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Acta Anaesthesiol Scand 2002 Jul;46(6):684-91
Department of Anaesthesia, Gentofte University Hospital, Denmark. dooe@herlevhosp.kbhamt.dk
BACKGROUND: Mivacurium is hydrolyzed by plasma cholinesterase, and is therefore less dependent on liver metabolism and renal elimination than other neuromuscular blocking drugs. This might favor the use of mivacurium in elderly patients. The purpose of this study was to compare the pharmacodynamics and the pharmacokinetics of the three isomers of mivacurium and their metabolites in young adult and elderly patients. METHODS: Sixty-four patients were included in a dose-response study, in which 32 young adults and 32 elderly patients received one of four doses of mivacurium. An additional bolus dose of mivacurium to a total of 0.1 mg/kg was given followed by a continuous infusion adjusted to maintain a 91-99% neuromuscular block. The times to maximum block and different levels of recovery were measured using mechanomyography and train-of-four (TOF) nerve stimulation. Thirty-two patients were randomly selected for the pharmacokinetic study. Venous samples were taken for determination of the three mivacurium isomers and the metabolites. RESULTS: The estimated ED95 were 0.053 and 0.061 mg/kg in young adults and elderly patients, respectively (NS). The median infusion rate did not differ, but duration to a TOF ratio of 0.7 was significantly longer in elderly patients than in young adult patients (21.0 vs. 16.5 min). No statistically significant difference between the age groups in clearance and elimination half-life of the isomers was seen. The half-lives of the metabolites were significantly prolonged in the elderly patients. CONCLUSION: There were no significant differences in the potency or infusion requirements between the adult and elderly patients, but the rate of recovery was significantly, though only moderately prolonged, in the elderly patients. No significant difference in clearance was seen but the elimination half-lives of the metabolites was longer in the elderly patients.
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PMID: 12059892, UI: 22054538
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Acta Anaesthesiol Scand 2002 Jul;46(6):639-46
Clinica Medica e Anestesiologica/Hospital e Maternidade Sao Luiz, Sao Paulo, Brazil. rogeriovideira@aol.com
BACKGROUND: Post spinal meningitis (PSM) is a complication still currently being reported. After two PSM cases in our hospital an epidemiological study was initiated, which included a survey of techniques for asepsis that are applied in our department. METHODS: Cases defined as PSM comprised meningitis within a week after spinal anesthesia. Anesthesia records, anesthesia complication files and the records of the Hospital Commission for Infection Control from 1997 to 2000 were reviewed. Asepsis techniques applied were surveyed by a questionnaire answered by all our department's anesthesiologists. The equipment and procedures for spinal anesthesia were listed. Current anesthesia textbooks were reviewed for recommendations regarding asepsis techniques in conjunction with spinal anesthesia. RESULTS: Three cases of PSM were identified following 38,128 spinal anesthesias whereas none was observed in 12,822 patients subjected to other types of regional or general anesthesia (P>0.05). Culture of cerebrospinal fluid yielded Streptococcus in two patients and was negative in the other patient. The asepsis technique applied by the anesthesiologists varied considerably. The literature review showed that aspects on asepsis for spinal anesthesia are poorly covered. CONCLUSION: The incidence of meningitis was similar in patients subjected to spinal anesthesia and in those subjected to other anesthetic techniques. Asepsis techniques were found to differ considerably among our staff members, reflecting the lack of well-defined published standards for this procedure. We recommend that asepsis for spinal anesthesia should not be less rigorous than for surgical asepsis.
PMID: 12059885, UI: 22054531
Anaesthesist 2002 Jul;51(7):582-98; quiz 598-9
Klinik fur Anasthesiologie und Operative Intensivmedizin, Universitatsklinikum Kiel, Schwanenweg 21, 24105 Kiel. bein@anaesthesie.uni-kiel.de
PMID: 12243047, UI: 22228616
Anaesthesist 2002 Jul;51(7):564
PMID: 12243043, UI: 22228612
Anaesthesist 2002 Jul;51(7):547-51
Abteilung Anasthesie, Orthopadische Universitatsklinik Balgrist, Zurich, Schweiz.
For correction of a shoulder instability (Bankart's operation) in a 33-year-old woman, a combined regional and general anaesthesia was chosen. An interscalene catheter to block the brachial plexus was placed preoperatively without complication. The following day this resulted in an upper extremity almost without motor function and with complete hypoesthesia of the dermatomes C5-C7. Surgical exploration of the plexus was performed 41/2 months later. Stimulation of the three truncs of the brachial plexus was possible and showed electrophysiological signs of recovery of distal parts of the plexus. After 2 years no clinical corresponding recovery could be observed. Despite all investigations (electroneuromyography, evoked potentials, etc.) no clear etiology could be established to explain this adverse outcome.
PMID: 12243040, UI: 22228609
Anaesthesist 2002 Jul;51(7):539-46
Klinik fur Anasthesiologie und Intensivtherapie, Philipps-Universitat Marburg, Baldingerstrasse 1, 35033 Marburg. eberhart@mailer.uni-marburg.de
BACKGROUND: Transient neurologic symptoms (TNS) after spinal anesthesia (SPA) is defined as back pain with radiation or dysesthesia in the buttocks, thighs, hips and calves, occurring within 24 h after recovery from otherwise uneventful SPA. The symptoms last for about 1-3 days but neurophysiologic evaluation does not show pathologic findings. The type and the preparation of the local anesthetic drug (baricity, concentration, additives or preservatives) are most often discussed as the underlying cause of TNS. METHODS: Randomized controlled comparative studies reporting the incidence of TNS were systematically searched. Descriptive statistics are presented summarizing the identified trials and the pooled relative risk (RR), the number-needed-to-harm (NNH) with their 95% confidence intervals (95%-CI) were calculated using a random effects model. RESULTS: A total of 29 studies with a 2,813 patients fulfilled the inclusion criteria. Summarizing all patients in these trials without further adjustment, the incidence of TNS was 16.9% after lidocaine, 19.1% after mepivacaine, but only 1.1% after bupivacaine and 1.7% after prilocaine. For tetracaine, procaine, and ropivacaine there were too few studies to draw meaningful conclusions. Using meta-analysis techniques these data were confirmed: the pooled relative risk (RR) for suffering from TNS was 6.7-fold higher after lidocaine (95%-CI: 2.5-18) than after SPA with bupivacaine and 5.5-fold higher (95%-CI: 2-15) than after prilocaine. Furthermore, data show that baricity, concentration of the local anesthetic, and addition of vasoconstrictors have no significant influence on the occurrence of TNS. CONCLUSION: Prilocaine and bupivacaine for SPA are associated with less TNS than lidocaine and mepivacaine. For the other local anesthetics there were not enough comparative trials to give conclusive recommendations.
PMID: 12243039, UI: 22228608
Anaesthesist 2002 Jul;51(7):533-8
Klinik fur Anasthesiologie, Intensivmedizin und Schmerztherapie, Klinikum der J.W. Goethe-Universitat, Theodor-Stern-Kai 7, 60590 Frankfurt. p.kessler@em.uni-frankfurt.de
OBJECTIVE: High thoracic epidural anesthesia (TEA) combined with general anesthesia is increasingly being used for coronary artery bypass grafting (CABG) with extracorporeal circulation. Recent developments in beating heart techniques have rendered the use of TEA alone in conscious patients possible and have been reported for single-vessel beating heart CABG via lateral thoracotomy. For multi-vessel revascularization the heart is usually approached via median sternotomy, therefore the use of TEA alone was applied in awake patients with multi-vessel coronary artery disease who underwent CABG via median sternotomy. METHODS: A total of 10 patients scheduled for awake coronary artery bypass grafting (ACAB) received TEA via an epidural catheter placed at T1/2 or T2/3. Total arterial myocardial revascularization was performed after median sternotomy. In addition to standard monitoring, anesthetic sensory and motor block levels were determined using an epidural scoring scale for arm movements (ESSAM). RESULTS: Except for one patient who required intraoperative endotracheal intubation due to a pneumothorax, all patients were awake and maintained spontaneous breathing during the entire procedure. Compared to baseline values, hemodynamic parameters, e.g. arterial blood pressure (SAP, MAP, DAP) and heart rate significantly declined during coronary anastomosis. No significant hypercarbia was observed. The intraoperative pain level was subjectively estimated by the patients as less than 20 out of 100 (median 10.95% confidence interval 4.2-21.6) using a visual analogue scale. All patients rated TEA as "good" or "excellent." Adverse effects associated with TEA were not observed. CONCLUSIONS: We could demonstrate that the use of TEA alone for CABG via median sternotomy was feasible and produced good results. High patient satisfaction in our small and highly selected cohort could be reported. Nevertheless, randomized controlled trials in large cohorts are mandatory to definitively evaluate the role of TEA alone in cardiac surgery.
PMID: 12243038, UI: 22228607
Ann Fr Anesth Reanim 2002 Sep;21 Suppl 2:181s-480s
PMID: 12375584, UI: 22261662
Br J Anaesth 2002 Aug;89(2):325-7
Department of Anaesthetics and Intensive Care, Division of Surgery, Anaesthetics and Intensive Care, Faculty of Medicine, Imperial College, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK.
[Medline record in process]
BACKGROUND: In clinical use, midazolam reduces the dose requirement for propofol. We studied the effect of midazolam given before anaesthesia on the amount of propofol needed and the time taken, to achieve loss of consciousness (LOC) in 20 patients. METHODS: We compared the auditory evoked responses (AER) in these patients with those in a group of 20 patients who were not given midazolam. RESULTS: LOC, as defined by a loss of response to verbal command and eyelash reflex, occurred after 113 (95% CI, 99-131) s in the control group and 75 (56-101) s in the midazolam group (P < 0.05). In the control group 2.3 (2.0-2.6) mg kg-1 propofol caused LOC compared with 1.3 (1.1-1.5) mg kg-1 in the group pretreated with midazolam (P < 0.001). Pa amplitude decreased by 60% in the control group and by 54% in the midazolam group while Nb latency increased by 24% in the control group and by 32% in the midazolam group following LOC. These differences were not significant. CONCLUSIONS: We confirmed that coinduction of anaesthesia with midazolam and propofol reduces the requirement of propofol. We also demonstrated that the AER reflects anaesthetic depth rather than plasma concentrations of anaesthetic drugs.
PMID: 12378673, UI: 22266338
Br J Anaesth 2002 Aug;89(2):306-24
Department of Anaesthesia, Guy's and St Thomas' Hospital Trust, St Thomas' Street, London SE1 9RT, UK.
In the wake of recent atrocities there has been renewed apprehension regarding the possibility of chemical and biological weapon (CBW) deployment by terrorists. Despite various international agreements that proscribe their use, certain states continue to develop chemical and biological weapons of mass destruction. Of greater concern, recent historical examples support the prospect that state-independent organizations have the capability to produce such weapons. Indeed, the deliberate deployment of anthrax has claimed several lives in the USA since September 11, 2001. In the event of a significant CBW attack, medical services would be stretched. However, victim survival may be improved by the prompt, coordinated response of military and civil authorities, in conjunction with appropriate medical care. In comparison with most other specialties, anaesthetists have the professional academic background in physiology and pharmacology to be able to understand the nature of the injuries caused by CBWs. Anaesthetists, therefore, play a vital role both in the initial resuscitation of casualties and in their continued treatment in an intensive care setting. This article assesses the current risk of CBW deployment by terrorists, considers factors which would affect the severity of an attack, and discusses the pathophysiology of those CBWs most likely to be used. The specific roles of the anaesthetist and intensivist in treatment are highlighted.
PMID: 12378672, UI: 22266337
Br J Anaesth 2002 Aug;89(2):271-6
Department of Anaesthesiology, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan.
BACKGROUND: The Brandt tracheal tube keeps cuff pressure constant during anaesthesia, but the mechanisms have not been examined. We assessed volume, pressure and gas concentration in the cuff and pilot balloon using the Brandt system. METHODS: The pressure in an air-filled cuff of the Brandt system (Mallinckrodt Brandt tracheal tube, n = 60) was recorded during anaesthesia with 67% nitrous oxide; gas volume and concentration in cuffs and balloons were measured for up to 12 h from the start of anaesthesia. The volume change of each gas was calculated to assess its contribution to the cuff pressure. We also measured cuff compliance in vitro. RESULTS: Cuff pressure increased slightly during anaesthesia (P < 0.05). The nitrous oxide concentration increased to 47.7 (8.2)% (mean (SD)) in the cuff and to 2.2 (0.9)% in the pilot balloon. The nitrous oxide volume in the cuff and pilot balloon increased by approximately 2 ml during the first 4 h of anaesthesia. The carbon dioxide volume increased slightly, and nitrogen and oxygen did not change significantly. The compliance of the Brandt tube cuff was six times greater than that of a standard tube cuff (Mallinckrodt Hi-Contour tracheal tube). CONCLUSIONS: The Brandt tracheal tube maintains stable cuff pressure during nitrous oxide anaesthesia because of a highly compliant balloon. The concentration gradient of nitrous oxide between the cuff and pilot balloon also contributes to the stable-cuff pressure because the high nitrous oxide concentration in the cuff reduces nitrous oxide influx.
PMID: 12378666, UI: 22266331
Br J Anaesth 2002 Aug;89(2):211-4
PMID: 12378653, UI: 22266318
JAMA 2002 Oct 16;288(15):1847-8
Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pa.
PMID: 12377079, UI: 22265837
Department of Anaesthesia, Peterborough District Hospital, Peterborough, England.
PMID: 12377078, UI: 22265836
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