfully with i.m. ketamine followed by a more conventional anaesthetic technique.
PMID: 11573604, UI: 21457507
Br J Anaesth 2001 Jun;86(6):859-68
Sir Humphry Davy Department of Anaesthesia, St Michael's Hospital, Bristol, UK.
Reflex cardiovascular depression with vasodilation and bradycardia has been variously termed vasovagal syncope, the Bezold-Jarisch reflex and neurocardiogenic syncope. The circulatory response changes from the normal maintenance of arterial pressure, to parasympathetic activation and sympathetic inhibition, causing hypotension. This change is triggered by reduced cardiac venous return as well as through affective mechanisms such as pain or fear. It is probably mediated in part via afferent nerves from the heart, but also by various non-cardiac baroreceptors which may become paradoxically active. This response may occur during regional anaesthesia, haemorrhage or supine inferior vena cava compression in pregnancy; these factors are additive when combined. In these circumstances hypotension may be more severe than that caused by bradycardia alone, because of unappreciated vasodilation. Treatment includes the restoration of venous return and correction of absolute blood volume deficits. Ephedrine is the most logical choice of single drug to correct the changes because of its combined action on the heart and peripheral blood vessels. Epinephrine must be used early in established cardiac arrest, especially after high regional anaesthesia.
PMID: 11573596, UI: 21457499
Br J Anaesth 2001 Jun;86(6):798-804
Department of Anaesthesiology, University of Heidelberg, Germany.
Epidural anaesthesia is an important analgesia technique for obstetric delivery. During pregnancy, however, obesity and oedema frequently obscure anatomical landmarks. Using ultrasonography, we investigated the influence of these changes on spinal and epidural anatomy. We examined 53 pregnant women who were to receive epidural block for vaginal delivery or Caesarean section. The first ultrasound imaging was performed immediately before epidural puncture; the follow-up scan was done 9 months later. The ultrasound scan of the spinal column was performed at the L3/4 interspace in transverse and longitudinal planes, using a Sonoace 6000 ultrasonograph (Kretz, Marl, Germany) equipped with a 5.0-MHz curved array probe. We measured two distances from the skin to the epidural space: the minimum (perpendicular) and the maximum (oblique) needle trajectory. The quality of ultrasonic depiction was analysed by a numerical scoring system. An average weight reduction of 12.5 kg had occurred by the follow-up examination. During pregnancy, the optimum puncture site available on the skin for epidural space cannulation was smaller, the soft-tissue channel between the spinal processes was narrower, and the skin-epidural space distance was greater. The epidural space was narrower and deformed by the tissue changes. The visibility of the ligamentum flavum, of the dura mater and of the epidural space decreased significantly during pregnancy. Nevertheless, ultrasonography offered useful pre-puncture information. Thus far, palpation has been the only available technique to facilitate epidural puncture. Ultrasound imaging enabled us to assess the structures to be perforated. We anticipate that this technique will become valuable clinically.
PMID: 11573586, UI: 21457489
Br J Anaesth 2001 Jun;86(6):769-76
Division of Cardiovascular Anaesthesia, University Hospital, Zurich, Switzerland.
The level of sedation of 28 patients undergoing elective coronary artery bypass grafting with fentanyl-propofol anaesthesia was monitored with bispectral analysis (BIS), spectral edge frequency, and band power of the electroencephalogram. Fourteen patients underwent hypothermic cardiopulmonary bypass (CPB) (32 degrees C, group H), and 14 normothermic CPB (group N). The level of sedation was measured with Observer's Assessment of Alertness/Sedation Score and with Ramsay Sedation Score. BIS was the only EEG measurement that paralleled the clinical course of the patients' sedation level. Values (median, 95% confidence intervals (CI)) changed significantly over time in both groups (P<0.0001). In group H, BIS decreased from 97 (95, 99) the day before surgery to 48 (44, 52) after tracheal intubation, to 46 (41, 52) before going off CPB, to 91 (85, 97) immediately before extubation. In group N, values were 93 (91, 97) the day before surgery, 53 (47, 59) after tracheal intubation, 48 (43, 53) before going off CPB, and 90 (84, 96) before extubation. During CPB, BIS values were significantly different between the two groups. Group H had a median of 41 (95% CI, 39, 42), and group N had a median of 49 (95% CI, 48, 51, P<0.0001). Peak values of all other processed EEG parameters during anaesthesia and surgery overlapped with values from the day before, when patients had no sedating medication, and these values did not correlate to the patients' course of sedation during the study. There was no explicit recall of the surgery in either group. During the phases of anaesthesia and surgery without CPB, the progression of BIS levels was comparable with previously published data for non-cardiac surgery. During normothermic CPB, the highest BIS values were close to values representing insufficient depth of sedation. It remains to be elucidated whether the much lower BIS values in the hypothermic group were solely a result of brain cooling or if increased serum propofol concentrations, because of slowed pharmacodynamics during hypothermia, also contributed.
PMID: 11573582, UI: 21457485
Br J Anaesth 2001 Jun;86(6):749-53
PMID: 11573579, UI: 21457482
Br J Anaesth 2001 Jun;86(6):746-9
PMID: 11573578, UI: 21457481
Br J Anaesth 2001 Mar;86(3):459
PMID: 11573551, UI: 21457454
Br J Anaesth 2001 Mar;86(3):457; discussion 457-8
PMID: 11573549, UI: 21457452
Br J Anaesth 2001 Mar;86(3):453-4
PMID: 11573543, UI: 21457446
Br J Anaesth 2001 Mar;86(3):349-53
Royal Liverpool Children's Hospital, UK.
In children with congenital cyanotic heart disease, right-to-left intracardiac shunting causes an obligatory difference between arterial and end-tidal carbon dioxide tension (PaCO2-PE'CO2) as venous blood, rich in carbon dioxide, is added to the arterial circulation. This obligatory PaCO2-PE'CO2 difference, which can be predicted from knowledge of oxygen saturation, haemoglobin concentration and PaCO2, increases as oxygen saturation decreases, most markedly when the haemoglobin concentration is high. A second possible cause of the PaCO2-PE'CO2 difference is the effect of pulmonary hypoperfusion caused by the shunt. We studied 60 children undergoing cardiac surgery and compared the predicted the PaCO2-PE'CO2 difference with measured values to investigate the extent to which additional factors influence the clinically observed PaCO2-PE'CO2. In many children, observed values were much greater than predicted, which is compatible with some degree of pulmonary hypoperfusion. However, this was not felt to represent the complete picture in all patients. Another cause of ventilation-perfusion mismatch was suspected in those children who showed a considerable improvement in oxygen saturation during ventilation with an increased FIO2. We believe that pulmonary congestion caused by large left-to-right shunts may further increase the PaCO2-PE'CO2 difference.
PMID: 11573523, UI: 21457426
Br J Anaesth 2001 Mar;86(3):345-8
Department of Anaesthesia, Ghent University, Gent, Belgium.
In an in vitro study, less compound A was formed when a KOH-free carbon dioxide absorbent was used. To confirm this observation we used a lung model in which carbon dioxide was fed in at 160 ml min(-1) and sampling gas was taken out for analysis at 200 ml min(-1); ventilation aimed for a PE'CO2 of 5.4 kPa. The soda lime canister temperatures in the inflow and outflow ports (Tin and Tout) were recorded. In six runs of 240 min each, a standard soda lime, Sodasorb (Grace, Epernon, France) was used and in eight runs KOH-free Sofnolime (Molecular Products, Thaxted, UK) was used. Liquid sevoflurane was injected using a syringe pump to obtain 2.1% E'. Compound A was measured by capillary gas chromatography combined with mass spectrometry. Median (range) compound Ainsp increased to a maximum of 22.7 (7.9) ppm for Sodasorb and 33.1 (20) for Sofnolime at 60 min and decreased thereafter; the difference between groups was significant (P<0.05) at each time of analysis up to 240 min. The canister temperatures were similar in both groups and increased to approximately 40 degrees C at 240 min. Contrary to expectation, compound A concentrations were greater with the KOH-free absorbent despite similar canister temperatures with both absorbents.
PMID: 11573522, UI: 21457425
Br J Anaesth 2001 Sep;87(3):502-4
Department of Anaesthesia, Christian Medical College and Hospital, Vellore 632 004, India.
Eighty-one consenting women undergoing elective Caesarean section under spinal anaesthesia were randomly divided into two groups. In Group O patients, ondansetron 4 mg was given intravenously at the end of the surgery and 8 mg added to the morphine solution in the PCA syringe. Patients in Group P received only morphine via PCA syringe. Analgesia and nausea were measured until PCA was discontinued 24 h after the operation. Women in the two groups were similar with respect to age, duration of use of the PCA, amount of morphine used, previous history of PONV, and incidence of motion sickness and morning sickness during the current pregnancy. The number of women who complained of nausea and those needing rescue antiemetic medication was significantly less in Group O. However, there was no statistically significant difference between the two groups in the patient's perception of the control of nausea and their overall satisfaction. It was noted that PONV was more frequent among women who had significant morning sickness during early pregnancy and ondansetron was beneficial in reducing PONV in these women. Although the ondansetron reduced the incidence of PONV and the need for further antiemetic medication, this did not affect patient's satisfaction regarding their postoperative care.
PMID: 11517140, UI: 21407622
Br J Anaesth 2001 Sep;87(3):441-6
Department of Anaesthesiology and Intensive Care Medicine, Justus-Liebig-University, Rudolf-Buchheim-Strasse 7, D-35385 Giessen, Germany.
We studied the effects of continuous positive airway pressure (CPAP) on pulmonary gas exchange during external chest wall oscillation (ECWO), and the relationship with obesity, in nine patients with normal body weight (group 'N') and 10 obese patients (group 'O'). During ECWO with CPAP 5, PaCO2 decreased in group 'O' (6.0 (SD 0.8) to 5.6 (0.5) kPa, P<0.05), whereas it increased in group 'N' at all levels (P<0.01). Arterial PO(2) (P<0.001) was greater and PaCO2 (P<0.01) less in group 'N' during CPPV and ECWO plus CPAP. We also compared the haemodynamic effects of ECWO plus CPAP with those of continuous positive pressure ventilation (CPPV). ECWO plus CPAP and CPPV were applied for 30 min to 6 ASA III patients. Cardiac output (CI 2.7 (0.5) vs 2.1 (0.2) litre x min(-1) x m(-2), P<0.05) and stroke volume (SVI 49 (9) vs 32 (6) ml x m(-2), P<0.05) were greater during ECWO plus CPAP than with CPPV. ECWO is less effective in obese individuals than in those with normal body weight, and the effect of CPAP in overweight individuals is small.
PMID: 11517129, UI: 21407611
Lancet 2001 Sep 29;358(9287):1110
PMID: 11589964, UI: 21474545
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