Ultimo Aggiornamento: 31 Dicembre 2002

32 citations found

Anesth Analg 2002 Apr;94(4):1041

Is 0.375% bupivacaine safe in caudal anesthesia in neonates and young infants?

Uejima T, Suresh S

Children's Memorial Hospital, Chicago, IL.

[Medline record in process]

PMID: 11916824, UI: 21914029

Anesth Analg 2002 Apr;94(4):1041-2

Searching the preferred anesthetic technique during one-lung-ventilation.

Garutti I, Olmedilla L

Service of Anesthesiology and Reanimation, Hospital General "Gregorio Maranon", Madrid, Spain. Department of Anesthesiology and Intensive Care, Humboldt-University, Campus Mitte Charite, Berlin, Germany.

[Medline record in process]

PMID: 11916823, UI: 21914028

Anesth Analg 2002 Apr;94(4):1023-7

Intubating laryngeal mask airway size selection: a randomized triple crossover study in paralyzed, anesthetized male and female adult patients.

Kihara S, Yaguchi Y, Brimacombe J, Watanabe S, Taguchi N, Hosoya N

Department of Anaesthesia, Pain Clinic, and Clinical Toxicology, Mito Saiseikai General Hospital, Ibaraki, Japan.

[Medline record in process]

We determined the optimal size of intubating laryngeal mask airway (ILM) for ventilation and blind tracheal intubation in men and women. We also determined the distance the tracheal tube needs to protrude beyond the distal aperture to ensure that the cuff is through the vocal cords. Fifty male and 50 female anesthetized, paralyzed patients (ASA physical status I or II, aged 18-80 yr) were studied. Three operators (A, B, and C) were involved for the purposes of blinding. The size 3, 4, or 5 ILM was inserted into each patient in random order by Operator A, and the quality of ventilation was scored (adequate, suboptimal, or failed) by Operator B. The fiberoptic position (correct, too shallow, or too deep) and the distance between the distal aperture and the vocal cords was determined by Operator B. A single attempt at blind intubation was made by Operator C. Operators B and C were blinded to the size of the ILM. Operator C was also blinded to the information recorded by Operator B. All ILMs were inserted into the laryngopharynx at the first attempt. For men and women, the ventilation score was smaller for the Size 3 than the Size 4 or 5 (all: P < 0.002). For men, correct positioning was less common with the Size 3 than the Size 4 or 5 (both: P < 0.02). For women, correct positioning was similar among sizes. For men, tracheal intubation was successful less frequently with the Size 3 (84%) than the Size 4 (100%) or 5 (98%) (both: P </= 0.01). For women, tracheal intubation success was similar among sizes (Size 3, 4, and 5: 86%, 96%, and 92%, respectively). Intubation was always successful if the ILM was correctly positioned and always failed if it was too shallow or deep. In both male and female patients, the distance between the distal aperture and the vocal cords increased with increasing ILM size (all: P < 0.04) and patient height (P < 0.0001) and was always longer for men (all: P < 0.0001). The overall mean distance (95% confidence interval) that the tracheal tube needed to protrude was 10-12 cm (8-13 cm) in men and 8-11 cm (8-12 cm) in women. We conclude that for men, the Size 4 and 5 ILMs are better than the Size 3 for ventilation and blind intubation. For women, the Size 4 and 5 ILMs are better than the Size 3 for ventilation, but there is no difference among sizes for blind intubation. The length the tracheal tube must protrude from the distal aperture to ensure that the cuff is completely through the vocal cords is 8-13 cm, depending on ILM size, the tracheal tube size, and the sex and height of the patient. IMPLICATIONS: For men, the Size 4 and 5 intubating laryngeal mask airways are better than the Size 3 for ventilation and blind tracheal intubation. For women, the Size 4 and 5 are better than the Size 3 for ventilation, but there is no difference among sizes for blind intubation. The length the tracheal tube must protrude from the distal aperture of the intubating laryngeal mask airway to ensure that the cuff is completely through the vocal cords is 8-13 cm, depending on the size of the mask and tracheal tube and on the sex and height of the patient.

PMID: 11916817, UI: 21914022

Anesth Analg 2002 Apr;94(4):1019-22

The threshold and gain of thermoregulatory vasoconstriction differs during anesthesia in the dependent and upper arms in the lateral position.

Greif R, Laciny S, Rajek A, Doufas AG, Sessler DI

Department of Anesthesiology and Intensive Care Medicine, Donauspital/SMZO.

[Medline record in process]

Increased intraluminal pressure may help maintain vasodilation in a dependent arm even after hypothermia triggers centrally mediated thermoregulatory vasoconstriction. We therefore tested the hypotheses that the threshold (triggering core temperature) and gain (increase in vasoconstriction per degree centigrade) of cold-induced vasoconstriction is reduced in the dependent arm during anesthesia. Anesthesia was maintained with 0.4 minimum alveolar anesthetic concentration of desflurane in 10 volunteers in the left-lateral position. Mean skin temperature was reduced to 31 degrees C to decrease core body temperature. Fingertip blood flow in both arms was measured, as was core body temperature.The vasoconstriction threshold was slightly, but significantly, less in the dependent arm (36.2 degrees C +/- 0.3 degrees C, mean +/- SD) than in the upper arm (36.5 degrees C +/- 0.3 degrees C). However, the gain of vasoconstriction in the dependent arm was 2.3-fold greater than in the upper arm. Consequently, intense vasoconstriction (i.e., a fingertip blood flow of 0.15 mL/min) occurred at similar core temperatures. In the lateral position, the vasoconstriction threshold was reduced in the dependent arm; however, gain was also increased in the dependent arm. The thermoregulatory system may thus recognize that hydrostatic forces reduce the vasoconstriction threshold and may compensate by sufficiently augmenting gain. IMPLICATIONS: The threshold for cold-induced vasoconstriction is reduced in the dependent arm, but the gain of vasoconstriction is increased. Consequently, the core temperature triggering intense vasoconstriction was similar in each arm, suggesting that the thermoregulatory system compensates for the hydrostatic effects of the lateral position.

PMID: 11916816, UI: 21914021

Anesth Analg 2002 Apr;94(4):1014-8

Calibrated Pneumoperitoneal Venting to Prevent N(2)O Accumulation in the CO(2) Pneumoperitoneum During Laparoscopy with Inhaled Anesthesia: An Experimental Study in Pigs.

Diemunsch PA, Van Dorsselaer T, Torp KD, Schaeffer R, Geny B

Departement d'Anesthesiologie, I.R.C.A.D., Hopitaux Universitaires, Strasbourg, France.

[Medline record in process]

Nitrous oxide (N(2)O) accumulates in the CO(2) pneumoperitoneum during laparoscopy when N(2)O is used as an adjuvant for inhaled anesthesia. This may worsen the consequences of gas embolism and introduce a fire risk. In this study, we quantified the pneumoperitoneal gas venting necessary to prevent significant contamination by inhaled N(2)O. Four domestic pigs (26-30 kg) were anesthetized and ventilated with 66% N(2)O in oxygen. A CO(2) pneumoperitoneum was insufflated and maintained at a pressure of 12 mm Hg. Each animal underwent three experimental conditions, in random sequence, for 70 min each: 1) no pneumoperitoneal leak, 2) leak of 2 L every 10 min (12 L/h), and 3) leak of 4 L every 10 min (24 L/h). Every 10 min, pneumoperitoneal gas samples were analyzed for fractions (FPn) of N(2)O and CO(2). Without leaks, FPnN(2)O increased continually and reached 29.58% +/- 3.15% at 70 min. With leaks of 2 and 4 L every 10 min (12 and 24 L/h), FPnN(2)O reached a plateau of <10% after 30 min. We conclude that calibrated pneumoperitoneal venting of 12 or 24 L/h is enough to prevent the constitution of potentially dangerous pneumoperitoneal gas mixtures if venting is constant. IMPLICATIONS: External venting calibrated at four or eight initial pneumoperitoneal volumes per hour with compensation by fresh CO(2) is sufficient to prevent nitrous oxide buildup of more than 10% in the pneumoperitoneum during laparoscopy with inhaled general anesthesia if venting is constant.

PMID: 11916815, UI: 21914020

Anesth Analg 2002 Apr;94(4):1007-9

Subdural block complicating spinal anesthesia?

Singh B, Sharma P

Department of Anaesthesiology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India.

[Medline record in process]

IMPLICATIONS:Features suggestive of subdural block appeared after an apparently normal subarachnoid block. The long bevel of the reusable Quincke-type spinal needle may have contributed to the development of this complication. We propose that spinal needles should have a smaller bevel to minimize the possibility of such a complication.

PMID: 11916813, UI: 21914018

Anesth Analg 2002 Apr;94(4):920-6

A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery.

Lee A, Ngan Kee WD, Gin T

Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, China.

[Medline record in process]

This quantitative systematic review compared the efficacy and safety of ephedrine with phenylephrine for the prevention and treatment of hypotension during spinal anesthesia for cesarean delivery. Seven randomized controlled trials (n = 292) were identified after a systematic search of electronic databases (MEDLINE, EMBASE, The Cochrane Controlled Trials Registry), published articles, and contact with authors. Outcomes assessed were maternal hypotension, hypertension and bradycardia, and neonatal umbilical cord blood pH values and Apgar scores. For the management (prevention and treatment) of maternal hypotension, there was no difference between phenylephrine and ephedrine (relative risk [RR] of 1.00; 95% confidence interval [CI], 0.96-1.06). Maternal bradycardia was more likely to occur with phenylephrine than with ephedrine (RR of 4.79; 95% CI, 1.47-15.60). Women given phenylephrine had neonates with higher umbilical arterial pH values than those given ephedrine (weighted mean difference of 0.03; 95% CI, 0.02-0.04). There was no difference between the two vasopressors in the incidence of true fetal acidosis (umbilical arterial pH value of <7.2; RR of 0.78; 95% CI, 0.16-3.92) or Apgar score of <7 at 1 and 5 min. This systematic review does not support the traditional idea that ephedrine is the preferred choice for the management of maternal hypotension during spinal anesthesia for elective cesarean delivery in healthy, nonlaboring women. IMPLICATIONS:Phenylephrine and ephedrine to manage hypotension during spinal anesthesia for elective cesarean delivery were compared in this systematic review. Women given ephedrine had neonates with lower umbilical cord blood pH values compared with those given phenylephrine. However, no differences in the incidence of fetal acidosis (pH value of <7.2) or neonatal Apgar scores were found.

PMID: 11916798, UI: 21914003

Anesth Analg 2002 Apr;94(4):835-40

Terlipressin-ephedrine versus ephedrine to treat hypotension at the induction of anesthesia in patients chronically treated with Angiotensin converting-enzyme inhibitors: a prospective, randomized, double-blinded, crossover study.

Meersschaert K, Brun L, Gourdin M, Mouren S, Bertrand M, Riou B, Coriat P

Departments of Anesthesiology and Critical Care and Emergency Medicine and Surgery, Centre Hospitalier Universitaire (CHU) Pitie-Salpetriere, Assistance-Publique-Hopitaux de Paris (AP-HP), Pierre et Marie Curie University, Paris, France.

[Medline record in process]

In patients chronically treated with angiotensin con-verting-enzyme inhibitors (ACEI), typically selected doses of ephedrine do not always restore arterial blood pressure when anesthesia-induced hypotension occurs. We postulated that the administration of terlipressin, an agonist of the vasopressin system, with ephedrine more effectively restores pressure in this setting than the administration of ephedrine alone. This prospective, randomized, cross-over, double-blinded study compared terlipressin combined with ephedrine (n = 19) with ephedrine alone (n = 21) in treating hypotension at the induction of anesthesia in 40 ACEI-treated patients undergoing hypotension (mean arterial blood pressure [MAP] <65 mm Hg or <30% of baseline value) after standardized anesthetic protocol (target-controlled IV anesthesia with propofol). Data are mean +/- SD. Patient characteristics, MAP, and heart rate before and after the induction of anesthesia during hypotensive episodes were not significantly different between the two groups. After the first bolus, MAP was significantly greater in the Terlipressin-Ephedrine group (72 +/- 12 mm Hg versus 65 +/- 8 mm Hg, P < 0.05). The occurrence of a second hypotensive episode (5% versus 71%, P < 0.001), the duration (2 +/- 1 min versus 3 +/- 1 min, P < 0.01) of hypotensive episodes, and the median dose of ephedrine (3 versus 6 mg, P < 0.05) were significantly less in the Terlipressin-Ephedrine group. In conclusion, terlipressin combined with ephedrine is more effective than ephedrine alone for treating anesthesia-induced hypotension in ACEI-treated patients. We conclude that this patient population with a partially blocked endogenous response to hypotension may be good candidates for successful use of a vasopressin analog to counteract intraoperative refractory hypotension. IMPLICATIONS: Vascular surgical patients chronically treated with drugs that inhibit the functioning of the renin-angiotensin system may experience hypotension unresponsive to conventional therapy. This double-blinded, cross-over study demonstrated that in these patients the use of a vasopressin analog, terlipressin given with ephedrine, was effective in reversing intraoperative systemic hypotension refractory to ephedrine.

PMID: 11916781, UI: 21913986

Anesth Analg 2002 Feb;94(2):476-7

Primary score predicting the difficulty of neuraxial block.

Karraz MA

Publication Types:

• Letter

PMID: 11812725, UI: 21670893

Anesth Analg 2002 Feb;94(2):475-6

The effects of single or multiple injections on the volume of 0.5% ropivacaine required for femoral nerve blockade.

Ekatodramis G, Bonvini JM, Borgeat A

Publication Types:

• Letter

PMID: 11812724, UI: 21670892

Anesth Analg 2002 Feb;94(2):450-2, table of contents

Interscalene and infraclavicular block for bilateral distal radius fracture.

Maurer K, Ekatodramis G, Rentsch K, Borgeat A

Department of Anesthesiology, University Hospital Zurich/Balgrist, Zurich, Switzerland.

Brachial plexus blockade is a suitable technique for surgery of the forearm, because it provides good intraoperative anesthesia as well as prolonged postoperative analgesia when long-acting local anesthetics are used. However, simultaneous blockade of both upper extremities has rarely been performed (1), because local anesthetic toxicity caused by the amount of drug needed to achieve an efficient block on both sides may be a problem. We report a case of successful bilateral brachial plexus block with ropivacaine in a patient with bilateral distal radius fracture, with each fracture requiring an open osteosynthesis. IMPLICATIONS: This case report presents the performance of a simultaneous blockade of both upper extremities in a patient who sustained a bilateral distal radius fracture. The patient was known to be difficult to intubate and to have a severe hypersensitivity to opioids.

PMID: 11812717, UI: 21670885

Anesth Analg 2002 Feb;94(2):445-9, table of contents

An evaluation of the cutaneous distribution after obturator nerve block.

Bouaziz H, Vial F, Jochum D, Macalou D, Heck M, Meuret P, Braun M, Laxenaire MC

Department of Anesthesiology and Intensive Care, Hopital Central, Nancy, France. h.bouaziz@chu-nancy.fr

In 1973, Winnie et al. introduced the inguinal paravascular three-in-one block, which allegedly provides anesthesia of three nerves--the femoral, lateral cutaneous femoral, and obturator nerves--with a single injection. This concept was undisputed until the success of the obturator nerve block was reassessed by using evidence of adductor weakness rather than cutaneous sensory blockade, the latter being variable in its distribution and often absent. We performed this study, therefore, to evaluate the area of sensory loss produced by direct injection of local anesthetic around the obturator nerve. A selective obturator nerve block with 7 mL of 0.75% ropivacaine was performed in 30 patients scheduled for knee surgery. Sensory deficit and adductor strength were evaluated for 30 min by using sensory tests (cold and light-touch perception) and the pressure generated by the patient's squeezing a blood pressure cuff placed between the knees. Subsequently, a three-in-one block was performed, and the sensory deficit was reassessed. The obturator nerve block was successful in 100% of cases. The strength of adductors decreased by 77% +/- 17% (mean +/- SD). In 17 patients (57%), there was no cutaneous contribution of the obturator nerve. The remaining 7 patients (23%) had an area of hypoesthesia (cold sensation was blunt but still present) on the superior part of the popliteal fossa, and the other 6 (20%) had sensory deficit located at the medial aspect of the thigh. The three-in-one block resulted in blockade of the lateral aspect of the thigh in 87% of cases, whereas the anteromedial aspect was always anesthetized. By use of magnetic resonance imaging in eight volunteers, we demonstrated that the obturator nerve has already divided into its two branches at the site of local anesthetic injection. However, the injection of blue dye after having simulated the technique in five cadavers showed that the fluid regularly spread to both branches. We conclude that after three-in-one block, a femoral nerve block may have been assessed as an obturator nerve block in 100% of cases when testing the cutaneous distribution of the obturator nerve on the medial aspect of the thigh. IMPLICATIONS: Previous studies reporting an incidence of obturator nerve block after three-in-one block may have mistaken a femoral nerve block for an obturator nerve block in 100% of cases when the cutaneous distribution of the obturator nerve was assessed on the medial aspect of the thigh. The only way to effectively evaluate obturator nerve function is to assess adductor strength.

PMID: 11812716, UI: 21670884

Anesth Analg 2002 Feb;94(2):409-14, table of contents

Active warming during cesarean delivery.

Horn EP, Schroeder F, Gottschalk A, Sessler DI, Hiltmeyer N, Standl T, Schulte am Esch J

Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany. ephorn@12move.de

We tested the hypothesis that 15 min of forced-air prewarming, combined with intraoperative warming, prevents hypothermia and shivering in patients undergoing elective cesarean delivery. We simultaneously tested the hypothesis that maintaining maternal normothermia increases newborn temperature, umbilical vein pH, and Apgar scores. Thirty patients undergoing elective cesarean delivery were randomly assigned to forced-air warming or to passive insulation. Warming started 15 min before the induction of epidural anesthesia. Core temperature was measured at the tympanic membrane, and shivering was graded by visual inspection. Patients evaluated their thermal sensation with visual analog scales. Rectal temperature and umbilical pH were measured in the infants after birth. Results were compared with unpaired, two-tailed Student's t-tests and chi(2) tests. Core temperatures after 2 h of anesthesia were greater in the actively warmed (37.1 degrees C +/- 0.4 degrees C) than in the unwarmed (36.0 degrees C +/- 0.5 degrees C; P < 0.01) patients. Shivering was observed in 2 of 15 warmed and 9 of 15 unwarmed mothers (P < 0.05). Babies of warmed mothers had significantly greater core temperatures (37.1 degrees C +/- 0.5 degrees C vs 36.2 degrees C +/- 0.6 degrees C) and umbilical vein pH (7.32 +/- 0.07 vs 7.24 +/- 0.07). IMPLICATIONS: Perioperative forced-air warming of women undergoing cesarean delivery with epidural anesthesia prevents maternal and fetal hypothermia, reduces maternal shivering, and improves umbilical vein pH.

PMID: 11812709, UI: 21670877

Anesth Analg 2002 Feb;94(2):400-3, table of contents

Venous air emboli occur during release of positive end-expiratory pressure and repositioning after sitting position surgery.

Schmitt HJ, Hemmerling TM

Department of Anesthesiology, University Erlangen-Nuremberg, Germany.

We studied the effect of positive end-expiratory pressure (PEEP) release and positioning on the occurrence of venous air embolism (VAE). Eighteen consecutive patients (8 women, 10 men; ASA grade I-III) undergoing neurosurgery in the sitting position were studied. After induction of anesthesia ventilation was controlled with a PEEP of 5 cm H(2)O in an oxygen-air gas mixture. A transesophageal echocardiographic (TEE) probe was inserted. Preoperatively, a patent foramen ovale was excluded in all patients. TEE monitoring was performed during surgery, during PEEP release at the end of surgery with the patient still in the sitting position, and during change of the patient position into the supine position. The severity of VAE was differentiated as follows: grade 1 = only microbubbles; grade 2 = microbubbles and decrease of end-tidal carbon dioxide partial pressure (PETCO(2)) by more than 1.5 mm Hg; grade 3 = microbubbles combined with a decrease of PETCO(2) by more than 1.5 mm Hg, and a decrease of mean arterial blood pressure by at least 20 mm Hg. During surgery, VAE with a grade of 1, 2 or 3 occurred in 7, 4, and 2 patients, respectively. After PEEP release, VAE of grades 1, 2, and 3 were observed in 7, 2, and 1 patients, respectively. During repositioning from sitting to supine position, VAE of grades 1, 2, and 3 was observed in 6, 1, and 1 patients, respectively. The patient with VAE grade 3 needed inotropic support until 2 h after surgery to maintain sufficient blood pressure. No patient showed any sign of paradoxical arterial embolism or cardiac dysfunction. We conclude that VAE occurs not only during surgery in the sitting position, but also with release of PEEP and during repositioning to the supine position. IMPLICATIONS: This study shows that venous air embolism (VAE) occurs not only during surgery in the sitting position but also during positive end-expiratory pressure release and repositioning of the patient into the supine position. Continuous monitoring for VAE should be performed until the patient is returned to the supine position.

PMID: 11812707, UI: 21670875

Anesth Analg 2002 Feb;94(2):355-9, table of contents

Paravertebral blockade for minor breast surgery.

Terheggen MA, Wille F, Borel Rinkes IH, Ionescu TI, Knape JT

Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands. mterhegg@euronet.nl

Paravertebral blockade (PVB) has been advocated as a useful technique for breast surgery. We prospectively compared the efficacy of PVB via a catheter technique with the efficacy of general anesthesia (GA) for minor breast surgery. Thirty patients were randomized into two groups to receive either PVB or GA. Variables of efficacy were postoperative pain measured on a visual analog scale, postoperative nausea and vomiting (PONV), recovery time, and patient satisfaction. Postoperative visual analog scale scores in the PVB group were significantly lower in the early postoperative period (maximum, 12 vs 45 mm; P < 0.01). In both groups, PONV was nearly absent. There was no difference in recovery time. Patient satisfaction was better in the PVB group (2.8 vs 2.3; scale, 0-3; P < 0.01). There was one inadvertent epidural block and one inadvertent pleural puncture in the PVB group. Although PVB resulted in better postoperative pain relief, the advantages over GA were marginal in this patient group because postoperative pain was relatively mild and the incidence of PONV was small. Considering that the technique has a certain complication rate, we conclude that at present the risk/benefit ratio of PVB does not favor routine use for minor breast surgery. IMPLICATIONS: This study confirms the previously reported superior pain relief after paravertebral blockade (PVB) for breast surgery. However, considering the relatively mild postoperative pain and therefore the limited advantage of PVB for these patients, the risk/benefit ratio does not favor the routine use of PVB for minor breast surgery.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 11812698, UI: 21670866

Anesth Analg 2002 Feb;94(2):266-70, table of contents

Age-stratified pharmacokinetics of ketorolac tromethamine in pediatric surgical patients.

Dsida RM, Wheeler M, Birmingham PK, Wang Z, Heffner CL, Cote CJ, Avram MJ

Department of Pediatric Anesthesiology, Children's Memorial Hospital, Chicago, Illinois 60614, USA. r-dsida@northwestern.edu

Published data suggest that ketorolac pharmacokinetics are different in children than in adults. We sought to better characterize ketorolac pharmacokinetics in children. Thirty-six children, aged 1-16 yr, were stratified into four age groups: 1-3 yr, 4-7 yr, 8-11 yr, and 12-16 yr. Each child received 0.5 mg/kg of ketorolac tromethamine IV after completion of elective surgery. A maximum of 16 venous blood samples (mean, 13 +/- 2) were collected at predetermined times up to 10 h after drug administration. Plasma ketorolac concentrations were measured by high-performance liquid chromatography after solid-phase extraction. Individual concentration-versus-time relationships were best fit to a two-compartment pharmacokinetic model by using SAAM II. Body weight-normalized pharmacokinetic variables did not differ among the age groups and were similar to those reported for adults, including a volume of distribution at steady state of 113 +/- 33 mL/kg (mean +/- SD) and an elimination clearance of 0.57 +/- 0.17 mL x min(-1) x kg(-1). Our study demonstrates that a single dose of ketorolac (0.5 mg/kg) results in plasma concentrations in the adult therapeutic concentration range for 6 h in most children. Our data provide no evidence that children require either larger weight-adjusted doses or shorter dosing intervals than adults to provide similar plasma drug concentrations. IMPLICATIONS: The literature suggests that ketorolac disposition differs between children and adults. We characterized ketorolac pharmacokinetics in 36 children. Body weight-normalized two-compartment pharmacokinetic variables did not differ among pediatric patients <17 yr old and were similar to adult values.

PMID: 11812682, UI: 21670850

Anesth Analg 2002 Feb;94(2):259-65, table of contents

Ropivacaine undergoes slower systemic absorption from the caudal epidural space in children than bupivacaine.

Karmakar MK, Aun CS, Wong EL, Wong AS, Chan SK, Yeung CK

Department of Anesthesia and Intensive Care, Pediatric Surgical Division, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong. karmakar@cuhk.edu.hk

We compared the systemic absorption of ropivacaine and bupivacaine after caudal epidural administration in children. Twenty ASA physical status I or II children aged 1-7 yr undergoing elective hypospadias repair were randomized after the induction of general anesthesia to receive a single caudal epidural injection of 2 mg/kg of either ropivacaine 0.2% (R) or bupivacaine 0.2% (B) in a double-blinded fashion. Peripheral venous blood samples (1 mL) were obtained before and 1, 5, 10, 15, 20, 30, 40, 50, 60, 70, 80, 90, and 120 min after the caudal injection. The total R and B concentration was measured in plasma by using high-performance liquid chromatography. All blocks were successful, and there were no complications. The peak plasma concentration (mean +/- SD) (R = 0.67 +/- 0.16 and B = 0.73 +/- 0.23 microg/mL) and the area under the plasma concentration curve (R = 61.9 +/- 20.6 and B = 62.7 +/- 18.2 microg x mL(-1) x min(-1)) were comparable between the two study groups. The median (range) time to attain peak plasma concentration was significantly slower in children who received ropivacaine (R = 65 [10-120] min and B = 20 [15-50] min, P < 0.05). We conclude that ropivacaine undergoes slower systemic absorption from the caudal epidural space in children than does bupivacaine. IMPLICATIONS: We compared the systemic absorption of ropivacaine (0.2%) and bupivacaine (0.2%) after caudal epidural injection of 2 mg/kg in children aged 1-7 yr. Our results show that ropivacaine undergoes slower systemic absorption from the caudal epidural space in children than does bupivacaine.

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 11812681, UI: 21670849

Anesth Analg 2002 Feb;94(2):255-8, table of contents

Preserved CO(2) reactivity and increase in middle cerebral arterial blood flow velocity during laparoscopic surgery in children.

Huettemann E, Terborg C, Sakka SG, Petrat G, Schier F, Reinhart K

Departments of Anesthesiology and Intensive Care Medicine, Neurology, and Pediatric Surgery, Friedrich-Schiller-University Jena, Jena, Germany.

In adult patients, the creation of pneumoperitoneum (PP) by means of carbon dioxide (CO(2)) insufflation leads to an increase in cerebral blood flow velocity (CBFV), which is thought to be caused by hypercapnia. We evaluated whether PP leads to an increase of CBFV in children, and whether this increase is directly related to PP. The effects of PP on middle cerebral artery blood flow velocity were investigated in 12 children (mean age 3 yr, range 15-63 mo) undergoing laparoscopic herniorrhaphy under general anesthesia with sevoflurane and nitrous oxide/oxygen. CBFV was measured by using transcranial Doppler ultrasonography. During CO(2) insufflation, the end-tidal CO(2) concentration was kept constant by adjustment of ventilation by increasing minute volume. The CBFV increased significantly at an intraabdominal pressure of 12 mm Hg compared with baseline from 68 +/- 11 cm/s to 81 +/- 12 cm/s (P < 0.05). CO(2) reactivity remained in the normal range (4.0% +/- 1.9%/mm Hg) during PP. We conclude that the induction of PP leads to an increase in middle cerebral artery blood flow velocity in young children independent from hypercapnia, whereas CO(2) reactivity remains normal. IMPLICATIONS: Laparoscopic surgery is performed frequently in pediatric patients. Cerebral blood flow velocities increase during insufflation of the intraperitoneal cavity for minimally invasive surgery in children. The vasoreactivity as part of the cerebral autoregulation remains unaffected.

PMID: 11812680, UI: 21670848

Eur J Anaesthesiol 2002 Jan;19(1):63-8

Prophylactic intravenous bolus ephedrine for elective Caesarean section under spinal anaesthesia.

Loughrey JP, Walsh F, Gardiner J

Department of Anesthesia, Rotunda Hospital, Dublin, Ireland. jloughrey@eircom.net

[Medline record in process]

BACKGROUND AND OBJECTIVE: To evaluate the efficacy and optimal dose of prophylactic intravenous ephedrine for the prevention of maternal hypotension associated with spinal anaesthesia for Caesarean section. METHODS: After patients had received an intravenous preload of 0.5 L of lactated Ringer's solution, spinal anaesthesia was administered in the sitting position with hyperbaric bupivacaine 2.5 mL 0.5% combined with 25 microg fentanyl. A total of 68 patients were randomized to receive a simultaneous 2 mL bolus intravenously of either 0.9% saline (Group C, n = 20), ephedrine 6 mg (Group E-6, n = 24), or ephedrine 12 mg (Group E-12, n = 22). Further rescue boluses of ephedrine 6 mg were given if systolic arterial pressure fell to below 90 mmHg, greater than 30% below baseline, or if symptoms suggestive of hypotension were reported. RESULTS: There was a significantly higher incidence of hypotension in Group C (60% patients) compared to Group E-12 (27%), but not in Group E-6 (50%). The 95% Confidence Interval for the difference in proportions between Groups C and E-12 was 6-60%, P < 0.05. Fewer rescue boluses of ephedrine were required in Group E-12 compared with Group C (1.8 +/- 1.2 vs. 3.3 +/- 2.1, P < 0.05). There were no significant differences in the incidence of maternal nausea or vomiting, or of neonatal acidaemia between groups. CONCLUSION: A prophylactic bolus of ephedrine 12 mg intravenously given at the time of intrathecal block, plus rescue boluses, leads to a lower incidence of hypotension following spinal anaesthesia for elective Caesarean section compared to intravenous rescue boluses alone.

PMID: 11915786, UI: 21910481

Eur J Anaesthesiol 2002 Jan;19(1):9-17

Anaesthetic agents in paediatric day case surgery: do they affect outcome?

Moore EW, Pollard BJ, Elliott RE

University of Liverpool, University Department of Anaesthesia, UK. e.w.m@17druids.freeserve.co.uk

[Medline record in process]

Both the numbers of children undergoing day case surgery and the type of procedures performed in this way are increasing. This expansion will only be beneficial if anaesthesia and surgery are provided with minimal post-operative morbidity e.g. postoperative delirium or nausea and vomiting. The choice of anaesthetic technique is considered critical to optimizing the service provided to patients and for this reason much research has addressed this question. This review considers the effect of anaesthetic technique on postoperative outcome in paediatric day case surgery. The outcome measures reviewed by this article are induction of anaesthesia, effects on the cardiovascular system, recovery from anaesthesia and postoperative nausea and vomiting. In each section both quantitative and qualitative outcome measures are discussed. Comparisons are made between sevoflurane and halothane, sevoflurane and propofol, propofol and halothane, desflurane and halothane and the presence or absence of nitrous oxide.

PMID: 11913809, UI: 21910473

Eur J Anaesthesiol 2002 Jan;19(1):75

From which countries do chairpersons and invited speakers at important anaesthesia and intensive care meetings come?

Gelb AW

[Medline record in process]

Publication Types:

• Letter

PMID: 11913808, UI: 21910484

J Oral Maxillofac Surg 2002 Mar;60(3):244-50; discussion 250-1

Remifentanil for use during conscious sedation in outpatient oral surgery.

Ganzberg S, Pape RA, Beck FM

Department of Oral and Maxillofacial Surgery, Pathology and Anesthesiology, College of Dentistry, The Ohio State University, Columbus, OH 43218-2357, USA.

PURPOSE: Remifentanil is a new, short-acting opioid that is similar pharmacodynamically to currently available opioids but differs in its pharmacokinetics. In the present study, we compared the use of remifentanil with the use of meperidine during intravenous conscious sedation for third molar surgery. PATIENTS AND METHODS: Forty patients who were scheduled for the removal of impacted third molars were randomly assigned to undergo 1 of 2 intravenous conscious sedation techniques. For both groups, 50:50 nitrous oxide oxygen were administered via nasal hood, and midazolam was titrated to Verril's sign. Twenty patients each then received either remifentanil 0.05 microgram/kg/min or meperidine 50 mg. Both patients and surgeons were blinded to the narcotic that was used. Blood pressure, heart rate, and oxygen saturation were determined before sedation and every 5 minutes during surgery. Recovery was measured using serial Trieger tests every 5 minutes after surgery. Patient and surgeon satisfaction of the quality of sedation was measured with a visual analog scale. RESULTS: Peak heart rate (91 beats/min for remifentanil vs 107 beats/min for meperidine, P <.01) and peak systolic blood pressure (131 mm Hg for remifentanil vs. 142 mm Hg for meperidine, P <.05) were significantly lower for the remifentanil group. Although there was a trend toward increased surgeon satisfaction with remifentanil (86 of 100 with remifentanil vs. 73 of 100 with meperidine), it was not found to be statistically significant. Likewise, other physiologic parameters were not found to be statistically significant. CONCLUSIONS: The lower peak heart rate and systolic blood pressure levels indicate that remifentanil may allow for less fluctuation in cardiovascular parameters. This could prove beneficial in patients with cardiovascular compromise. Copyright 2002 American Association of Oral and Maxillofacial Surgeons

Publication Types:

• Clinical trial
• Randomized controlled trial

PMID: 11887131, UI: 21884224

Neurosci Lett 2002 Feb 22;319(3):141-4

Decrease of the electroacupuncture-induced analgesic effects in nuclear factor-kappa B1 knockout mice.

Park HJ, Lee HS, Lee HJ, Yoo YM, Lee HJ, Kim SA, Leem K, Kim HC, Seo JC, Kim EH, Lim S, Chung JH

Research Group of Pain and Neuroscience, Kyung Hee University, Hoegidong, Dongdaemoongu, Seoul, South Korea.

To investigate the involvement of nuclear factor kappa B1 (NF-kappaB1; p50/p105) in electroacupuncture (EA)-induced analgesia, 2 and 100 Hz EA stimulations were applied at acupoint ST36 (Zusanli) in NF-kappaB1 knockout mice. EA was performed for 30 min and tail-flick latencies (TFLs) were evaluated every 15 min for 1 h. Wild-type mice displayed a 63.3% increase in TFLs compared to baseline after 2 Hz EA, whereas NF-kappaB1+/- mice exhibited a 41.8% increase and NF-kappaB1-/- mice showed only a 3.9% increase of TFLs. The TFLs of 100 Hz EA showed similar trends: a 72.6% increase of TFLs in wild-type, a 38.6% increase in NF-kappaB1+/- and a 9.3% increase in NF-kappaB1-/- mice. The present findings suggest that NF-kappaB1 may play a crucial role in both low and high frequency EA-induced analgesic effects.

PMID: 11834313, UI: 21824271

Pediatr Dent 2001 Nov-Dec;23(6):487-90

The influence of medical history on restorative procedure failure rates following dental rehabilitation.

Ng MW, Tate AR, Needleman HL, Acs G

Pediatric Dentistry Residency Program, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA.

PURPOSE: This study evaluated the association between patient medical history and the outcomes of restorative procedures performed under general anesthesia. METHODS: The dental records of patients who had dental rehabilitation under general anesthesia at Children's Hospital in Boston (1990-1992) and Children's National Medical Center in Washington, DC (1994-1998) were examined. Data regarding restorative outcomes and the association between patient medical history and restorative failures were assessed using chi-square tests with correction for continuity. T-tests were performed on parametric data. RESULTS: Significantly higher stainless steel crown failure rates were found in young patients diagnosed with developmental disabilities when compared to patients without such disabilities (p<0.025, x2 = 5.50). However, there was no difference in the failure rates of SSCs in young patients with significant medical histories compared to patients without significant medical histories. Regarding amalgam and composite restorations, there were no differences in failure rates among patients with and without significant medical histories, including developmental disabilities. CONCLUSIONS: SSC failures were higher in young children with developmental disabilities compared to children without these disabilities.

PMID: 11800448, UI: 21658677

Reg Anesth Pain Med 2002 Mar-Apr;27(2):220-4

Vertebral osteomyelitis and psoas abscess occurring after obstetric epidural anesthesia.

Lee BB, Kee WD, Griffith JF

Departments of Anaesthesia and Intensive Care (B.B.L., W.D.N.K.) and Diagnostic Radiology and Organ Imaging (J.F.G.), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.

[Medline record in process]

BACKGROUND AND OBJECTIVES: Back pain and infectious complications occasionally occur after epidural anesthesia in obstetrics, and accurate diagnosis can be difficult. We report a patient who developed low back pain soon after obstetric epidural anesthesia and was diagnosed 6 months later with lumbar vertebral osteomyelitis, discitis, and a psoas abscess. CASE REPORT: A 34-year-old woman developed persistent low back pain after receiving epidural anesthesia for labor analgesia and cesarean delivery. After 6 months, a diagnosis of lumbar vertebral osteomyelitis, discitis, and psoas abscess was made, and surgery was performed. Because of the temporal and anatomical relationships between epidural catheterization and the development of symptoms, the preceding epidural anesthesia was initially suspected as a potential cause. However, because the posterior spinal elements were unaffected and the infectious agent was subsequently identified as tuberculous, the cause was eventually determined as unlikely to be related to the epidural procedure. CONCLUSION: Investigation of severe back pain after epidural anesthesia should include consideration of infectious causes, such as vertebral osteomyelitis and discitis, which may not be causally related to the epidural catheterization itself. Reg Anesth Pain Med 2002;27:220-224.

PMID: 11915074, UI: 21912603

Reg Anesth Pain Med 2002 Mar-Apr;27(2):217-219

Patient-controlled epidural analgesia for labor and delivery in a parturient with chronic inflammatory demyelinating polyneuropathy.

Velickovic IA, Leicht CH

Department of Anesthesiology, The Western Pennsylvania Hospital, Pittsburgh, Pennsylvania.

[Record supplied by publisher]

OBJECTIVE: The anesthetic management of labor and delivery in patients with any form of chronic inflammatory demyelinating polyneuropathy (CIDP) is not well defined. Using patient-controlled epidural analgesia (PCEA), or epidural analgesia, in such a rare clinical situation has not been previously reported. CASE REPORT: A 32-year-old, gravida 3, para 2, woman with a 2(1/2) year history of CIDP was admitted for labor and delivery at 38 weeks of pregnancy. At the time she presented for labor analgesia, she complained of bilateral hand and foot weakness and tingling. PCEA with 0.1% ropivacaine and fentanyl 2 &mgr;g/mL was used for labor analgesia. The patient was pain free during labor and delivery and had an uneventful postpartum course. CONCLUSION: PCEA had no apparent detrimental affect on the patient's disease and may be a reasonable option for patients with CIDP presenting for labor and delivery. Reg Anesth Pain Med 2002;27:217-219.

PMID: 11915073

Reg Anesth Pain Med 2002 Mar-Apr;27(2):193-6

The anesthesiologist's guide to personal digital assistants.

Jahan A, Gretter B, Smith MP

Department of General Anesthesiology, The Cleveland Clinic Foundation (A.J., M.P.S.), Cleveland, Ohio; and Ohio State University (B.G.), Columbus, Ohio.

[Medline record in process]

BACKGROUND AND OBJECTIVES: Personal digital assistants (PDAs) are being used more frequently by anesthesiologists. PDAs are pocket-sized electronic devices that, at their most basic level, store information. Basic features include calendar, phone directory, memo pad, and checklist. More advanced features are increasingly common and blur the distinction between PDAs and personal computers (PCs). This article reviews the main options for PDAs, purchasing tips, and software applications, especially as they apply to anesthesiologists. Reg Anesth Pain Med 2002;27:193-196.

PMID: 11915067, UI: 21912596

Reg Anesth Pain Med 2002 Mar-Apr;27(2):180-92

Airway regional anesthesia for awake fiberoptic intubation.

Simmons ST, Schleich AR

Department of Anesthesia, University of Iowa, Iowa City, Iowa.

[Medline record in process]

PMID: 11915066, UI: 21912595

Reg Anesth Pain Med 2002 Mar-Apr;27(2):173-179

Use of a charged lidocaine derivative, tonicaine, for prolonged infiltration anesthesia.

Khan MA, Gerner P, Sudoh Y, Wang GK

Department of Anesthesiology, Tufts University School of Medicine and New England Medical Center (M.A.K.) and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School (P.G., Y.S., G.K.W.), Boston, Massachusetts.

[Record supplied by publisher]

BACKGROUND AND OBJECTIVES: We tested the hypothesis that the duration of cutaneous anesthesia elicited by the permanently charged compound N-phenylethyl lidocaine (tonicaine) would be longer than that elicited by its parent structure, lidocaine, and that it would be less affected by epinephrine (epi), after subcutaneous injection in rats, as a model for infiltration anesthesia. METHODS: Subcutaneous injections were performed on the shaved dorsal skin of rats with either tonicaine or lidocaine (0.1% or 0.5%, n = 8 in each group) with and without epi (1:200,000). Inhibition of the cutaneous trunci muscle reflex was quantitatively evaluated by a blinded observer by the number of times pinpricks failed to elicit the nocifensive motor response out of a total of 6 pinpricks applied to the injected area. RESULTS: Duration of complete nociceptive blockade in the 0.5% tonicaine and lidocaine groups was 619 +/- 47 and 58 +/- 2 minutes, respectively; duration of full recovery in these groups was 1,106 +/- 19 and 86 +/- 3 minutes, respectively. Epi increased the duration of complete block in the 0.5% tonicaine and lidocaine groups to 750 +/- 13 and 97 +/- 11 minutes, respectively, and the duration of full recovery to 1,185 +/- 13 and 172 +/- 6 minutes, respectively. Skin toxicity was seen only in the 0.5% tonicaine with epi group (3 of 8 rats). CONCLUSIONS: Tonicaine is a substantially longer lasting local anesthetic with a delayed onset of action compared with lidocaine and may be useful in situations where long duration of infiltration block is desirable. Reg Anesth Pain Med 2002;27:173-179.

PMID: 11915065

Reg Anesth Pain Med 2002 Mar-Apr;27(2):162-7

Buprenorphine added to the local anesthetic for axillary brachial plexus block prolongs postoperative analgesia.

Candido KD, Winnie AP, Ghaleb AH, Fattouh MW, Franco CD

Departments of Anesthesiology and Pain Management, Cook County Hospital (A.H.G., M.W.F.), and Rush Medical College (K.D.C., A.P.W., C.D.F.), Chicago, Illinois.

[Medline record in process]

BACKGROUND AND OBJECTIVES: Buprenorphine added to local anesthetic solutions for supraclavicular block was found to triple postoperative analgesia duration in a previous study when compared with local anesthetic block alone. That study, however, did not control for potentially confounding factors, such as the possibility that buprenorphine was affecting analgesia through intramuscular absorption or via a spinal mechanism. To specifically delineate the role of buprenorphine in peripherally mediated opioid analgesia, the present study controlled for these 2 factors. METHODS: Sixty American Society of Anesthesiologists (ASA) P.S. I and II, consenting adults for upper extremity surgery, were prospectively assigned randomly in double-blind fashion to 1 of 3 groups. Group I received local anesthetic (1% mepivacaine, 0.2% tetracaine, epinephrine 1:200,000), 40 mL, plus buprenorphine, 0.3 mg, for axillary block, and intramuscular (IM) saline. Group II received local anesthetic-only axillary block, and IM buprenorphine 0.3 mg. Group III received local anesthetic-only axillary block and IM saline. Postoperative pain onset and intensity were compared, as was analgesic medication use. RESULTS: The mean duration of postoperative analgesia was 22.3 hours in Group I; 12.5 hours in group II, and 6.6 hours in group III. Differences between groups I and II were statistically significant (P =.0012). Differences both between groups I and III and II and III were also statistically significant (P <.001). CONCLUSIONS: Buprenorphine-local anesthetic axillary perivascular brachial plexus block provided postoperative analgesia lasting 3 times longer than local anesthetic block alone and twice as long as buprenorphine given by IM injection plus local anesthetic-only block. This supports the concept of peripherally mediated opioid analgesia by buprenorphine. Reg Anesth Pain Med 2002;27:162-167.

PMID: 11915063, UI: 21912592

Reg Anesth Pain Med 2002 Mar-Apr;27(2):157-161

Comparison of racemic bupivacaine, ropivacaine, and levo-bupivacaine for pediatric caudal anesthesia: Effects on postoperative analgesia and motor block.

Ivani G, Denegri P, Conio A, Grossetti R, Vitale P, Vercellino C, Gagliardi F, Eksborg S, Lonnqvist PA

Department of Anesthesiology, Regina Margherita Children's Hospital, (G.I., A.C., R.G., P.V., C.V., F.G.), Turin, Italy; Department of Anesthesiology, Casa Sollievo Sofferenza, San Giovanni (P.DN.), Rotondo, Italy; and the Department of Anesthesiology, KS/Astrid Lindgrens Children's Hospital (S.E., P.-A.L), Stockholm, Sweden.

[Record supplied by publisher]

BACKGROUND AND OBJECTIVES: To compare ropivacaine, levo-bupivacaine, and racemic bupivacaine for caudal blockade in children. METHODS: Using a prospective observer blinded design, 60 sevoflurane anesthetized children (1 to 7 years) undergoing minor subumbilical surgery, were randomized to receive a caudal block (1 mL/kg) with either ropivacaine 0.2%, racemic bupivacaine 0.25%, or levo-bupivacaine 0.25%. Postoperative analgesia (number of patients needing supplemental analgesia as defined by an objective pain score [OPS] score of >/= 5; time to first analgesic demand) during the first 24 postoperative hours was chosen as the primary end-point. Early postoperative motor block (3-point scale) was assessed as a secondary end-point. RESULTS: All blocks were judged to be clinically successful based on the presence of adequate intraoperative and early postoperative analgesia. An OPS score >/= 5 was found in 5/20 patients in each study group. No difference regarding the time to first analgesic demand was found between the study groups. The use of ropivacaine (P =.02), but not levo-bupivacaine (P =.18), was found to be associated with less motor block during the first postoperative hour compared with racemic bupivacaine. CONCLUSION: All 3 investigated local anesthetics were found to be clinically comparable despite the slight reduction of early postoperative motor block associated with the use of ropivacaine. Reg Anesth Pain Med 2002;27:157-161.

PMID: 11915062

Reg Anesth Pain Med 2002 Mar-Apr;27(2):132-8

Epidural analgesia and postoperative lipid metabolism: Stable isotope studies during a fasted/fed state.

Carli F, Lattermann R, Schricker T

Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada.

[Medline record in process]

BACKGROUND AND OBJECTIVES: Although previous studies have reported an inhibitory effect of epidural block and glucose feeding on plasma concentrations of glycerol and free fatty acids (FFA), it remains unclear how epidural analgesia modifies the postoperative production and uptake of lipid metabolites. This can be achieved by determining the rate of lipolysis during a feeding state with dextrose. METHODS: Twelve patients with or without postoperative epidural analgesia were studied 48 hours after surgery. They underwent a 6-hour stable isotope infusion study using [1,1,2,3,3,-(2)H(5)] glycerol; 3 hours of fasting, and 3 hours of dextrose infusion (4 mg/kg/min). The rate of glycerol appearance (R(a) glycerol) i.e., rate of lipolysis, and plasma concentrations of glycerol, FFA, glucose, lactate, insulin, glucagon, and cortisol were measured during the fasted and the fed states. RESULTS: The rates of lipolysis were similar in both groups during the fasted state and were not modified by dextrose infusion. In contrast, plasma concentrations of glycerol and FFA were decreased significantly during the fed state (P <.01). Glycerol clearance (ratio between R(a) glycerol and plasma glycerol concentration) increased significantly in both groups (P <.05) with feeding. Similarly, plasma concentrations of glucose and insulin increased significantly following feeding with dextrose in both groups. CONCLUSIONS: The elevated rates of lipolysis associated with surgery cannot be suppressed by either epidural analgesia or dextrose feeding implying that the sustained stress response continues in the postoperative period and is the most important factor responsible for the increased release of glycerol. Reg Anesth Pain Med 2002;27:132-138.

PMID: 11915058, UI: 21912587