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Anaesth Intensive Care 2002 Aug;30(4):530-1; discussion 531-2
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PMID: 12180597, UI: 22167908
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Anaesth Intensive Care 2002 Aug;30(4):438-41
Department of Anaesthesiology and Critical Care, Centre for Opthalmic Sciences, India Institue of Medical Sciences, New Delhi.
Clonidine added to local anaesthetics prolongs the duration of anaesthesia and analgesia of peripheral, neuraxial and retrobulbar blocks. The present randomized blinded controlled study was conducted to evaluate the effect of the addition of clonidine to local anaesthetic mixture on the quality, onset time, duration of peribulbar block, perioperative analgesia and patients' comfort. The study comprised two groups of 12 patients each. Group A (control) patients received 7 ml of a mixture of 2% lignocaine and hyaluronidase with 1 ml normal saline, while group B (clonidine group) patients had clonidine 1 microg/kg added to the above mixture. Onset and duration of lid akinesia, globe anaesthesia and akinesia, time to first analgesic medication and total analgesic requirement were assessed. Patients were monitored for heart rate, blood pressure, sedation and respiratory depression. Addition of clonidine to local anaesthetic mixture resulted in a significant increase in duration of lid akinesia (85.4+/-25.6 vs 173.3+/-35.3 min, P<0.001), globe anaesthesia (63.2+/-6.9 vs 78.8+/-17.5 min, P=0.012) and globe akinesia (161.3+/-24.3 vs 201.2+/-45.7 min, P=0.016). The onset time and quality of block were similar in both the groups. No significant haemodynamic, respiratory or sedative effects were recorded. The perioperative pain scores and the analgesic requirements were significantly (P<0.01) lower in group B patients. We found that addition of clonidine 1 microg/kg to local anaesthetic mixture significantly increases the duration of anaesthesia and analgesia after peribulbar block.
PMID: 12180581, UI: 22167892
Anaesth Intensive Care 2002 Aug;30(4):413-21
Department of Anaesthesia and Intensive Care, University of Adelaide, South Australia.
Propofol and isoflurane are commonly used in neuroanaesthesia. Some published data suggest that the use of these agents is associated with impaired cerebral blood flow/carbon dioxide (CO2) reactivity. Cerebrovascular CO2 reactivity was therefore measured in three cohorts of adult merino sheep: awake (n=6), anaesthetized with steady-state propofol (15 mg/min; n=6) and anaesthetized with 2% isoflurane (n=6). Changes in cerebral blood flow were measured continuously from changes in velocities of blood in the sagittal sinus via a Doppler probe. Alterations in the partial pressure of carbon dioxide in arterial blood (PaCO2) over the range 18-63 mmHg were achieved by altering either the inspired CO2 concentration or the rate of mechanical ventilation. Cerebral blood flow/CO2 relationships were determined by linear regression analysis, with changes in cerebral blood flow expressed as a percentage of the value for a PaCO2 of 35 mmHg. Propofol decreased cerebral blood flow by 55% relative to pre-anaesthesia values (P=0.0001), while isoflurane did not significantly alter cerebral blood flow (88.45% of baseline, P=0.39). Significant linear relationships between cerebral blood flow and CO2 tension were determined in all individual studies (r2 ranged from 0.72 to 0.99). The slopes of the lines were highly variable between individuals for the awake cohort (mean 4.73, 1.42-7.12, 95% CI). The slopes for the propofol (mean 2.67, 2.06-3.28, 95% CI) and isoflurane (mean 2.82, 219-3.45, 95% CI) cohorts were more predictable. However, there was no significant difference between these anaesthetic agents with respect to the CO2 reactivity of cerebral blood flow.
PMID: 12180577, UI: 22167888
Anaesthesia 2002 Aug;57(8):835-6
PMID: 12180425, UI: 22167771
Anaesthesia 2002 Aug;57(8):834-5
PMID: 12180424, UI: 22167770
Anaesthesia 2002 Aug;57(8):819-20
PMID: 12180417, UI: 22167760
Anaesthesist 2002 May;51(5):425-6
PMID: 12125318, UI: 22121607
Anaesthesist 2002 May;51(5):420-1
Klinik fur Anaesthesiologie und operative Intensivmedizin, Universitatsklinikum Benjamin Franklin, FU Berlin, Hindenburgdamm 30, 12200 Berlin.
PMID: 12125315, UI: 22121604
Anaesthesist 2002 May;51(5):409-17
Klinik fur Anasthesie und Intensivtherapie, Klinikum, Philipps-Universitat-Marburg, Baldingerstrasse, 35033 Marburg. langc@mailer.uni-marburg.de
In obstetric anaesthesia almost all anaesthetic agents are capable of traversing the fetomaternal blood barrier. They all carry potential side-effects putting the unborn or newborn child at risk. Of major relevance is their potential for embryotoxicity, teratogenicity, postpartal cardiorespiratory or neuromuscular depression and the disturbance of thermoregulation. This can possibly lead to fetal malformation, asphyxia or floppy infant syndrome. Furthermore compromisation of uterine blood flow or contractility of the mature uterus plays an important role for the incidence of intrauterine asphyxia and premature labour or birth. Considering the physiological and pathophysiological alterations during pregnancy regarding all organ systems, the overall goal is to find an ideal choice of anaesthetic drugs and techniques in order to minimise an increased anaesthetic risk during pregnancy.
PMID: 12125314, UI: 22121603
Anaesthesist 2002 May;51(5):374-7
Klinik fur Anasthesie und operative Intensivmedizin, Klinikum Leverkusen gGmbH, Dhunnberg 60, 51375 Leverkusen. soltesz@klinikum-lev.de
OBJECTIVE: To compare the onset, duration and maximum effect of 0.1 mg/kg cisatracurium during balanced anesthesia with sevoflurane and remifentanil between infants and children. METHODS: We measured the time course of the neuromuscular blockade in 15 infants and 15 children by electromyography. Anesthesia was induced with propofol/remifentanil and maintained with sevoflurane (constant 2% endtidal) and remifentanil according to the patients individual requirements. After injection of 0.1 mg/kg cisatracurium we measured the following parameters: onset time: time between the beginning of injection of cisatracurium and maximum T1 depression, clinical duration: time between injection of the drug and recovery of T1 to 25%, recovery index: time between recovery of T1 from 25% to 75%. TOFR 0.9: time between injection of cisatracurium and recovery of the train-of-four ratio to 90%. In addition, we determined the maximum neuromuscular blockade Tmax after 0.1 mg/kg cistracurium. RESULTS: Both groups differed significantly with regard to onset time and clinical duration. In the infants, the onset time was shorter (74 s vs. 198 s) and the clinical duration longer (55 min vs. 41 min) compared to the older children. The TOFR 0.9 was 73 min (range 56-86 min) in the group of the infants and 59 min (range 43-72 min) in the group of the older children (p < 0.001). Tmax was 100% (range 97-100%) in the infants and 98% (range 92-100%) in the children (p < 0.01). However, the recovery index was comparable in both groups (21 vs. 16 min). CONCLUSIONS: Infants are substantially more sensitive to cisatracurium than children, which can be demonstrated in a significantly shorter onset time, a prolonged clinical duration and a delayed neuromuscular recovery. As there exist large interindividual differences, we recommend the use of neuromuscular monitoring in the routine practice of pediatric anesthesia.
PMID: 12125308, UI: 22121597
Anaesthesist 2002 May;51(5):359-66
Klinik und Poliklinik fur Anasthesiologie und spezielle Intensivmedizin, Universitat Bonn. vspiegel@ukb.uni-bonn.de
INTRODUCTION: Indocyanine green (ICG) elimination tests have been repeatedly suggested as an early predictor of graft function in patients with liver transplantation. Conventionally, ICG clearance (ClICG) is measured by a series of blood samples with subsequent laboratory analysis. More recently bedside techniques have become available to measure ICG concentrations in vivo and in addition to ClICG, the plasma disappearance rate of ICG (PDRICG) is increasingly being used. The aim of this study was to assess and to compare the normal time courses of ClICG and PDRICG in liver transplant recipients. METHODS: ClICG and PDRICG were measured perioperatively and at various times up to 24 h after liver transplantation. The bedside transpulmonary indicator dilution technique with an arterial fiberoptic-thermistor catheter was used to assess the ICG concentration time curve together with total circulating blood volume (Vd circ). RESULTS: Similar patterns of the time courses of ClICG and PDRICG with a fast recovery of ICG elimination in the early reperfusion period were observed. Compared to healthy subjects, ClICG was supranormal and PDRICG was slightly subnormal. In this study, Vd circ was increased at baseline and remained increased during surgery. CONCLUSIONS: PDRICG and ClICG are well suited to monitor onset and maintenance of graft function in patients undergoing liver transplantation. The PDRICG values measured tend to be relatively lower than ClICG because of an increased blood volume in these patients. By knowing these differences it is justified to monitor liver function in a very simple manner with PDRICG.
PMID: 12125306, UI: 22121595
Anesth Analg 2002 Aug;95(2):503
PMID: 12145092, UI: 22139679
Anesth Analg 2002 Aug;95(2):503; discussion 503-4
PMID: 12145091, UI: 22139678
Anesth Analg 2002 Aug;95(2):502
PMID: 12145090, UI: 22139677
Anesth Analg 2002 Aug;95(2):496; discussion 496-7
PMID: 12145081, UI: 22139668
Anesth Analg 2002 Aug;95(2):485-6, table of contents
Department of General Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. abdelmb@ccf.org
IMPLICATIONS: We describe a patient who developed respiratory arrest 4 h after successful laser treatment of tracheal stenosis. Respiratory arrest was caused, presumably, by airway narrowing due to delayed tissue edema secondary to thermal injury by deep penetration of the laser beam.
PMID: 12145077, UI: 22139664
Anesth Analg 2002 Aug;95(2):480-4, table of contents
Department of Anesthesiology, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Japan. shinjitk@md.tsukuba.ac.jp
Lightwand devices are effective and safe as an aid to tracheal intubation. Theoretically, avoiding direct-vision laryngoscopy could allow for less stimulation by intubation than the conventional laryngoscopic procedure. We designed this prospective randomized study to assess the cardiovascular changes after either lightwand or direct laryngoscopic tracheal intubation in adult patients anesthetized with sevoflurane. Sixty healthy adult patients with normal airways were randomly assigned to one of three groups according to intubating procedure under sevoflurane/nitrous oxide anesthesia (fraction of inspired oxygen = 0.33) (n = 20 each). The lightwand group received tracheal intubation with Trachlight, the laryngoscope-intubation group received tracheal intubation with a direct-vision laryngoscope (Macintosh blade), and the laryngoscopy-alone group received the laryngoscope alone. Heart rate and systolic blood pressure were recorded continuously for 5 min after tracheal intubation or laryngoscopy with enough time to intubate. All procedures were successful on the first attempt. The maximum heart rate and systolic blood pressure values obtained after intubation with Trachlight (114 +/- 20 bpm and 143 +/- 30 mm Hg, respectively) did not differ from those with the Macintosh laryngoscope (114 +/- 20 bpm and 138 +/- 23 mm Hg), but they were significantly larger than those in the laryngoscopy-alone group (94 +/- 19 bpm and 112 +/- 21 mm Hg) (P < 0.05). Direct stimulation of the trachea appears to be a major cause of the hemodynamic changes associated with tracheal intubation. IMPLICATIONS: The magnitude of hemodynamic changes associated with tracheal intubation with the Trachlight is almost the same as that which occurs with the direct laryngoscope. Hemodynamic changes are likely to occur because of direct tracheal irritation rather than direct stimulation of the larynx.
PMID: 12145076, UI: 22139663
Anesth Analg 2002 Aug;95(2):441-3, table of contents
Department of Anesthesiology, The University of Pittsburgh School of Medicine, Magee Womens Hospital, Pittsburgh, Pennsylvania 15213, USA. kaulb@anes.upmc.edu
IMPLICATIONS:A single shot spinal anesthetic is not practical in a patient with a lumboperitoneal shunt. Neuraxial block and a blood patch (if necessary) may be performed in a patient on enoxaparin therapy if current guidelines for managing patients on anticoagulant therapy are followed.
PMID: 12145068, UI: 22139655
Anesth Analg 2002 Aug;95(2):436-40, table of contents
Department of Anaesthesia and Intensive Care, Helsinki University Central Hospital, Helsinki, Finland. johanna.sarvela@hus.fi
We randomized 150 parturients into a double-blinded trial to receive intrathecal (IT) 100 microg (IT 100 group) or 200 microg (IT 200 group) or epidural 3 mg (Epidural group) of morphine for elective cesarean delivery with a combined spinal/epidural technique. The patients additionally received ketoprofen 300 mg/d. Postoperative pain relief and side effects were registered every 3 h up to 24 h, and all patients were interviewed on the first postoperative day. Pain control was equally good, but the parturients in the IT 100 group requested rescue analgesics more often compared with the other groups (P < 0.05). Itching was a common complaint and was reported by 74% of the parturients in the Epidural group and 65% and 91% in the IT 100 and IT 200 groups, respectively (P < 0.01). Medication for itching was requested by 44%, 24%, and 45% of the patients, respectively (P < 0.05). There was no difference in postoperative nausea or vomiting. The pain relief was perceived as good by >90% of the patients in all groups. In conclusion, because of the decreased incidence of and lesser requirements of medication for itching, IT morphine 100 microg with ketoprofen is recommended in cesarean deliveries. Rescue analgesics nevertheless need to be prescribed. IMPLICATIONS: Spinal morphine is an effective analgesic after cesarean delivery, but it has several side effects. The purpose of this study was to compare the prevalence of side effects and the level of analgesia of epidural morphine with two different doses of spinal morphine after elective cesarean delivery. Although rescue analgesics may be required, intrathecal morphine 100 microg is suggested for postoperative analgesia after cesarean delivery.
PMID: 12145067, UI: 22139654
Anesth Analg 2002 Aug;95(2):400-2, table of contents
Department of Anesthesia, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan. HFB01245@nifty.com
IMPLICATIONS: A dose of 0.1 mg/kg of verapamil, administered immediately before anesthesia, significantly reduces the increase in peak heart rate and mean arterial blood pressure after electroconvulsive therapy. Furthermore, the administration of verapamil does not reduce the duration of the seizure.
PMID: 12145060, UI: 22139647
Anesth Analg 2002 Aug;95(2):393-6, table of contents
Tizanidine, an alpha2-adrenoceptor agonist, has an antinociceptive effect in animals. In humans premedicated with oral tizanidine, the increase in blood pressure associated with laryngoscopy and intubation was attenuated, and the amount of midazolam required for loss of consciousness was significantly reduced. We speculated that the oral administration of tizanidine might reduce the minimum alveolar anesthetic concentration (MAC) of sevoflurane. Fifty-two ASA physical status I-II patients, aged 24-56 yr, were randomly allocated into two groups: a Control group (n = 26) and a Tizanidine group (n = 26). As premedication, the Control group received a placebo, and the Tizanidine group received 4 mg of oral tizanidine 90 min before surgical skin incision. Anesthesia was induced in all patients by using vital capacity rapid inhaled induction with sevoflurane (5%). Loss of consciousness was defined as both the loss of the eyelid reflex and the lack of a response to a verbal command. MAC was determined by a technique adapted from the conventional up-down method for quantal responses. The MAC of sevoflurane was 2.2% +/- 0.2% in the Control group and 1.8% +/- 0.2% in the Tizanidine group (P = 0.0004). The time to loss of consciousness in the Tizanidine group (60.2 +/- 22.5 s) was significantly shorter than that in the Control group (73.7 +/- 26.3 s) (P = 0.03). The oral administration of tizanidine 4 mg successfully reduced the MAC of sevoflurane by 18% in human adults. IMPLICATIONS: Oral tizanidine (4 mg), an alpha2-adrenoceptor agonist, reduces the minimum alveolar concentration of sevoflurane by 18%.
PMID: 12145058, UI: 22139645
Anesth Analg 2002 Aug;95(2):385-8, table of contents
Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA. montgoml@mskcc.org
In the United States, identification of the sentinel lymph node (SLN) requires the use of (99m)Tc-labeled colloid, 1% isosulfan blue dye, or both to trace the lymphatic drainage of a given neoplasm. We report our experience with adverse reactions to isosulfan blue dye during SLN mapping in breast cancer. A chart review of the breast cancer SLN database was performed; it included 2392 sequential patients who underwent SLN biopsy involving isosulfan blue dye at Memorial Sloan-Kettering Cancer Center from September 12, 1996, to August 17, 2000. Thirty-nine of 2392 patients (1.6%) had a documented allergic reaction during the mapping procedure. Most reactions (69%) produced urticaria, blue hives, a generalized rash, or pruritus. The incidence of hypotensive reactions was 0.5%. Although anaphylaxis after the injection of isosulfan blue dye is rare, this article highlights the need to suspect anaphylaxis when hemodynamic instability occurs after the injection of this compound. Our experience indicates that bronchospasm and respiratory compromise are unusual and that most patients do not require emergent intubation and can be managed with short-term pressor support. In addition, our data indicate that patients with a sulfa allergy do not display a cross-sensitivity to isosulfan blue dye. IMPLICATIONS: We report the largest single-institution review of adverse reactions to injection of isosulfan blue dye during sentinel lymph node mapping in breast cancer. Bronchospasm and respiratory compromise are unusual, and most patients can be treated with short-term pressor support. Patients with a sulfa allergy do not display a cross-sensitivity to isosulfan blue dye.
PMID: 12145056, UI: 22139643
Anesth Analg 2002 Aug;95(2):379-84, table of contents
Department of Anesthesiology and Intensive Care, Fondation Adolphe de Rothschild, Paris, France.
Hypotension is common after mivacurium injection in healthy patients. This hemodynamic event had not been investigated in hypertensive patients characterized by more intense hemodynamic instability. In this open-label, multicenter, randomized, and controlled study, we sought to determine whether mean arterial blood pressure (MAP) and heart rate variations were larger in hypertensive versus normotensive patients after a bolus dose of mivacurium injected over 10 or 30 s. After the induction of anesthesia with fentanyl and etomidate, normotensive (n = 149) and hypertensive (n = 57) patients received a single dose of mivacurium 0.2 mg/kg injected over 10 or 30 s by random allocation. Heart rate and MAP were recorded electronically. The incidence of hypotension (defined as a 20% MAP decrease from the control value before mivacurium injection) was 21% and 36% (10-s injection) or 11% and 10% (30-s injection) in the Normotensive and Hypertensive groups, respectively. In Hypertensive patients, the maximum decrease in MAP was significantly greater when mivacurium was injected over 10 s compared with 30 s: 20% vs 11%, respectively (P = 0.002). This difference was not observed in Normotensive patients. Hypotension after rapid (e.g., 10 s) mivacurium injection was more frequent and more pronounced in Hypertensive than in Normotensive patients. IMPLICATIONS: When mivacurium (0.2 mg/kg) is injected rapidly (e.g., 10 s) the incidence and the intensity of hypotension are greater in hypertensive patients than in healthy patients.
PMID: 12145055, UI: 22139642
Anesth Analg 2002 Aug;95(2):351-5, table of contents
Department of Anesthesiology and International Regional Research Center, The University of Texas Medical School at Houston, Houston, Texas 77030, USA.
Carpal tunnel release is often performed as an outpatient procedure. We designed this retrospective study to assess the effect of different anesthesia techniques on intraoperative cardiovascular stability and discharge time. According to the anesthesia technique received, 62 consecutive patients were categorized in Group BIER (IV regional anesthesia), Group BLOCK (distal nerve blocks), and Group GENERAL (general anesthesia). Incidences of intraoperative periods of tachycardia or bradycardia and hyper- or hypotension were studied, as were tourniquet, surgical, operating room, and discharge times. Cardiovascular stability was better achieved in Group BLOCK, as indicated by a significantly smaller incidence of periods of hypertension compared with Group BIER (5% vs 25%) and a significantly less frequent incidence of periods of hypotension compared with Group GENERAL (14% vs 42%). Patients in Group BLOCK spent significantly less time in the hospital after surgery than patients in Group BIER (65 vs 88 min) or patients in Group GENERAL (65 vs 133 min). We conclude that distal nerve blocks for outpatient carpal tunnel surgery are associated with greater intraoperative cardiovascular stability than general anesthesia. After surgery, patients in Group BLOCK could be discharged earlier than patients who received IV regional anesthesia or general anesthesia; this could be related to the superior postoperative analgesia provided by this technique. IMPLICATIONS: This retrospective analysis of three different anesthetic techniques for ambulatory carpal tunnel surgery shows that nerve blocks performed at the wrist provided excellent intraoperative cardiovascular stability and allowed for earlier discharge.
PMID: 12145050, UI: 22139637
Anesth Analg 2002 Aug;95(2):326-30, table of contents
Department of Anesthesiology and Pain Medicine, University of Alberta Hospitals, Walter Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada. btsui@ualberta.ca
We examined the success of inserting epidural catheters via the caudal route in infants by using electrocardiographic guidance. A case series of 20 patients with thoracic epidural analgesia was studied. After the induction of general anesthesia, an 18-gauge IV catheter was inserted into the caudal space to allow threading of a 20-gauge epidural catheter. The electrocardiogram (ECG) tracings via the epidural catheter, as well as the surface ECG at the target spine level, were recorded simultaneously with a modified two-channel five-lead ECG system. The epidural catheter was advanced from the caudal space until the tip reached the target level as demonstrated by a match in the configuration of the epidural ECG tracing to that of the surface ECG tracing at the target level. The catheter tip location was verified by postoperative radiographs. All catheter tips were located within two vertebrae of the target level, and satisfactory intraoperative epidural anesthesia was achieved in all subjects. IMPLICATIONS: Epidural electrocardiography may be used to guide the positioning of the thoracic epidural catheter tip via the caudal approach to the appropriate dermatome for optimum analgesia.
PMID: 12145046, UI: 22139633
Anesth Analg 2002 Aug;95(2):322-3, table of contents
Department of Anesthesiology, Centre Hospitalier de l'Universite de Montreal, Hotel-Dieu, Universite de Montreal, Quebec, Canada. thomashemmerling@hotmail.com
IMPLICATIONS: Falsely increased bispectral index (BIS) values of >70 occur during forced-warm-air therapy in patients undergoing cardiac surgery. When forced-warm-air therapy for the head is used (as in ultra-fast-tracking cardiac patients), BIS interpretation needs careful examination. Falsely increased BIS values can easily be recognized when the warm-air flow is stopped. Within 2-3 min, BIS returns to a much lower, "true" value.
PMID: 12145044, UI: 22139631
Anesth Analg 2002 Aug;95(2):294-8, table of contents
Department of Anesthesiology, Medical Faculty of Marmara University, Istanbul, Turkey. takilarzu@hotmail.com
In this study, we compared the effects of large intravascular volume infusion of 0.9% saline (NS) or lactated Ringer's (LR) solution on electrolytes and acid base balance during major spine surgery and evaluated the postoperative effects. Thirty patients aged 18-70 yr were included in the study. General anesthesia was induced with 5 mg/kg thiopental and 0.1 mg/kg vecuronium IV. Anesthesia was maintained with oxygen in 70% nitrous oxide and 1.5%-2% sevoflurane. In Group I, the NS solution, and in Group II, the LR solution were infused 20 mL. kg(-1). h(-1) during the operation and 2.5 mL. kg(-1). h(-1), postoperatively. Electrolytes (Na+, K+, Cl-) and arterial blood gases were measured preoperatively, every hour intraoperatively and at the 1st, 2nd, 4th, 6th, and 12th hours postoperatively. In the NS group, pHa, HCO3 and base excess decreased, and Cl- values increased significantly at the 2nd hour and Na+ values increased at the 4th hour intraoperatively (P < 0.001). The values returned to normal ranges at the 12th hour postoperatively. In the LR group, blood gas analysis and electrolyte values did not show any significant difference intraoperatively, but the increase in PaCO2 and the decrease in pHa and serum Na+ was significant at the 1st hour postoperatively. Although intraoperative 20 mL. kg(-1). h(-1) LR infusion does not cause hyperchloremic metabolic acidosis as does NS infusion, it leads to postoperative respiratory acidosis and mild hyponatremia. IMPLICATIONS: The infusion of large-volume lactated Ringer's solution does not cause hyperchloremic metabolic acidosis as does 0.9% saline during major surgery, but leads to postoperative mild hyponatremia and respiratory acidosis.
PMID: 12145036, UI: 22139623
Anesth Analg 2002 Aug;95(2):287-93, table of contents
Departement d'Anesthesie-Reanimation, Centre Hospitalo-Universitaire (CHU) Avicenne, Bobigny, France. cmsamama@invivo.edu
We conducted a prospective, multicenter, double-blinded, dose-ranging study to compare the risk/benefit ratio of large- and small-dose aprotinin with placebo after major orthopedic surgery. Fifty-eight patients were randomized into three groups: Large-Dose Aprotinin (4 M kallikrein inactivator unit [KIU] bolus before surgery followed by a continuous infusion of 1 M KIU/h until the end of surgery), Small-Dose Aprotinin (2 M KIU bolus plus 0.5 M KIU/h), and Placebo. Bleeding was measured and calculated. Bilateral ascending venography was systematically performed on the third postoperative day. Measured and calculated blood loss decreased in the Large-Dose Aprotinin group (calculated bleeding, whole blood, hematocrit 30%, median [range], 2,023 mL [633-4,113] as compared with placebo, 3,577 mL [1,670-21,758 mL]). The total number of homologous and autologous units was also significantly decreased in the Large-Dose Aprotinin group (2 U [0-5 U] as compared with placebo, 4 U [0-42 U]). No increase in deep vein thrombosis or pulmonary embolism was observed in the aprotinin groups. Large-dose aprotinin was safe and effective in dramatically reducing the measured and calculated bleeding and the amount of transfused red blood cell units after major orthopedic surgery. IMPLICATIONS: Large doses of aprotinin decrease blood loss and transfusion amount in major orthopedic surgery.
PMID: 12145035, UI: 22139622
Anesth Analg 2002 Aug;95(2):278-86, table of contents
Department of Anesthesiology, Saitama Cardiovascular and Pulmonary Center, Saitama, Japan. richard@ka2.so-net.ne.jp
Hepatic sinusoidal endothelial cells (SECs) are more vulnerable to hypoxia or hypothermia than hepatocytes. To test the hypothesis that hepatic venous desaturation during cardiopulmonary bypass (CPB) leads to impairment of SEC function, we studied the plasma kinetics of endogenous hyaluronate (HA), a sensitive indicator of SEC function, and hepatosplanchnic oxygenation during and after CPB. Twenty-five consecutive patients scheduled for elective coronary artery bypass graft surgery, who underwent normothermic (>35 degrees C; n = 15) or mild hypothermic (32 degrees C; n = 10) CPB participated in this study. A hepatic venous catheter was inserted into each patient to monitor hepatosplanchnic oxygenation and serum levels of HA concentration. Hepatic venous oxygen saturation decreased essentially to a similar degree during normothermic and mild hypothermic CPB. Hepatosplanchnic oxygen consumption and extraction increased during normothermic (P < 0.05), but not mild hypothermic, CPB. Both arterial and hepatic venous HA concentrations showed threefold increases during and after CPB in both groups. A positive correlation was found between hepatosplanchnic oxygen consumption and arterial HA concentrations during CPB, suggesting a role of changes in hepatosplanchnic oxygen metabolism in the mechanisms of increases in serum HA concentrations. The failure of the liver to increase HA extraction to a great degree suggests that a functional impairment of the SEC may contribute to the observed increase of serum HA. IMPLICATIONS: Hepatic sinusoidal endothelial cells (SECs) are pivotal in the regulation of sinusoidal blood flow. This study showed that SEC function might be impaired during and after cardiopulmonary bypass, irrespective of the temperature management.
PMID: 12145034, UI: 22139621
Anesth Analg 2002 Aug;95(2):266-72, table of contents
Department of Anesthesiology and Reanimatology and Division of Intensive Care Unit, School of Medicine, Gunma University, Gunma, Japan. kadoi@med.gunma-u.ac.jp
Preexisting diabetes mellitus is one of the major factors related to adverse postoperative neurological disorders after cardiac surgery. In previous reports, we found that diabetic patients more often experienced cerebral desaturation than nondiabetic patients during normothermic cardiopulmonary bypass (CPB). The purpose of this study was to examine the effects of increasing mean arterial blood pressure (MAP) by the administration of phenylephrine on internal jugular venous oxygen hemoglobin saturation (SjvO2) during tepid CPB in diabetic patients. We studied 20 diabetic patients scheduled for elective coronary artery bypass graft surgery and, as a control, 20 age-matched nondiabetic patients. After the induction of anesthesia, a fiberoptic oximetry catheter was inserted into the right jugular bulb to monitor SjvO2. After measuring the baseline partial pressure of the arterial and jugular venous blood gases and cardiovascular hemodynamic values, MAP was increased by the repeated administration of a 10-microg bolus of phenylephrine until it reached 100% of baseline values. There was a significant difference in SjvO2 value between the Diabetic and Control groups after the administration of phenylephrine (Diabetic group, 56% +/- 6%; Control group: 60% +/- 4%) (P < 0.05). There was a significant difference in the arterial-jugular oxygen content difference value between the Diabetic and Control groups after the administration of phenylephrine (diabetic group, 4.9% +/- 0.6%; Control group, 4.5% +/- 0.4%) (P < 0.05). We subdivided the Diabetic group into three groups (Diet Therapy group [n = 4], Glibenclamide group [n = 10], and Insulin-Dependent group [n = 6]). There was a significant difference in the mean slopes of SjvO2 versus cerebral perfusion pressure for increasing cerebral perfusion pressure between the Insulin-Dependent group and the other groups (Dunnett test: P = 0.04). Increasing MAP had no effects on the SjvO2 value in insulin-dependent patients during tepid CPB. IMPLICATIONS: We examined the effects of increasing mean arterial blood pressure (MAP) by the administration of phenylephrine on internal jugular venous oxygen saturation (SjvO2) during tepid cardiopulmonary bypass in diabetic patients and found that increasing MAP had no effect on the SjvO2 value in insulin-dependent patients.
PMID: 12145032, UI: 22139619
Br Dent J 2002 Jul 13;193(1):43-5
University of Birmingham.
OBJECTIVE: To investigate the relationships between eruption status, gender, social class, grade of operator, anaesthetic modality and nerve damage during third molar surgery. DESIGN: Two centre prospective longitudinal study. SETTING: The department of oral and maxillofacial surgery, University Hospital Birmingham NHS Trust and oral surgery outpatient clinics at Birmingham Dental Hospital. SUBJECTS: A total of 391 patients had surgical removal of lower third molars. Sensory disturbance was recorded at one week post operatively. Patients with altered sensation were followed up at one month, three months and six months following surgery. RESULTS: 614 lower third molars in 391 patients were removed. Forty-six procedures (7.5%) were associated with altered sensation at one week with three procedures (0.49%) showing persistent symptoms at six months. Of these 46 nerve injuries, 26 (4.23%) involved the lingual nerve and 20 (3.25%) the inferior dental nerve (IDN). All three persistent sensations were IDN related. A logistic regression model found that the use ofa lingual retractor chi2 = 11.559, p = 0.003 was more significant than eruption status chi2 = 12.935, p = 0.007. There was no significant relationship between anaesthetic modality, age, social class, sex and seniority of operator. CONCLUSIONS: There was no link between the choices of local or general anaesthesia and nerve damage during lower third molar removal when difficulty of surgery was taken into account.
PMID: 12171206, UI: 22160691
Br J Anaesth 2002 Jul;89(1):91-101
Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305-5117, USA.
PMID: 12173244, UI: 22163566
Br J Anaesth 2002 Jul;89(1):79-90
Department of Physiology, University College London, Gower Street, London WC1A 6BT, UK.
PMID: 12173243, UI: 22163565
Br J Anaesth 2002 Jul;89(1):62-78
Departments of Anesthesiology and Physiology & Biophysics, School of Medicine, State University of New York, Stony Brook, NY 11794-8480, USA.
PMID: 12173242, UI: 22163564
Br J Anaesth 2002 Jul;89(1):52-61
Physiologisches Institut, Universitat Giessen, Aulweg 129, D-35392 Giessen, Germany.
PMID: 12173241, UI: 22163563
Br J Anaesth 2002 Jul;89(1):41-51
Department of Anesthesiology, State University of New York, Stony Brook, NY 11794-8480, USA.
The experimental effort that has been expended in investigating the effects of general anaesthetics on LGICs has been enormous over the past decade. Members of all three LGIC superfamilies have been examined using electrophysiological techniques. Anaesthetics that have been examined include volatile anaesthetics, gaseous anaesthetics, alcohols, i.v. anaesthetics and non-immobilizers. Obsolete anaesthetics (ether, cyclopropane, butane) have been used in order to increase the variability of the structure and polarity of experimental compounds. The tools of molecular biology have been used to make chimeric receptors and to make single-site mutations. Interestingly, this work has been taking place in parallel with efforts to understand the structure of these proteins. Anaesthetic research often stimulates structural research as well as vice versa. There are some common themes in the interactions between anaesthetics and the three superfamilies of LGICs. In many cases, anaesthetics have both inhibitory and potentiating effects on the channels. It is likely that the number of examples of this will increase when experiments are designed to look specifically for one or the other type of effect. So we must conclude that there are multiple binding sites for anaesthetics on LGICs. The degree of inhibition or potentiation is not easily predictable. In retrospect, this is not surprising when we consider that the sensitivity of a channel to anaesthetics can be altered by a single amino-acid mutation. The large structural differences between the cys-loop, glutamate-activated and P2X superfamilies do not lead to large differences in anaesthetic sensitivity. It is the smaller, almost insignificant, changes that do this. This observation that small changes may lead to large effects reinforces the idea that at least some of the interactions between anaesthetics and LGICs are direct drug-protein interactions that are not mediated by the lipids. This review has not addressed the question of whether the effects of anaesthetics seen on LGICs are relevant to anaesthesia. This question cannot really be answered at present. Although potent effects can be observed on the channels themselves, we have only begun to try to understand whether these effects are important for a synapse, a neuronal circuit or the function of an animal's nervous system. We have studied the trees; now we must go on to study the forest and the ecosystem.
PMID: 12173240, UI: 22163562
Br J Anaesth 2002 Jul;89(1):32-40
Department of Anaesthesia, Beckman Program for Molecular and Genetic Medicine, Stanford University, Stanford, CA 94305-5117, USA.
There has been rapid progress in molecular modelling in recent years. The convergence of improved software for molecular mechanics and dynamics, techniques for chimeric substitution and site-directed mutations, and the first x-ray structures of transmembrane ion channels have made it possible to build and test models of anaesthetic binding sites. These models have served as guides for site-directed mutagenesis and as starting points for understanding the molecular dynamics of anaesthetic-site interactions. Ligand-gated ion channels are targets for inhaled anaesthetics and alcohols in the central nervous system. The inhibitory strychnine-sensitive glycine and gamma-aminobutyric acid type A receptors are positively modulated by anaesthetics and alcohols; site-directed mutagenesis techniques have identified amino acid residues important for the action of volatile anaesthetics and alcohols in these receptors. Key questions are whether these amino acid mutations form part of alcohol- or anaesthetic-binding sites or if they alter protein stability in a way that allows anaesthetic molecules to act remotely by non-specific mechanisms. It is likely that molecular modelling will play a major role in answering these questions.
PMID: 12173239, UI: 22163561
Br J Anaesth 2002 Jul;89(1):3-16
Klinik fur Anasthesiologie und spezielle Intensivmedizin, Universitatsklinikum Bonn, Sigmund-Freud-Strasse 25, D-53127 Bonn, Germany.
PMID: 12173238, UI: 22163559
Br J Anaesth 2002 Jul;89(1):17-31
Department of Anaesthesia and Critical Care, Massachusetts General Hospital, Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, MA, USA.
The molecular nature of the site of general anaesthesia has long been sought through the process of comparing the in vivo potencies of general anaesthetics with their physical properties, particularly their ability to dissolve in solvents of various polarities. This approach has led to the conclusion that the site of general anaesthesia is largely apolar but contains a strong polar component. However, there is growing evidence that several physiological targets underlie general anaesthesia, and that different agents may act selectively on subsets of these targets. Consequently research now focuses on the details of general-anaesthetic-protein interactions. There are large amounts of structural data that identify cavities where anaesthetics bind on soluble proteins that are readily crystallizable. These proteins serve as models, having no role in anaesthesia. Two problems make studies of the more likely targets--excitable membrane proteins--difficult. One is that they rarely crystallize and the other is that the sites have their highest affinity for general anaesthetics when the channels are in the open state. Such states rarely exist for more than tens of milliseconds. Crystallographers are making progress with the first problem, whilst anaesthesia researchers have developed a number of strategies for addressing the second. Some of these (kinetic analysis, site-directed mutagenesis) provide indirect evidence for sites and their nature, whilst others seek direct identification of sites by employing newly developed general anaesthetics that are photoaffinity labels. Such studies on acetylcholine, glycine and GABA receptors point to the existence of sites located within the plane of the membrane either within the ion channel lumen (acetylcholine receptor), or on the outer side of the alpha-helix lining that lumen (GABAA and glycine receptors). Bound anaesthetics generally exert their actions on ion channels by binding to allosteric sites whose topology varies from one conformation to another, but definitive proof for this mechanism remains elusive.
PMID: 12173229, UI: 22163560
Br J Anaesth 2002 Jul;89(1):167-83
PMID: 12173228, UI: 22163572
Br J Anaesth 2002 Jul;89(1):156-66
Department of Anesthesiology, TB-170, University of California at Davis, Davis, CA 95616, USA.
PMID: 12173227, UI: 22163571
Br J Anaesth 2002 Jul;89(1):143-55
Laboratory of Molecular Biology, National Institute of Mental Health, Building 36/Room 1B08, 9000 Rockville Pike, Bethesda, MD 20892-4034, USA.
PMID: 12173226, UI: 22163570
Br J Anaesth 2002 Jul;89(1):123-42
Institut fur Physiologie, Universitatsklinikum Hamburg-Eppendorf, D-20246 Hamburg, Germany.
PMID: 12173225, UI: 22163569
Br J Anaesth 2002 Jul;89(1):112-22
Department of Anaesthesiology and Intensive Care Therapy, University of Leipzig, Liebigstrasse 20a, D-04103 Leipzig, Germany.
PMID: 12173224, UI: 22163568
Br J Anaesth 2002 Jul;89(1):102-11
Department of Anaesthesiology, University of Tubingen, Max Planck Institute for Biological Cybernetics, Tubingen, Germany.
PMID: 12173223, UI: 22163567
Br J Anaesth 2002 Jul;89(1):1-2
PMID: 12173222, UI: 22163558
Br J Anaesth 2002 Jun;88(6):836-40
Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan.
BACKGROUND: A number of authors have reported that anaesthetics suppress myogenic motor evoked potentials (MEPs). However, the influence of hypothermia on these effects is unknown. Therefore we investigated the effects of hypothermia on nitrous oxide-induced suppression of myogenic MEPs. METHODS: Twenty-two rabbits anaesthetized with ketamine, fentanyl and propofol were randomly allocated to one of three groups, with oesophageal temperatures of 40 degrees C (n = 8), 35 degrees C (n = 7) and 30 degrees C (n = 7). Myogenic MEPs in response to electrical stimulation of the motor cortex with a train of five pulses were recorded from the soleus muscle. Following the control recording, nitrous oxide was administered at concentrations of 30%, 50%, and 70% in random order, and MEPs were recorded. Control MEP amplitudes and percentage of control MEP amplitudes (%MEP amplitude) during the administration of nitrous oxide were compared between the three groups. RESULTS: Control MEP amplitudes were similar between the three groups. Nitrous oxide suppressed MEPs in a dose-dependent manner in all groups. During the administration of nitrous oxide, % MEP amplitudes at 35 degrees C and 30 degrees C (hypothermia) were significantly lower than those at 40 degrees C (normothermia). CONCLUSION: These results suggest that nitrous oxide-induced suppression of MEPs may be augmented during hypothermia.
PMID: 12173203, UI: 22163539
Br J Anaesth 2002 Jun;88(6):814-8
Department of Anaesthetics, PO Box 114-D, Catholic University School of Medicine, Marcoleta 367, Santiago, Chile.
BACKGROUND: Since the time to peak analgesic effect of intravenous morphine can be longer than 40-60 min in volunteers, the goal of this study was to evaluate the effect of the timing of intraoperative morphine administration on early postoperative pain. METHODS: A total of 120 adult patients undergoing laparoscopic cholecystectomy were studied. Anaesthesia was induced with remifentanil and etomidate and maintained with remifentanil and sevoflurane/nitrous oxide. Morphine 150 micrograms kg-1 was given randomly at three different times during surgery, and a fourth group received placebo. Times to eyes opening and extubation were measured, and pain was evaluated in the post-anaesthesia care unit (PACU) using a visual analogue scale (VAS). Morphine 2-3 mg was given when the VAS score was > or = 50 mm. The four groups were, according to the time elapsed from morphine administration to the end of surgery, group 1 (n = 30): placebo; group 2 (n = 33): < 20 min; group 3 (n = 30): 20-40 min; group 4 (n = 27): > 40 min. RESULTS: Recovery from anaesthesia and pain scores were similar in all groups. However, mean (SD) morphine consumption was 5.7 (4.7) mg in group 1, 4.4 (4.2) mg in group 2, 4.7 (4.7) mg in group 3, and 2.2 (4.0) mg in group 4 (P < 0.05, group 1 vs 4). Morphine was required in only 38% of patients in group 4 compared with 83%, 67% and 69% in groups 1, 2, and 3, respectively (P < 0.01, group 1 vs 4). CONCLUSIONS: The timing of intraoperative morphine administration did not affect the early recovery from anaesthesia. However, the reduction in the number of patients requiring morphine in the PACU when morphine had been given more than 40 min before the end of surgery supports this practice, rather than administration closer to the end of surgery.
PMID: 12173199, UI: 22163535
Br J Anaesth 2002 Jun;88(6):809-13
Department of Anaesthesiology, Hopital de la Croix-Rousse, F-69004 Lyon, France.
BACKGROUND: Ropivacaine has been claimed to produce less motor block than bupivacaine during epidural analgesia. However, this advantage has not been clearly confirmed in obstetric studies using low analgesic concentrations in a ratio close to that suggested to be equianalgesic. METHODS: This double-blind, randomized, prospective study was performed in 140 parturients who requested epidural analgesia. After a lumbar epidural catheter had been placed, patients received either 0.10% bupivacaine plus sufentanil 0.5 microgram ml-1 or 0.15% ropivacaine plus sufentanil 0.5 microgram ml-1 followed by a continuous infusion. Additional boluses were used for inadequate levels of analgesia. Visual analogue pain scores, motor block, level of sensory block, supplementary boluses and main characteristics of labour were recorded. RESULTS: No differences were observed between the two groups for pain scores, total volume of anaesthetic solution used [59 (23) and 57 (24) ml in the bupivacaine and ropivacaine groups respectively], duration of labour, mode of delivery, side-effects or satisfaction score. The incidence of motor block was not statistically different between the groups (54 and 69% in the bupivacaine and ropivacaine groups respectively, P = 0.07). However, when motor block occurred, survival analysis showed that it occurred sooner in the course of labour with ropivacaine compared with bupivacaine (log rank test, P = 0.012). CONCLUSION: Combined with sufentanil 0.5 microgram ml-1, 0.10% bupivacaine and 0.15% ropivacaine produce effective and equivalent analgesia during labour, with similar incidences of motor block.
PMID: 12173198, UI: 22163534
Chest 2002 Aug;122(2):473-8
Division of Pediatric Anesthesia (Drs. Reber, Bobbia, Bruppacher, and Frei), University Children's Hospital of Basel, Basel, Switzerland.
STUDY OBJECTIVE:s: To quantify thoracoabdominal asynchrony (TAA) in children during anesthesia, and to measure the effect of continuous positive airway pressure (CPAP) on TAA, tidal volume (VT), and minute ventilation (E). DESIGN: Prospective, nonrandomized, controlled study. SETTING: Operating room of a university children's hospital. PARTICIPANTS: Ninety children aged 2 to 9 years scheduled for elective outpatient day surgery who were enrolled prospectively. METHODS: Each subject was anesthetized with sevoflurane 3% in equal parts O(2) and N(2)O while breathing spontaneously through a facemask. Respiratory impedance plethysmography was used to calculate TAA indexes (phase angle [PA], phase relation in inspiration [PhRIB], phase relation in expiration, phase relation in total breath [PhRTB], and ratio of the inspiratory time to the total duration of the respiratory cycle [TI/TTOT]), VT, and E. Tidal gas flows were measured with a dual-hotwire anemometer with the sensor inserted between the facemask and the Y-piece of the anesthetic breathing circuit. This enabled the volume calibration of the respiratory impedance plethysmography equipment. The following conditions were compared: (1) no CPAP, (2) CPAP of 5 cm H(2)O, and (3) CPAP of 10 cm H(2)O. RESULTS: Eighty-one children completed the study protocol. All measurements of TAA with an inspiratory component (PA, PhRIB, PhRTB, and TI/TTOT) decreased significantly from baseline with the addition of CPAP to the circuit. Application of CPAP of 10 cm H(2)O decreased significantly mean VTs and Es compared with CPAP of 5 cm H(2)O and no CPAP. There were no differences in TAA for all conditions when comparing children scheduled for adenoidectomy with other surgical procedures. CONCLUSIONS: With spontaneously breathing anesthetized children, TAA decreases with the application of CPAP. CPAP of 5 cm H(2)O was as effective as CPAP of 10 cm H(2)O in reducing PA, PhRIB, PhRTB, and TI/TTOT. However, CPAP of 10 cm H(2)O also caused a significant decrease in VT and E.
PMID: 12171819, UI: 22161796
JAMA 2002 Aug 7;288(5):629-32
Department of Anesthesiology, Acute Pain Service, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA. jcrews@wfubmc.edu
PMID: 12150675, UI: 22146467
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