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Anaesthesia 2002 Oct;57(10):1031-3
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PMID: 12358969, UI: 22246019
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Anaesthesia 2002 Oct;57(10):1029-30
PMID: 12358967, UI: 22246017
Anaesthesia 2002 Oct;57(10):1028
PMID: 12358963, UI: 22246013
Anaesthesia 2002 Oct;57(10):1007-11
Department of Anaesthesiology and Clinical Research Institute, University Hospital, Seoul National University College of Medicine, Seoul, Korea.
This study was performed to determine how the use of an introducer affects the extent to which a needle deflects during a spinal or combined spinal-epidural injection. A polystyrene block was used to simulate the paraspinal area of the back. A line was drawn perpendicular to the edge of the block to use as a guide and to measure the deflection. The use of an introducer needle decreased the deflection in all the bevelled needles (p < 0.001). Depending on the direction of both the bevels, the deflection decreased as the introducer bevel was changed from the same direction, to right-angles to bevel direction and then to a direction opposite to that of the spinal needle (p < 0.05). Deflection was decreased when a thick introducer was used (p < 0.001). The use of an introducer increased the deflection of the pencil-point needle only in the deflection direction of the introducer (p < 0.001). The 18-gauge Tuohy needle with a "backhole" deflected more than the corresponding needle without a backhole (p < 0.001), and the spinal needle inserted through the Tuohy needle with a backhole deflected more (p = 0.002). Besides the tip type and gauge, the deflection of a spinal needle depends upon the use of introducer, its gauge and bevel direction. The deflection of a Tuohy needle depends upon its design, gauge and the presence of a backhole.
PMID: 12358959, UI: 22246009
Anaesthesia 2002 Oct;57(10):947-8
PMID: 12358950, UI: 22246000
Anaesthesist 2002 Sep;51(9):747-53
Abteilung fur Anasthesie und Schmerztherapie, Rheumazentrum Oberammergau, Germany. gmeier@wz-kliniken.de
This study assesses a modified approach for suprascapular nerve block in a single shot and continuous catheter technique for the treatment of chronic shoulder pain. After thorough anatomic examinations, a new technique was performed in 30 patients by inserting the catheter into the suprascapular fossa. Complications of the technique, time of onset, effect and patient satisfaction were evaluated. The results show that there were no complications due to the technique and only one patient had a minor VAS score during physiotherapeutic exercise. Local inflammation occurred in one patient and dislocation of the catheter in another patients. Patient satisfaction (97%) was very high. The modified technique of continuous suprascapular nerve block is a safe and easy-to-perform technique in the treatment of acute and chronic shoulder pain.
PMID: 12232647, UI: 22217080
Anaesthesist 2002 Sep;51(9):721-5
Klinik fur Anasthesiologie und Intensivmedizin, Universitatskliniken des Saarlandes, Homburg/Saar, Germany. thomas.mencke@uniklinik-saarland.de
PURPOSE: To determine the influence of two different pretreatment intervals, i.e. 3 and 6 min, on the efficacy of 0.01 mg/kg cisatracurium in preventing succinylcholine-induced fasciculations and myalgia. METHODS: A total of 60 adult patients were randomized and received either 0.01 mg/kg cisatracurium (0.2*ED(95)) i.v. (Cis 3 group: pretreatment interval 3 min, Cis 6 group: pretreatment interval 6 min) or normal saline i.v. (placebo group) prior to injection of succinylcholine. The incidence and severity of fasciculations and myalgia and side-effects of precurarization were assessed. RESULTS: The incidence of muscle fasciculations was only reduced in the Cis 6 group (45%) compared with the Placebo group (85%), p<0.05. Cisatracurium was associated with a higher incidence of paralytic symptoms in both pretreatment groups (Cis 3: 75%, Cis 6: 80%) compared with the Placebo group (30%), p<0.05. CONCLUSION: Cisatracurium is only effective in preventing succinylcholine-induced fasciculations when a longer pretreatment interval, i.e. 6 min instead of 3 min, is chosen. Precurarization led to signs of paralysis in both pretreatment groups in the majority (75-80%) of patients without reducing the incidence or severity of postoperative myalgia.
PMID: 12232643, UI: 22217076
Anesth Analg 2002 Nov;95(5):1245-7, table of contents
Department of Anesthesiology, Pediatric Anesthesia N-65, Kosair Children's Hospital, 231 E. Chestnut Street, Louisville, KY 40202, USA. magidoc@yahoo.com
IMPLICATIONS: This case report describes a rare and potentially fatal anesthetic complication. It occurred during the care of a small premature infant as a result of improper use of medical equipment.
PMID: 12401603, UI: 22288622
Anesth Analg 2002 Nov;95(5):1173-8, table of contents
Department of Anesthesiology and Critical Care, Groupe Hospitalier Pitie-Salpetriere, Assistance Publique-Hopitaux de Paris, University Pierre et Marie Curie, 47 Boulevard de l'Hopital, 75013 Paris, France. daniel.eyraud@psl.ap-hop-paris.fr
Hepatic vascular exclusion (HVE) combines portal triad clamping and occlusion of the inferior vena cava. Although HVE has been performed for major liver resections during the last 2 decades, little is known about the mechanisms that explain its satisfactory hemodynamic tolerance. Consequently, we performed a comprehensive study of both hemodynamic and hormone responses to HVE. Twenty-two patients who underwent liver resection for secondary tumors developed in noncirrhotic livers were prospectively studied. Heart rate, arterial blood pressure, pulmonary artery pressure, mixed venous saturation, cardiac output, and left ventricular dimensions determined by transesophageal echocardiography were monitored in HVE patients. Blood concentrations of arginine vasopressin (AVP), epinephrine, norepinephrine, dopamine, and atrial natriuretic peptide and plasma renin activity (PRA) were measured before clamping; 5, 15, and 30 min after clamping; and 15 min after unclamping. Hemodynamic response to HVE was characterized by a significant (P < 0.05) decrease in left ventricular dimensions, fractional area change, and pulmonary artery pressure. We also observed a marked decrease in cardiac output (50%) and an increase in heart rate and systemic vascular resistance. After unclamping, there was peripheral vasodilation, assessed by a significant decrease in systemic vascular resistance from the preclamping value to unclamping. An acute and sustained increase in AVP and norepinephrine that returned to baseline after unclamping and the absence of modification in PRA concentrations were noted. The marked decrease in venous return that characterizes HVE is compensated for by an increase in vascular resistance secondary to an important activation of the AVP and sympathetic systems. The PRA system does not play an important role in maintaining arterial blood pressure during HVE. IMPLICATIONS: Hemodynamic and hormonal responses to the acute interruption of caval venous return to the heart were investigated in patients undergoing liver resection with hepatic vascular exclusion. A compensatory role for arginine vasopressin and sympathetic systems that provoked increased vascular resistance was demonstrated.
PMID: 12401586, UI: 22288605
Anesth Analg 2002 Nov;95(5):1147-53, table of contents
Post-Anesthesia Care Unit, Department of Anesthesiology and Critical Care, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel. draviw@tasmc.health.gov.il
Placing an implantable cardioverter defibrillator (ICD) involves the induction of ventricular fibrillation, whereupon the minimally effective defibrillation energy threshold (DFT) is determined. We evaluated the effects of 0.7% halothane, 1% isoflurane, or 1.5 micro g/kg of IV fentanyl during N(2)O/oxygen-based general anesthesia (GA) or those of subcutaneous 1.5% lidocaine plus IV 0.35 mg/kg of propofol on the DFT during ICD implantation in humans (n = 20 per group). Thirty minutes after the first set of DFT measurements under such conditions, the inhaled anesthetics were withdrawn, and all three GA groups received fentanyl 1 microg/kg IV (second set). A third set was taken 30 min later, before the GA patients awakened and when only N(2)O/oxygen was delivered for GA. The lidocaine plus propofol patients were given the same IV propofol bolus 1 min before each fibrillation/defibrillation trial and at the same time points as the three GA groups. The first DFTs were 16.1 +/- 2.2 J (halothane), 17.7 +/- 2.7 J (isoflurane), 16.4 +/- 2.9 J (fentanyl), and 12.9 +/- 3.8 J (lidocaine plus propofol) (P = 0.01). The second set of DFTs were significantly lower than the first sets for the halothane (P = 0.01) and isoflurane (P = 0.02), but not the fentanyl or lidocaine plus propofol, regimens. The third DFTs were significantly (P < 0.01) lower than the first ones for the three GA groups, but not for the lidocaine plus propofol patients. Thus, halothane, isoflurane, and fentanyl increased DFT values during ICD implantation in humans, whereas lidocaine plus intermittent small-dose IV propofol minimized these thresholds. IMPLICATIONS: Halothane, isoflurane, and IV fentanyl added to N(2)O/oxygen-based general anesthesia similarly increase minimal defibrillation threshold energy requirements (DFT) during cardioverter defibrillator implantation in humans. Subcutaneous lidocaine plus intermittent small-dose IV propofol minimizes DFT compared with these general anesthetics while providing equal patient satisfaction.
PMID: 12401582, UI: 22288601
Anesth Analg 2002 Nov;95(5):1142-6, table of contents
Department of Anesthesiology, College of Physicians & Surgeons, Columbia University, 622 West 168th Street, New York, NY 10032, USA. mrs21@columbia.edu
The increased use of transesophageal echocardiography (TEE) by anesthesiologists may lead to an increase in the intraoperative detection of previously undiagnosed patent foramen ovale (PFO). The impact of heart manipulation on interatrial shunting through a PFO during off-pump coronary artery bypass graft (CABG) has not been studied. We retrospectively studied 11 patients with PFOs who underwent off-pump CABG. TEE contrast studies and blood gas analyses were performed at baseline, during heart elevation for distal coronary arteries anastomoses, and at the end of the surgery. At baseline, 5 of 11 patients had left-to-right shunting and 2 of 11 had right-to-left shunting. Heart elevation did not result in oxygen desaturation in any patient; however, it caused the disappearance of a right-to-left shunt (n = 1), persistence of this shunt (n = 1), and the development of a new right-to-left shunt (n = 2). Return of the heart to its original position resulted in a return of TEE findings to the baseline state in all patients. This series suggests that off-pump CABG can be performed safely in the majority of patients with PFOs; however, additional investigation is needed to assure that adverse effects do not occur in a subset of patients undergoing off-pump CABG in the presence of a PFO. IMPLICATIONS: This case series suggests that coronary artery bypass graft surgery can be safely performed in most patients with patent foramen ovale without the use of a cardiopulmonary bypass.
PMID: 12401581, UI: 22288600
Anesth Analg 2002 Nov;95(5):1134-41, table of contents
Department of Anesthesiology, First Hospital, Peking University, No. 8 Xishiku Street, Beijing 100034, China. wangdongxin@hotmail.com
We investigated the effect of lidocaine on the incidence of cognitive dysfunction in the early postoperative period after cardiac surgery. One-hundred-eighteen patients undergoing elective coronary artery bypass surgery with cardiopulmonary bypass (CPB) were randomized to receive either lidocaine (1.5 mg/kg bolus followed by a 4 mg/min infusion during operation and 4 mg/kg in the priming solution of CPB) or placebo. A battery of nine neuropsychological tests was administered before and 9 days after surgery. A postoperative deficit in any test was defined as a decline by more than or equal to the preoperative SD of that test in all patients. Any patient showing a deficit in two or more tests was defined as having postoperative cognitive dysfunction. Eighty-eight patients completed pre- and postoperative neuropsychological tests. Plasma lidocaine concentrations (microg/mL) were 4.78 +/- 0.52 (mean +/- SD), 5.38 +/- 0.95, 4.52 +/- 0.39, 5.82 +/- 0.76, and 7.10 +/- 1.09 at 10 min before CPB; 10, 30, and 60 min of CPB; and at the end of operation, respectively. The proportion of patients showing postoperative cognitive dysfunction was significantly reduced in the lidocaine group compared with that in the placebo group (18.6% versus 40.0%; P = 0.028). We conclude that intraoperative administration of lidocaine decreased the occurrence of cognitive dysfunction in the early postoperative period. IMPLICATIONS: Postoperative cognitive dysfunction is a commonly recognized complication after cardiac surgery. Intraoperative cerebral microembolism and hypoperfusion have been proposed to be the major mechanisms. The results of this study show that intraoperative administration of lidocaine decreased the occurrence of early postoperative cognitive dysfunction, perhaps because of its neuroprotective effects.
PMID: 12401580, UI: 22288599
Br Dent J 2002 Aug 24;193(4):221-4
Eastman Dental Institute, London. rashid@kids-dentist.net
OBJECTIVE: To determine whether parents of children attending the outpatient general anaesthesia (OPGA) session at the Eastman Dental Hospital, London fully understand the proposed treatment. DESIGN: Observational study supported by structured questionnaires and interviews. SETTING: Casualty service in the Department of Paediatric Dentistry and the Victor Goldman Unit (a day-stay general anaesthetic unit) of the Eastman Dental Hospital. MAIN OUTCOME MEASURES: The parents' understanding of the consent was assessed based on their knowledge of the actual treatment procedure, the type of anaesthesia to be used and the number and type of teeth that would be extracted. RESULTS: Fifty-two of the 70 subjects (74%) approached completed both parts of the survey (interviews one and two). Results showed that 40% of the written consent obtained from the parents were not valid. The subjects' knowledge of the proposed treatment improved on the day of the actual treatment although 19% of them still did not fully understand the procedure. There was a statistically significant increase in the proportion of valid consent on the day of the actual treatment. Many of the subjects had no knowledge of the type of anaesthesia that would be used for their children but were more aware of the number and type of teeth that were going to be extracted. The time interval between the consent process and the actual treatment did not have any significant effect on the subjects' understanding of the consent, but it implied that with time the subjects' knowledge improved. CONCLUSION: A proportion of subjects did not fully understand the proposed treatment procedure even after being adequately informed. Appropriate measures should be taken to ensure that the patients or their guardians truly understand the proposed treatment.
PMID: 12222909, UI: 22210722
Br Dent J 2002 Aug 24;193(4):203-5
Oral Surgery Department, Edinburgh. Nick.Malden@lpct.scot.nhs.uk
Lingual nerve damage subsequent to lower wisdom tooth removal affects a small number of patients, sometimes producing permanent sensory loss or impairment. A number of surgical techniques have been described which are associated with low incidences of this distressing post-operative complication. When a technique is adopted by an individual clinician then a personal audit may be prudent to establish how effective it is in relation to established nerve injury rates. This audit looks at a technique involving the minimal interference of lingual soft tissues during lower wisdom tooth removal in a high street practice situation for patients having mild to moderate impacted wisdom teeth removed under local anaesthetic. It was concluded that the technique employed was associated with a low incidence of lingual nerve trauma, comparable with that reported elsewhere.
PMID: 12222906, UI: 22210719
Br Dent J 2002 Aug 10;193(3):161-4
Department of Paediatric Dentistry, Dundee Dental Hospital. j.foley@dundee.ac.uk
OBJECTIVES: Firstly to determine the current provision of sedation in primary dental care in an area of Scotland without local secondary care support and secondly, to investigate dental practitioners' desire for formal postgraduate training in sedation techniques. DESIGN: A prospective postal questionnaire-based study. SETTING: Grampian Primary Care NHS Trust, UK, 2001. SUBJECTS: Questionnaires were sent to all NHS dental practitioners and community dental service clinicians (N = 194] employed through Grampian Primary Care NHS Trust, Scotland during March - April 2001. The questionnaires sought details about personal status and the use and perceived need for conscious sedation techniques in practice in addition to the stated desire for postgraduate training in sedation techniques. RESULTS: One hundred and thirty-six questionnaires were returned (70%). Forty-nine per cent of respondents reported current sedation use, with intravenous sedation the favoured technique (82%), followed by oral sedation (33%) and inhalation sedation (19%). Seventy-four per cent of participants considered that there was a need for sedation in their own practice and 68% were interested in further postgraduate training in sedation techniques. CONCLUSION: Nearly three-quarters of practitioners who responded felt that there was a need for sedation in their own practice, although less than half were able to offer sedation to their patients. Nearly 70% of practitioners felt there was a need for postgraduate training in sedation techniques.
PMID: 12213010, UI: 22200731
Br Dent J 2002 Aug 10;193(3):145-6
Tees and North EastYorkshire NHS Trust. g.j.brown@tinyworld.co.uk
From time to time a patient may attend your practice with a systemic condition that you may or may not remember from the small print of your undergraduate text books. This paper describes one such systemic condition, porphyria, and its dental management. This paper also describes the use of relative analgesia as an aid to anxiety management in porphyria.
PMID: 12213008, UI: 22200729
Br J Anaesth 2002 Oct;89(4):662; discussion 663
PMID: 12393380, UI: 22280462
Br J Anaesth 2002 Oct;89(4):652-5
Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
We describe a case of a 36-yr-old patient who presented at 14 weeks gestation with multifocal dysrrhythmic episodes. Despite treatment with anti-arrythmic agents and an implantable cardioverter defibrillator (ICD) in situ, she continued to experience persistent dysrrhythmic episodes. She was delivered by Caesarean section at 34 weeks under general anaesthesia. We discuss some of the anaesthetic challenges of parturients with ICD devices.
PMID: 12393373, UI: 22280455
Br J Anaesth 2002 Oct;89(4):641-3
Department of Anaesthesiology, Jichi Medical School, Minamikawachi-machi, Tochigi 329-0498, Japan.
A patient with learning difficulties had a large tracheal tumour at the carina that caused severe respiratory distress. I.v. anaesthesia with propofol, spontaneous breathing through a tracheal tube, and high frequency jet ventilation were successfully employed during bronchoscopic resection of the tumour.
PMID: 12393369, UI: 22280451
Br J Anaesth 2002 Oct;89(4):637-40
Department of Anaesthesia and Intensive Care, City of Vienna Hospital Lainz, A-1130 Vienna, Austria.
BACKGROUND: During carotid endarterectomy under regional anaesthesia, patients often require medication to control haemodynamic instability and to provide sedation and analgesia. Propofol and remifentanil are used for this purpose. However, the benefits, side-effects, and optimal dose of these drugs in such patients are unclear. METHODS: Sixty patients were included in a prospective, randomized, single blinded study. All patients received a deep cervical plexus block with 30 ml ropivacaine 0.75% and were randomized to receive either remifentanil 3 micro g kg(-1) h(-1) or propofol 1 mg kg(-1) h(-1). The infusions were started after performing the regional block and were stopped at the end of surgery. Arterial pressure, ECG, ventilatory rate, and Pa(CO(2)) were measured continuously and recorded at predetermined times. Twenty-four hours after surgery, patient comfort, and satisfaction were also evaluated. RESULTS: In three patients, the infusion of remifentanil had to be stopped because of severe respiratory depression or bradycardia. No significant differences were found between the two groups in haemodynamic variables or sedative effects, but there was a significantly greater decrease in ventilatory frequency and increase in Pa(CO(2)) in the remifentanil group. The patient's subjective impressions and pain control were excellent in both groups. CONCLUSION: As a result of the higher incidence of adverse respiratory effects with remifentanil and similar sedative effects, propofol is preferable for sedation during cervical plexus block in elderly patients with comorbid disease at the dosage used.
PMID: 12393368, UI: 22280450
Br J Anaesth 2002 Oct;89(4):622-32
Department of Surgical Gastroenterology, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark.
PMID: 12393365, UI: 22280447
Br J Anaesth 2002 Oct;89(4):541-5
Department of Anaesthetics and Intensive Care Medicine, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN, Wales, UK.
BACKGROUND: The filtration performance of breathing system filters can be determined by measuring the penetration of sodium chloride particles through the filter media. METHOD: The penetration of sodium chloride particles through 12 breathing system filters was measured by two different techniques (using either forward light-scattering laser photometers or a neutral hydrogen flame photometer). RESULTS: The geometric means of the penetration values for the 12 filters varied from 0.0039% to 22.6% and from 0.0004% to 20.6% for the two techniques, respectively. For 10 of the 12 filters, with penetration values greater than 0.03%, the penetration values measured by, and the repeatability of, the two techniques were similar. The ratio of the penetration values measured by the two techniques (calculated from the mean difference in log(10)(penetration) between the two techniques for these 10 filters) was 0.93 (95% confidence interval 0.38 to 2.30). There is therefore only a small difference (at most a factor of about two either way) between the two techniques compared with the thousand-fold range in penetration values of the breathing system filters. For the remaining two filters, penetration values obtained using the flame photometer were less, and were close to or below the detection threshold of the laser photometer. CONCLUSION: The neutral hydrogen flame photometer provides similar results to the forward light-scattering laser photometer technique.
PMID: 12393352, UI: 22280434
Br J Anaesth 2002 Aug;89(2):342; discussion 343
PMID: 12378680, UI: 22266345
PMID: 12378679, UI: 22266344
Br J Anaesth 2002 Aug;89(2):331-4
St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK.
The prolonged anticoagulant effects of high-dose low molecular weight heparin (LMWH) pose problems in pregnant women when unanticipated delivery is required. We present two pregnant women on therapeutic doses of LMWH whose labour did not progress smoothly. The Thrombelastograph coagulation analyser was used to assess the coagulation status periodically. It influenced surgical and anaesthetic management and there was a safe outcome.
PMID: 12378675, UI: 22266340
Br J Anaesth 2002 Aug;89(2):328-30
Department of Anaesthesia, University Hospital, Nottingham NG7 2UH, UK.
We describe a case in which regional anaesthesia for Caesarean section was initially avoided because of the presence of systemic infection. However, attempted induction of general anaesthesia resulted in failed tracheal intubation and so an epidural catheter was sited and used for the operation. Awake fibreoptic tracheal intubation was performed after surgery, when it was clear that ventilatory support on the intensive care unit would be needed. The relative risks of regional versus general anaesthesia when infection and difficult laryngoscopy coincide are discussed.
PMID: 12378674, UI: 22266339
Br J Anaesth 2002 Aug;89(2):282-6
Department of Anaesthesia, Hammersmith Hospital, Ducane Road, London W12 0HS, UK.
BACKGROUND: Anaesthesia using xenon may be contraindicated in some situations because of its diffusion into intravascular bubbles. The expansion of air bubbles in water equilibrated with either nitrous oxide or xenon was studied. METHODS: Equilibrated water was transferred to a stirred vial, closed except for a long, narrow-bore tube. Injection of an air bubble caused displacement of water along the tube, allowing expansion of the bubble to be charted on a linear scale. RESULTS: At 20 degrees C, bubbles expanded from 10 microliters to a median volume of 23 microliters (range 20-23 microliters) and 30 microliters (range 27-34 microliters) in water equilibrated with xenon and nitrous oxide, respectively. Half of the expansion took place in the first 20 s (15-45 s) for xenon and in the first 5 s (5-10 s) for nitrous oxide. At 37 degrees C the expansion was less with both gases, but the relative differences were maintained between them. CONCLUSION: Xenon anaesthesia may be less likely to aggravate injury from intravascular bubbles than anaesthesia with nitrous oxide.
PMID: 12378668, UI: 22266333
Br J Anaesth 2002 Aug;89(2):260-4
Department of Anaesthesiology, Shanghai First People's Hospital, Shanghai 200080, China.
BACKGROUND: The bispectral index (BIS) and the rapidly extracted auditory evoked potentials index (A-line ARX Index or AAI) have been proposed as methods to measure the depth of sedation. A prospective study was designed to assess the performance of both these methods for measuring the depth of sedation induced by propofol or midazolam under epidural block. METHODS: Thirty-two ASA I and II adult patients undergoing elective gynaecological surgery under low-thoracolumbar epidural block were studied. Eighteen patients received propofol (Group P: 20 mg bolus every 3 min) and 14 received midazolam (Group M: 0.5 mg bolus every 5 min) until an observer's assessment of alertness/sedation (OAA/S) scale score of 1 was achieved. AAI and BIS were monitored for different OAA/S scores. RESULTS: AAI and BIS decreased and increased following the changes on the patients' OAA/S scores and correlated with sedation significantly. During the onset phase, the coefficients of Spearman's rank correlation for AAI and BIS were respectively 0.958 and 0.898 (P < 0.001) for Group P, and 0.973 and 0.945 (P < 0.001) for Group M. During the recovery phase in Group P, the coefficients were respectively 0.946 and 0.702 (P < 0.001). Linear regression analysis showed that both AAI and BIS were linearly related to the OAA/S scores. The coefficients of Spearman's rank correlation and linear regression for AAI were all greater than those for BIS (P < 0.05). CONCLUSIONS: Both AAI and BIS correlated well with the depth of sedation induced by propofol or midazolam under epidural block. AAI may be more valuable when monitoring depth of sedation.
PMID: 12378664, UI: 22266329
Br J Anaesth 2002 Aug;89(2):254-9
Department of Anesthesiology, New York University School of Medicine, 550 First Avenue, New York, NY 10016, USA.
BACKGROUND: Peripheral nerve blocks are almost always performed as blind procedures. The purpose of this study was to test the feasibility of seeing individual nerves of the brachial plexus and directing the block needle to these nerves with real time imaging. METHODS: Using ultrasound guidance, infraclavicular brachial plexus block was performed in 126 patients. Important aspects of this standardized technique included (i) imaging the axillary artery and the three cords of the brachial plexus posterior to the pectoralis minor muscle, (ii) marking the position of the ultrasound probe before introducing a Tuohy needle, (iii) maintaining the image of the entire length of the needle at all times during its advancement, (iv) depositing local anaesthetic around each of the three cords and (v) placing a catheter anterior to the posterior cord when indicated. RESULTS: In 114 (90.4%) patients, an excellent block permitted surgery without a need for any supplemental anaesthetic or conversion to general anaesthesia. In nine (7.2%) patients local or perineural administration of local anaesthetic, and in three (2.4%) conversion to general anaesthesia, was required. Mean times to administer the block, onset of block and complete block were 10.0 (SD 4.4), 3.0 (1.3) and 6.7 (3.2) min, respectively. Mean lidocaine dose was 695 (107) mg. In one patient, vascular puncture occurred. In 53 (42.6%) patients, an indwelling catheter was placed, but only three required repeat injections, which successfully prolonged the block. CONCLUSION: The use of ultrasound appears to permit accurate deposition of the local anaesthetic perineurally, and has the potential to improve the success and decrease the complications of infraclavicular brachial plexus block.
PMID: 12378663, UI: 22266328
Br J Anaesth 2002 Aug;89(2):251-3
Department of Anaesthesiology and Intensive Care Medicine, Hospital of the Philipps-University, Baldingerstrasse, D-35033 Marburg, Germany.
BACKGROUND: Absorption of local anaesthetics following intercostal blocks is rapid. Therefore, plasma concentrations of ropivacaine during intercostal blocks with ropivacaine 2, 5, 7.5 and 10 mg ml-1 (ropivacaine 5 ml injected into each of four intercostal spaces) in patients undergoing video-assisted thoracic surgery were determined. METHODS: After informed consent and ethics committee approval, 64 patients were randomly allocated to four groups for intercostal nerve block (ropivacaine 2, 5, 7.5 or 10 mg ml-1 at the end of surgery). Central (mixed) venous and arterial plasma samples were collected before the start of intercostal application, and 2, 5, 10, 15, 20, 30, 45, 60 and 90 min afterwards. Plasma concentrations of ropivacaine were measured by high performance liquid chromatography. RESULTS: Maximum venous plasma concentrations occurred after the mean times of 10.7 (range, 5-15), 10.8 (5-20), 11.3 (5-20) and 12.2 (5-45) min, respectively for each group. The groups had mean concentrations of 1.3 (SD, 0.6; range, 0.3-2.3), 2.1 (1.0; 0.5-4.5), 2.4 (1.0; 1.2-5.1) and 2.5 (0.9; 1.7-5.6) micrograms ml-1, respectively. Maximum arterial plasma concentration following 1.0% ropivacaine occurred after 16 (5-45) min with a mean of 2.3 (0.6; 1.5-3.6) micrograms ml-1. No signs of central nervous system or cardiac toxicity were observed. CONCLUSIONS: After intercostal blocks the absorption of ropivacaine is rapid compared with other techniques for regional anaesthesia and results in relatively high venous and arterial plasma concentrations, especially if a dose of 100 mg or more is used.
PMID: 12378662, UI: 22266327
Br J Anaesth 2002 Aug;89(2):226-30
Department of Anaesthesia, University of Cape Town, Medical School, Observatory, Cape 7925, South Africa.
BACKGROUND: This study investigated whether haemodilution-enhanced coagulation can be demonstrated under regional anaesthesia, whether this occurs before surgery, and whether the fluid used influences the effect. METHODS: Patients were randomly allocated to receive either crystalloid or colloid intravenous fluid. An epidural was administered. Samples of venous blood were taken before fluid administration, after completion of the epidural and initial fluid load, during surgery before heparin, and after 24 h. Thrombelastograph analysis was performed, and full blood count, international normalised ratio, activated partial thromboplastin time, D-dimers and thrombin-antithrombin complex were measured. RESULTS: In the crystalloid group, enhanced coagulation compared with baseline was demonstrated after initial fluid load (mean (SD) r-time 10.1 (4.9) min; P < 0.033; k-time 3.5 (1.7) min; P < 0.01; alpha-angle 54.9 (13.9) degrees; P < 0.01) and before heparin administration (r-time 8.8 (3.9) min; P < 0.01; alpha-angle 54.9 (12.6) degrees; P < 0.02). There was no enhancement of coagulation in the colloid group. There were no changes from baseline after 24 h. CONCLUSIONS: This study confirms that the enhanced perioperative coagulation mechanism is related to dilution, rather than surgery, and is triggered by rapid crystalloid haemodilution. Consideration should be given to the use of colloid rather than crystalloid solutions for rapid fluid loading in vasculopathic patients undergoing surgery.
PMID: 12378657, UI: 22266322
Chest 2002 Oct;122(4):1357-60
Department of Respiratory Medicine, Bowen Centre, Austin Campus, Austin and Repatriation Medical Centre, Heidelberg, Victoria 3084, Australia.
OBJECTIVE: To determine if topical 4% amethocaine gel can reduce the pain associated with arterial punctures. DESIGN: Randomized, placebo-controlled, double-blinded trial with parallel groups. SETTING: Teaching hospital. PATIENTS: Adults requiring arterial punctures for blood gas estimation as part of routine care. INTERVENTIONS: Four percent amethocaine gel applied for 30 min prior to the radial arterial puncture, compared with a placebo gel. MAIN OUTCOME MEASURES: Pain scored on a visual analog scale from 0 to 100, and heart rate during the procedure. RESULTS: The mean pain score for the amethocaine group was 16.0 (SD, 23.3) and for the placebo group was 20.7 (SD, 18.5). The mean heart rates during arterial puncture were 84.1 beats/min (SD, 10.7) for the amethocaine group, and 83.8 beats/min (SD, 12.7) for the placebo group. These differences were not statistically significant. CONCLUSION: The topical use of 4% amethocaine gel does not reduce the pain associated with arterial puncture.
PMID: 12377864, UI: 22265205
J Cardiothorac Vasc Anesth 2002 Jun;16(3):370-3
Departments of Anesthesiology and Cardiovascular Surgery, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL 60153, USA.
PMID: 12073214, UI: 22067864
J Cardiothorac Vasc Anesth 2002 Jun;16(3):359-69
Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA. kinney.michelle@mayo.edu
PMID: 12073213, UI: 22067863
J Cardiothorac Vasc Anesth 2002 Jun;16(3):351-3
Departments of Anesthesiology and Cardiology, University of Pennsylvania Medical School, Philadelphia, PA 19104-4283, USA. yiandoc@hotmail.com
PMID: 12073210, UI: 22067860
J Cardiothorac Vasc Anesth 2002 Jun;16(3):347-50
Departments of Anesthesiology and Surgery, The Mount Sinai Medical Center, New York, NY 10029-6574, USA. dfeierman@email.msn.com
PMID: 12073209, UI: 22067859
J Cardiothorac Vasc Anesth 2002 Jun;16(3):267-9
PMID: 12073194, UI: 22067844
J Cardiothorac Vasc Anesth 2002 Apr;16(2):218-33
Department of Anesthesiology, Mount Sinai Medical Center, New York, NY 10029, USA. ron.kahn@mountsinai.org
PMID: 11957176, UI: 21953101
J Cardiothorac Vasc Anesth 2002 Apr;16(2):214-7
Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India. neema@sctimst.ker.nic.in
PMID: 11957175, UI: 21953100
J Cardiothorac Vasc Anesth 2002 Apr;16(2):199-203
Department of Anesthesiology and Intensive Care Medicine, Hopital Europeen Georges Pompidou, Paris, France. tguenoun@invivo.edu
OBJECTIVE: To determine whether currently available preoperative and intraoperative variables related to arterial oxygen tension (PaO(2)) can be used as predictors for low PaO(2) during one-lung ventilation (OLV). DESIGN: A prospective cohort study. SETTING: Primary university hospital. PARTICIPANTS: Adult patients (n = 92) undergoing thoracic surgery requiring OLV. INTERVENTIONS: Preoperative and intraoperative data, including past medical history, physical examination, and usual preoperative and intraoperative tests, were collected and used as explanatory variables for PaO(2) during OLV by univariate and multivariate analysis. A stepwise logistic regression including the same independent variables was used to identify patients who should be expected to develop arterial hypoxemia (PaO(2) <70 mmHg). Arterial blood gas samples were analyzed 15 minutes after the onset of OLV and after thoracotomy to determine the lowest PaO(2) value during OLV. MEASUREMENTS AND MAIN RESULTS: Preoperative (age, hematocrit, relative perfusion of the nondependent lung) and intraoperative (PaO(2) during 2-lung ventilation and mean arterial pressure at the lowest PaO(2)) variables were identified as independent factors affecting PaO(2) in OLV. PaO(2) during 2-lung ventilation was the only independent variable accounting for arterial hypoxemia when multivariate logistic regression was performed. CONCLUSION: The PaO(2) during OLV can be predicted using routinely available preoperative and intraoperative data. From a clinical point of view, this study failed to identify patients at risk of arterial hypoxemia when OLV is instituted because mainly intraoperative independent variables are involved in the decrease of PaO(2) in this situation. Copyright 2002, Elsevier Science (USA). All rights reserved.
PMID: 11957171, UI: 21953096
J Cardiothorac Vasc Anesth 2002 Apr;16(2):180-5
Departments of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD 21201-1595, USA. tgilbert@anesthesia.ummc.umaryland.edu
OBJECTIVE: To study the effects of electrical applications and subsequent postshock hypotension on myocardial performance and vascular tone during implantable cardioverter-defibrillator (ICD) placement. DESIGN: Prospective, blinded, observational investigation. SETTING: Single, university-affiliated institution. PARTICIPANTS: Twenty patients undergoing elective ICD placement and testing under general anesthesia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Serial measurements were made of hemodynamic variables, left ventricular end-systolic (ESA) and end-diastolic (EDA) areas, fractional-area-of-contraction (FAC), time of hypoperfusion (when mean arterial pressure < or =50 mmHg postshock), and applied conversion energy. Multiple linear regression was performed to determine correlations among collected variables, and repeated measures analysis of variance was used to compare mean values. Minimal changes were detected in mean values of arterial, pulmonary, and central venous pressures; cardiac output; heart rate; and mixed venous saturation during repeated testing. Percentage changes in cardiac index (CI) rose and systemic vascular resistance index (SVRI) fell, however, as the number of shocks increased, reaching significance at the seventh and eighth shocks (v baseline; both p = 0.015). The percentage change in CI was linearly related to hypoperfusion time and accumulated energy (%deltaCI = 1.553 + [0.068 x sigma hypoperfusion time [sec]], r = 0.92, p < 0.001; %deltaCI = 0.326 + [0.125 x sigma Energy [J]], r = 0.94, p < 0.001). The percentage change in SVRI was inversely related to hypoperfusion time and accumulated energy (%deltaSVRI = 2.195 - [0.122 x sigma energy [J]], r = 0.79, p = 0.004; %deltaSVRI = 0.542 - [0.0634 - sigma hypoperfusion time [sec]], r = 0.73, p = 0.01). Echocardiographic EDA, ESA, and FAC were not significantly changed but showed substantial variability. CONCLUSION: Hemodynamic stability was generally well maintained during ICD placement and testing. Increases in CI were associated with concurrent reductions in systemic afterload, rather than enhanced FAC. Increasing postshock hypotension and applied energy were associated with decreases in CI and systemic afterload. Insignificant, but highly variable, changes were noted echocardiographically. Copyright 2002, Elsevier Science (USA). All rights reserved.
PMID: 11957167, UI: 21953092
J Cardiothorac Vasc Anesth 2002 Apr;16(2):175-9
Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany.
OBJECTIVE: To compare hemodynamics and oxygenation in patients with congestive heart failure and broad QRS complexes before and with biventricular DDD pacing and to report experience with this new procedure. DESIGN: Prospective, observational study. SETTING: Major university-affiliated community hospital. PARTICIPANTS: Ten patients with congestive heart failure (New York Heart Association III to IV) and broad QRS complexes (>160 msec). INTERVENTIONS: Patients underwent implantation of a biventricular pacemaker (n = 4) or implantation of a combined biventricular pacemaker and cardioverter-defibrillator (n = 6). Anesthesia was performed using remifentanil (0.2 to 0.3 microg/kg/min) and propofol. Propofol was used as target-controlled infusion (plasma target concentration, 1.5 to 2.5 microg/mL). MEASUREMENTS AND MAIN RESULTS: Hemodynamics and oxygenation were measured before and with biventricular DDD pacing. Mean arterial pressure was significantly increased from 64.7 +/- 5.8 mmHg to 77.8 +/- 10.6 mmHg by biventricular pacing, whereas cardiac index (2.2 +/- 0.3 L/min/m(2) before and 2.3 +/- 0.3 L/min/m(2) with biventricular pacing) and pulmonary capillary wedge pressure (12.1 +/- 3.8 mmHg before and 14.2 +/- 3.6 mmHg with biventricular pacing) remained unchanged. Left ventricular stroke work index was increased >10% in 7 patients. Oxygen delivery, oxygen consumption, and difference in arteriovenous oxygen concentration were not affected. Anesthesia with remifentanil and propofol was safe and well-controllable and allowed immediate extubation at the end of the operation. CONCLUSION: There was no acute intraoperative improvement of hemodynamics except increased mean arterial pressure with biventricular pacing. Left ventricular performance seemed to improve with biventricular pacing in some patients. These results might be due to a nonoptimized atrioventricular delay. Postoperatively, atrioventricular delay was individually programmed for each patient by Doppler transmitral flow patterns. Copyright 2002, Elsevier Science (USA). All rights reserved.
PMID: 11957166, UI: 21953091
J Cardiothorac Vasc Anesth 2002 Apr;16(2):170-4
Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL 60637, USA. fdupont@airway.uchicago.edu
OBJECTIVE: To investigate the influence of cardiopulmonary bypass (CPB) and fraction of inspired oxygen (F(I)O(2)) on the contrast effect of Optison, a second-generation ultrasound contrast agent, in humans during coronary artery bypass graft (CABG) surgery with transesophageal echocardiography (TEE). DESIGN: Prospective, observational, repeated-measures design. SETTING: A single university hospital. PARTICIPANTS: Ten patients who underwent elective CABG surgery. INTERVENTIONS: A transgastric, midpapillary, short-axis view of the left ventricle was obtained with TEE in the conventional imaging mode. A central injection of 0.3 mL of Optison was administered at 4 stages: after induction of anesthesia at F(I)O(2) = 1.0 and F(I)O(2) = 0.43 +/- 0.02 and after protamine administration at F(I)O(2) = 1.0 and F(I)O(2) = 0.52 +/- 0.09. Background-corrected maximal pixel intensity (PImax(corr)) in the left ventricle was determined with videodensitometry. To estimate the magnitude of change in pixel intensities, point estimates of differences in PImax(corr) and their 95% and 99% confidence intervals were calculated after repeated measures analysis of variance. MEASUREMENTS AND MAIN RESULTS: Decreasing the F(I)O(2) from 1.0 to <1 did not alter PImax(corr) significantly before or after CPB (mean change = -4.2 and 0.8; SE = 2.0 and 1.9; p = 0.06 and 0.68). Values for PImax(corr) before and after CPB were not significantly different at either F(I)O(2) = 1.0 or F(I)O(2) <1 (mean change = -3.3 and 1.7; SE = 2.4 and 2.7; p = 0.26 and 0.54). Mean differences from initial values ranged from a 10% decrease to a 5% increase. CONCLUSION: In patients who undergo CABG surgery, the contrast opacification of Optison in the left ventricle is not changed by CPB or alterations in F(I)O(2) during intraoperative TEE. The application of Optison for enhancement of the endocardial border is not limited during cardiac surgery. Copyright 2002, Elsevier Science (USA). All rights reserved.
PMID: 11957165, UI: 21953090
Neurosci Lett 2002 Oct 11;331(2):115-8
Department of Neurology, Graduate School of Medicine and Dentistry, Okayama University, 2-5-1 Shikatacho, Okayama 700-8558, Japan.
Electroacupuncture (EA) is an effective curative method for diseases including cerebral ischemia. In the current study, we investigated the effects of EA treatment on the activations of survival Akt and proapoptotic caspase-9 after 90 min of transient middle cerebral artery occlusion (tMCAO) in rat. Immunoreactivity of phospho-Akt (p-Akt) increased in the ipsilateral hemisphere after tMCAO with a peak at 8 h, and EA enhanced the Akt expression both in the number and the staining strength mainly in the ischemic penumbra (IP) at 8 and 24 h. Cleaved caspase-9 was strongly induced at 8 h in IP, which was suppressed with EA. The number of terminal deoxynucleotidyl transferase-mediated uridine 5' triphosphate-biotin nick end labelling positive cells reduced at 24 h in the cerebral cortex. These results suggest that EA potentiated the Akt and suppressed the caspase-9 activations, and may have a potential to reduce the number of neuronal cells undergoing apoptotic cell death.
PMID: 12361854, UI: 22249386
Neurosci Lett 2002 Oct 11;331(2):111-4
Department of Physiology, College of Medicine, Seoul National University, 28 Yonkeun-Dong, Chongno-Ku, Seoul, South Korea.
Many single neurons were simultaneously recorded from forepaw areas of both primary somatosensory cortex and the ventral posterior lateral thalamus of anesthetized rats to characterize the changes of presumable excitatory synaptic connections between two nuclei following temporary deafferentation (TD). Thalamic and cortical interactions were examined by analyzing spike-triggered cross-correlation histograms (STCCHs, n=426). Before TD, 46.48% of STCCHs exhibited thalamocortical (TC) excitation and 7.51% of STCCHs showed corticothalamic (CT) connectivity. After TD, these connections were less frequently observed (after 20 min of TD, TC: 13.38% of STCCHs, CT: 5.40% of STCCHs). Fifty-seven TC and nine CT connections were reversibly suppressed during TD. However, 23 CT connections were reversibly augmented following TD. These results imply that temporary blocking of afferent information may induce system-wide plasticity involving corticofugal modulation.
PMID: 12361853, UI: 22249385
Neurosci Lett 2002 Aug 23;329(1):1-4
Department of East-West Medicine, Graduate School, Kyung Hee University, Seoul, South Korea.
Electroacupuncture (EA) has been reported to modulate natural killer cell (NK cell) activities. Also it is well known that hypothalamus directly mediates the effects of EA on analgesia. Especially lateral hypothalamic area (LHA) is related to splenic NK cell activities. In order to investigate the relationship between hypothalamus and effects of EA on NK cell activity, lesions have been made bilaterally at LHA of Spraque-Dawley rats. Subsequently, NK cell cytotoxities of normal and lesioned rats were measured with (51)Cr release immunoassay after EA stimulation for 2 and 14 days. NK cell activity of EA group was significantly higher than sham group. In addition, lesions abolished effects of EA on NK cell activity. These results strongly suggest that LHA is closely related to increase of NK cell activity induced by EA. Copyright 2002 Elsevier Science Ireland, Ltd.
PMID: 12161248, UI: 22151630
Pediatr Dent 2002 Jul-Aug;24(4):343-6
Department of Pediatric Dentistry, Children's Hospital, Boston, Mass, USA. linda_nelson@hsdm.harvard.edu
Mastocytosis is a heterogeneous group of clinical disorders characterized by an excessive number of normal mast cells in a variety of tissues (skin, bone marrow, liver, spleen and lymph nodes). It is most often seen in the skin in pediatric-onset mastocytosis presenting as urticaria pigmentosa. Children with this disorder are on a strict avoidance protocol of triggering factors to decrease the likelihood of life-threatening anaphylactic reactions. Close monitoring and the avoidance of known histamine-releasing drugs is necessary in the pediatric dental office, as is a readiness to use resuscitative measures. A case of a 4-year, 6-month-old pediatric dental patient with mastocytosis is presented. Dental treatment was provided in an ambulatory setting utilizing nitrous oxide, oxygen analgesia and H1 and H2 antihistamines to prevent mast cell degranulation and to provide sedation.
PMID: 12212879, UI: 22200600
Pediatr Dent 2002 Jul-Aug;24(4):340-2
angelmanguel@shaw.ca
Intraoperative oxygen supplementation to sedated children has been shown to prevent hemoglobin desaturations even in the presence of apnea during pediatric conscious sedation. Although many practitioners deliver supplemental oxygen via a nasal hood, this method is impractical and often unsuccessful if the child is a mouth breather, has moderate adenotonsillar hypertrophy or occasionally cries during treatment (at which time there will be mouth breathing). This paper describes a method in which the saliva ejector is used to deliver supplemental oxygen to sedated children while they are receiving dental treatment. The advantages of this method and suggestions for its successful application are also included.
PMID: 12212878, UI: 22200599
Pediatr Dent 2002 Jul-Aug;24(4):289-94
Department of Pediatric Dentistry, New Jersey Dental School, Newark, USA. houpt@umdnj.edu
PURPOSE: A national survey of members of the American Academy of Pediatric Dentistry was conducted to provide a 15-year update of information regarding the use of sedative agents by pediatric dentists. METHODS: All 3,315 active members of the Academy were sent questionnaires regarding the frequency of their use of sedation and 1,778 responded. Practitioners were questioned regarding their use of sedative agents and the nature of their patients receiving sedation. In addition, they were questioned in regard to their use of restraints and reasons for change in their use of sedation during the past two years. RESULTS: In regard to the use of nitrous oxide alone, 47% of practitioners responded that they use nitrous oxide less than 11% of the time. In regard to other types of sedative agents, most practitioners use little, if any, sedation. Eighty-two percent use sedation for less than 11% of their patients. Of the 1,778 respondents, 1,224 used drugs other than nitrous oxide. In a typical three-month period, they performed 77,112 sedations. Of that number, 61,662 (80%) were administered by only 478 practitioners who use sedation on the average of once or greater each day. CONCLUSIONS: In comparison with previous surveys in 1985, 1991 and 1995, these results demonstrate an overall increased use of sedation by pediatric dentists. However, the increased use is due primarily to an increase in the numbers of practitioners who are heavier users of sedation (once or greater each day).
PMID: 12212869, UI: 22200590