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Anaesth Intensive Care 2002 Oct;30(5):698-9
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PMID: 12413273, UI: 22298897
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Anaesth Intensive Care 2002 Oct;30(5):671-4
Department of Anaesthesia, University of Cape Town, Groote Schuur Hospital, Observatory, South Africa.
This case describes the anaesthesia management of a patient with myasthenia gravis who required mastectomy with axillary lymph node clearance. After withholding medical therapy for the myasthenia preoperatively on the day of surgery, anaesthesia was maintained with halothane, nitrous oxide and a remifentanil infusion. Muscle relaxants were avoided, facilitated by the use of a ProSeal (Intravent, Orthofix, Maidenhead, United Kingdom) laryngeal mask airway for positive pressure ventilation. The ProSeal laryngeal mask airway is a new laryngeal mask device with a modified cuff and a drainage tube which has been shown to have advantages over older designs for use during positive pressure ventilation. The rationale for the management of this patient with myasthenia is discussed.
PMID: 12413272, UI: 22298896
Anaesth Intensive Care 2002 Oct;30(5):591-6
Department of Anaesthesia, The University of New South Wales, Prince of Wales Hospital, Sydney, NSW, Australia.
The volatile anaesthetic agents are known to influence uterine muscle tone. All of the agents studied to date have been found to produce uterine relaxation. This property has been used to produce therapeutic uterine relaxation for difficult obstetric deliveries and the Ex Utero Intrapartum Treatment (EXIT) procedure. This study describes the effects of sevoflurane on isolated human myometrium at concentrations of 0.1, 0.25, 0.5, 0.75, 1.0, 1.5, 2.5 and 3.5 MAC. Sevoflurane produces dose-dependent depression of uterine muscle contractility with an ED50 of 0.94 MAC. Frequency of contraction was increased at concentrations of 2.5 MAC and greater. At concentrations of 3.5 MAC and above, uterine activity was virtually abolished.
PMID: 12413258, UI: 22298882
Anaesth Intensive Care 2002 Oct;30(5):588-90
Division of Anesthesia, Kyoto Katsura Hospital, Japan.
Acute hypotension, transient hypoxaemia and elevation of pulmonary artery pressure are well known to occur during cemented arthroplasty. The aim of this prospective clinical study was to characterize the relationship between plasma concentrations of atrial and brain natriuretic peptides (ANP, BNP), and changes in blood pressure in patients undergoing hip arthroplasty. Elevated ANP and BNP levels may be markers of inadequate myocardial reserve. We measured plasma ANP and BNP levels before the operation and 20 minutes after the cementing in 18 patients (54-90 yr). We defined a hypotensive response after cementing as a decrease in systolic blood pressure of more than 15 mm Hg below the pre-cementing value. In the hypotensive group, preoperative values of ANP were 123 +/- 48.5 pg/ml and BNP, 138 +/- 71.7 pg/ml. These values are significantly greater than those in the normotensive group (ANP 35.9 +/- 7.7, and BNP 17.2 +/- 3.2 pg/ml). High preoperative values of ANP and BNP are associated with more hypotension during cemented arthroplasty and could provide an indication of which patients are at risk of this complication.
PMID: 12413257, UI: 22298881
Anaesth Intensive Care 2002 Oct;30(5):584-7
Anaemia, hypoproteinaemia and acidic pH in renal failure patients can alter the pharmacokinetics and pharmacodynamics of anaesthetic agents, resulting in altered dose requirements. We evaluated the induction dose of propofol in adult patients with end-stage renal disease by titrating the hypnotic effect by means of a clinical parameter as well as using a more objective assessment of hypnosis, the Bispectral Index (BIS) monitor. The dose was compared with that for patients with normal renal function. Propofol doses that provided the clinical end-point of hypnosis (syringe drop method), as well as the end-point of a mean (SD) BIS value of 50 (5), were evaluated in 27 end-stage renal disease and 27 normal renal function patients. Propofol was administered at 0.2 mg/kg every 15 seconds until these end-points were achieved. End-stage renal disease patients required significantly higher propofol doses to achieve the clinical end-point of hypnosis (1.42 (0.24) mg/kg versus 0.89 (0.2) mg/kg in normal renalfunction patients, P<0.05 unpaired "t" test). Propofol dose required to achieve a BIS of 50 (5) was also higher in end-stage renal disease patients (2.03 (0.4) mg/kg versus 1.39 (0.43) mg/kg in normal renal function patients, P<0.05). There was a significant negative correlation of propofol dose with preoperative haemoglobin concentration. A hyperdynamic circulation in renal failure patients with anaemia may be responsible for the higher propofol dose requirement in this group.
PMID: 12413256, UI: 22298880
Anaesth Intensive Care 2002 Oct;30(5):578-83
Department of Pharmacology, The University of Melbourne Victoria, Australia.
After institutional approval and with written informed consent, eight surgical patients were infused intravenously with remifentanil at 250 ngkg lean body mass (LBM)(-1) x min(-1) for 30 min. Cardiovascular and respiratory parameters were recorded and arterial blood samples were taken at regular intervals. In each patient, the same protocol was repeated 40 min later during propofol infused to a target concentration of 3.0 microg x ml(-1). Blood concentrations of remifentanil and propofol were assayed using capillary gas chromatography and high performance liquid chromatography techniques respectively. The number of subjects enrolled was determined by testing the successive areas under the remifentanil time-concentration curve (AUC) for significant difference or non-difference using sequential analysis. The median measured propofol concentration was 3.5 (range: 2.6-4.5) microg x ml(-1) which did not change significantly during the second remifentanil infusion. The median AUC during propofol infusion was greater than control in all subjects, although there was considerable variation of 94.4 (64.3-129.6) versus 64.6 (34.8-126.9) ng x ml(-1) x min; P=0.008, n=8. After 30 min, there was no significant difference in remifentanil concentration during propofol infusion when compared with remifentanil alone of 4.6 (3.2-5.7) versus 3.8 (1.6-4.9) ng x ml(-1); P=0.73, n=8. Co-administration of propofol and remifentanil may result in greater remifentanil concentrations than when remifentanil is infused alone.
PMID: 12413255, UI: 22298879
Anaesth Intensive Care 2002 Oct;30(5):551-69
Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, United Kingdom.
The Intubating Laryngeal Mask Airway (ILMA) was introduced into clinical practice in 1997 following numerous clinical trials involving 1110 patients. The success rate of blind intubation via the device after two attempts is 88% in "routine" cases. Successful intubation in a variety of difficult airway scenarios, including awake intubation, has been described, with the overall success rate in the 377 patients reported being approximately 98%. The use of the ILMA by the novice operator has also been investigated with conflicting reports as to its suitability for emergency intubation in this setting. Blind versus visualized intubation techniques have also been investigated. These techniques may provide some benefits in improved safety and success rates, although the evidence is not definitive. The use of a visualizing technique is recommended, especially whilst experience with intubation via the ILMA is being gained. The risk of oesophageal intubation is reported as 5% and one death has been described secondary to the complications of oesophageal perforation during blind intubation. Morbidity described with the use of the ILMA includes sore throat, hoarse voice and epiglottic oedema. Haemodynamic changes associated with intubation via the ILMA are of minimal clinical consequence. The ILMA is a valuable adjunct to the airway management armamentarium, especially in cases of difficult airway management. Success with the device is more likely if the head of the patient is maintained in the neutral position, when the operator has practised at least 20 previous insertions and when the accompanying lubricated armoured tube is used.
PMID: 12413253, UI: 22298877
Anaesthesist 2002 Dec;51(12):1026-7
Abteilung fur Anaesthesiologie und Intensivmedizin, Universitatsklinikum Tubingen.
[Medline record in process]
PMID: 12583350, UI: 22468460
Anaesthesist 2002 Dec;51(12):1024-5
Klinik fur Anasthesiologie der Ludwig-Maximilians-Universitat Munchen, Klinikum Grosshadern, Munich. ernst.weninger@helios.med.uni-muenchen.de
PMID: 12580181, UI: 22467593
Anaesthesist 2003 Jan;52(1):68-73
Klinik fur Anaesthesiologie, Universitatsklinikum Heidelberg.
The use of ultrasound as a diagnostic tool for the visualisation of the epidural space has effects on the quality and the performance of epidural anesthesia.This work presents an overview of the recent experiences with ultrasound for epidural anesthesia and on the possibilities for ultrasound imaging techniques.The results of visualisation of the epidural space and its limiting structures obtained by various working groups are presented.We review all presently available data on the prediction of the puncture depth.The various working groups found correlations between predicted and effective puncture depth between 0.79 and 0.98 and the precision of the measurement was 57-7.7 mm.Regarding the prediction of the puncture angle there was a poor correlation ranging between 0.07 and 0.31.The precision between the measured and the punctured angles was found to be 10-13.4 degrees. In all available prospective randomised studies on the puncture effects in the lumbar epidural space, the influence of ultrasound showed a significant reduction ( p<0.03) of the puncture attempts,and we found a significant ( p<0.05) reduction in the number of puncture levels.The ultrasound-guided puncture allowed an ideal needle trajectory and a more precise application of the catheter. A significant improvement of analgesia quality ( p<0.035) and patient satisfaction ( p<0.006) could be achieved.The metaanalysis of the different studies regarding puncture quality by ultrasound-guided peridural anaesthesia showed a clear advantage for the use of imaging techniques.
PMID: 12577168, UI: 22463865
Anaesthesist 2003 Jan;52(1):55-67
Universitatsklinik fur Anasthesie und Intensivmedizin, Universitat Wien.
Caudal anaesthesia is the most frequently used regional technique in paediatric anaesthesia. Caudal in combination with general anaesthesia is usually performed in healthy children (i.e. for herniotomy or hypospadias). Therefore every complication of this method is a catastrophe, even when the incidence of these complications is very low. Some of the documented complications of caudal anaesthesia in children are caused by the local anaesthetic solutions and/or by additives. Thus, the choice of substances for paediatric caudal blocks should minimize the risk associated with the substances used for this indication. Over the last decades the standard was bupivacaine but because of serious cardiovascular and central-nervous toxicity following inadvertent intravascular injection of bupivacaine during caudal puncture, the less toxic ropivacaine should be favoured for this indication. A huge number of clinical studies have proven the clinical effectiveness and safety of ropivacaine also for this indication. In addition, levobupivacaine, the L-enantiomere of bupivacaine, will also be an interesting local anaesthetic in the future for paediatric caudal anaesthesia. By using additives to local anaesthetics better analgesic properties should be obtained.Following an exact review of the literature, only clonidine and S(+)-ketamine are useful additives to local anaesthetics in paediatric caudal anaesthesia.
PMID: 12577167, UI: 22463864
Anaesthesist 2003 Jan;52(1):42-6
Abteilung fur Anasthesiologie,Kliniken der Stadt Koln, Krankenhaus Merheim.
Although there have been an increasing number of reports on secondary lung surgery following contralateral pneumonectomy in recent years, little information is available about the anaesthesiological management of these patients.We therefore report on a 58-year-old patient who had already undergone a left-sided pneumonectomy and now required a right-sided thoracotomy to remove a recurrent tumour in the right upper lobe.The patient received a total intravenous anaesthesia (propofol, fentanyl) combined with atracurium for muscle relaxation. Following the orotracheal intubation with a Woodbridge tube, the patient was ventilated with the high frequency jet ventilation technique.The jet stream was administered via a catheter placed in the tube.The arterial O(2) saturation during ventilation was always 100%, and arterial CO(2) partial pressure was also normal. No complications occurred during tumour resection from the right upper lobe, and the patient was transferred to the ICU with stable pulmonary and haemodynamic conditions.After 2 h of ventilation, the patient was extubated with a completely expanded lung.The postoperative recovery was uneventful.This case report shows that,presupposing a sufficient pulmonary capacity, secondary lung surgery in previously pneumonectomised patients is feasible without complications given an appropriate anaesthesiological management.
PMID: 12577164, UI: 22463861
Anaesthesist 2003 Jan;52(1):23-32
Abteilung Anasthesiologie II der MHH, Medizinische Hochschule Hannover im Klinikum Hannover Oststadt.
[Record supplied by publisher]
OBJECTIVES. The study was undertaken to compare different anaesthetic techniques for scheduled or urgent caesarean section with respect to maternal circulatory parameters, maternal and fetal endocrine stress response, fetal vitality parameters and further clinical parameters such as recovery and analgesic demand. METHODS. After ethical approval,patients scheduled for general anaesthesia were randomly allocated to the esketamine group ( n=21; induction with 0.5 mg/kg BW esketamine and 1.5 mg/kg BW methohexitone, ventilation until cord cuting with FiO(2) 1.0) and the sevoflurane-group ( n=21; induction with 1.5-2.0 mg/kg BW methohexitone, ventilation until uterotomia with N(2)O/O(2) [FiO(2) 0,5] and endtidal sevoflurane concentrations about 1.0 vol%).After fetal development, all patients received 2.5 &mgr;g/kg BW fentanyl and sevoflurane (about 1.0 vol% endtidal) during ventilation with N(2)O/O(2) (FiO(2) 0.33). As a further control, a group with spinal anaesthesia ( n=22; 2.6-3.0 ml isobaric bupivacaine 0.5 %) was investigated. Maternal circulatory and endocrine plasmatic stress parameters were investigated at five time points and fetal parameters once after development.alpha</=0.05 was considered significant. RESULTS. Biometric data were comparable in all groups.Systolic arterial pressure was higher in the esketamine group ( p=0.008), whereas the heart rate was lower during spinal anaesthesia ( p<0.001).Plasma noradrenaline decreased in all collectives ( p<0.001) and mean group levels of noradrenaline ( p=0.04) and adrenaline ( p<0.001) were lower during spinal anaesthesia. In all groups, antidiuretic hormone (ADH) remained within the normal range or was slightly increased.Adrenocorticotropic hormone (ACTH) initially increased in all groups and decreased in later time course ( p<0.001).Cortisol increased in all groups ( p<0.001) but group levels were lower during spinal anaesthesia ( p<0.001). In the groups with general anaesthesia, no significant differences in recovery times were obvious, and neither recall nor dream reactions were observed.Postoperative hypoxic incidents (psaO(2) <90%) were comparable between the groups.After spinal anaesthesia, first analgesic demand was later than in the controls ( p=0.001), and the total amount of piritramide was lower ( p=0.02).Nausea and vomiting were more frequent during spinal anaesthesia ( p=0.03). All patients were content with their regimen.Apgar scores, pH-values and adrenaline, noradrenaline and cortisol in plasma were comparable in all groups of children (69 children, 5 gemini). The fetal concentration of esketamine (251 ng/ml) was lower than the corresponding maternal values (493 ng/ml). CONCLUSIONS When compared with methohexitone, sevoflurane and N(2)O for caesarean section, initial total intravenous anaesthesia with esketamine and methohexitone mediated specific antinociception without negative maternal or fetal effects and not taking invasion kinetics or elimination between uterotomia and cord cutting into consideration. Avoidance of N(2)O allows optimal oxygenation of the fetomaternal unit.Stress protection and hemodynamic responses were well balanced, and intraoperative recall or negative dream reactions were lacking. Superior postoperative pain protection was advantageous after spinal anaesthesia, but in contrast, nausea and vomiting were more frequent in this group.
PMID: 12577162
Anaesthesist 2002 Nov;51(11):938-9
PMID: 12434271, UI: 22320717
Anaesthesist 2002 Nov;51(11):929-30
Univ.-Klinik fur Anasthesie und Allgemeine Intensivmedizin, Innsbruck, Germany. harald.j.sparr@uibk.ac.at
PMID: 12434269, UI: 22320715
Anaesthesist 2002 Nov;51(11):918-21
Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Georg-August-Universitat Gottingen, Germany.
We describe a case of postoperative subdural dislocation (between dura and arachnoidea spinalis) of an epidural catheter. After 24 h of normal functioning of the catheter, the injection of 5 ml lidocaine caused an extensive unilateral sensory block including the cranial nerves. X-ray control excluded an epidural or intrathecal position of the catheter. A delayed dislocation of the epidural catheter into the subdural space can occur but this complication only usually becomes evident after injection of a normal dose of local anaesthetic into the catheter and can have catastrophic consequences. The safety of patients can only be guaranteed if epidural catheters are managed solely by professional anaesthesiological personnel. Anatomy, mechanisms of complications and clinical differential diagnosis are discussed.
PMID: 12434266, UI: 22320712
Anesth Analg 2003 Feb;96(2):632; author reply 632
PMID: 12538234, UI: 22425397
Anesth Analg 2003 Feb;96(2):629
PMID: 12538228, UI: 22425391
Anesth Analg 2003 Feb;96(2):628; author reply 628
PMID: 12538226, UI: 22425389
Anesth Analg 2003 Feb;96(2):626; author reply 626-7
PMID: 12538224, UI: 22425387
Anesth Analg 2003 Feb;96(2):618-21, table of contents
Department of Anesthesiology and Intensive Care Medicine, University Hospital Kiel, Kiel, Germany. v.doerges@t-online.de
PMID: 12538222, UI: 22425385
Anesth Analg 2003 Feb;96(2):595-9, table of contents
Department of Anesthesiology, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran. arash_kashi@hotmail.com
We explored the possibility that a simple and single test could replace the modified Mallampati score for either a difficult or an unaccomplished tracheal intubation in an impending hypoxic patient. Three hundred adult patients were enrolled in this study. They were subjected to the following assessments: 1) oropharyngeal class according to the modified Mallampati criteria; 2) the new, upper lip bite criteria-class I = lower incisors can bite the upper lip above the vermilion line, class II = lower incisors can bite the upper lip below the vermilion line, and class III = lower incisors cannot bite the upper lip; and 3) laryngeal view grading according to Cormack's criteria. The incidence of difficult intubation was 5.7%. The upper lip bite test showed significantly higher specificity and accuracy than the modified Mallampati test (P < 0.001). Comparisons of sensitivity, positive and negative predictive values, between the two tests, however, did not reveal any significant differences (P > 0.05). In conclusion, the upper lip bite test is an acceptable option for predicting difficult intubation as a simple, single test.
PMID: 12538218, UI: 22425381
Anesth Analg 2003 Feb;96(2):576-82, table of contents
Department of Anesthesiology, Virginia Mason Clinic, Seattle, Washington, 98111 USA. anedjk@vmmc.org
Biodegradable microcapsules containing bupivacaine/dexamethasone produce an anesthetic duration of 7-11 days in animal models. In this investigation, we explored the effect of increasing doses (Part 1) and the effect of including dexamethasone (Part 2) on the onset, density, and duration of analgesia and anesthesia produced by bupivacaine microcapsules. Concentrations ranging from 0.3125% to 5.0% in microcapsules were compared with 0.25% aqueous bupivacaine (bilateral injection, three intercostal nerves, 2 mL per nerve) (Part 1). Part 2 compared 2.5% microcapsules with or without the inclusion of dexamethasone by unilateral blockade. Sensory block was assessed by pinprick, temperature sensation, and subjective numbness (0, not numb; 10, totally numb). Pharmacodynamic assessments and plasma drug concentrations of bupivacaine and dexamethasone were measured for 96 h. The onset time was reduced and the duration of analgesia increased over the 0.3125%-5.0% dose range (P < 0.02). Onset with 2.5% microcapsules approximated that of 0.25% aqueous bupivacaine. Microcapsule block duration increased to at least 96 h and was significantly longer than aqueous bupivacaine (P < 0.001). Inclusion of dexamethasone increased the duration of pinprick anesthesia in 2.5% microcapsules (P = 0.03). We conclude that bupivacaine/dexamethasone microcapsules are well tolerated and demonstrate a dose-related effect in onset and duration of intercostal blockade. Inclusion of dexamethasone increases intercostal block anesthesia.
PMID: 12538215, UI: 22425378
Anesth Analg 2003 Feb;96(2):570-5, table of contents
Department of Anesthesiology and Intensive Care, Karolinska Hospital and Institute, Stockholm, Sweden. asamodalen@hotmail.com
Sameridine is a new compound with both local anesthetic and opioid properties (partial micro -opioid receptor agonist). It was intended for intrathecal administration to provide anesthesia for surgery and extended postoperative analgesia. In this double-blinded pharmacodynamic study with a two-parallel-group design, we investigated, during a 24-h period, the effects of intrathecal sameridine and bupivacaine on ventilation at rest and at ventilatory challenges during hypercarbia and hypoxia. Twenty-four healthy volunteers received either 25 mg of sameridine or 15 mg of bupivacaine intrathecally. Ventilation was measured by pneumotachography and in-line capnography. Sedation was rated by a visual analog scale. Segmental spread and development of motor and sensory block were similar in both groups. There was a decrease in tidal volume 2.5 to 6 h after injection in the bupivacaine group. This was seen only at 4 h in the sameridine group. There were no other major ventilatory differences between sameridine and bupivacaine during resting ventilation. Hypercarbic (tidal volume, mean inspiratory flow) and hypoxic (mean inspiratory flow) ventilatory responses were slightly decreased in the sameridine group, but not in the bupivacaine group. We conclude that intrathecal administration of sameridine or bupivacaine in healthy volunteers produces similar, minor effects on ventilatory responses over a 24-h observation period.
PMID: 12538214, UI: 22425377
Anesth Analg 2003 Feb;96(2):563-9, table of contents
Department of Anesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland. pertti.pere@hus.fi
Reports on the efficacy and pharmacokinetics of local anesthetics in uremic patients have been controversial. Our study involved 29 uremic and 28 nonuremic patients. We performed axillary block with ropivacaine 300 mg (50 mL). Venous blood samples were drawn for 24 h for assay of total and unbound plasma ropivacaine, 3-hydroxyropivacaine, pipecoloxylidide (PPX), and serum alpha(1)-acid glycoprotein (AAG). Block quality was similar in both groups. No toxicity occurred. Plasma clearance of ropivacaine was smaller and the area under the concentration-time curve of ropivacaine, 3-hydroxyropivacaine, and PPX larger in the uremic patients. The plasma concentration of PPX increased until 24 h in uremic patients whose AAG concentrations were also larger throughout the study. The free fraction of ropivacaine in plasma was smaller in the uremic group when measured 60 min and 12 h after the block, but the unbound concentration of ropivacaine was larger in the uremic group at 12 h. Enhanced absorption of ropivacaine into circulation, increased binding to AAG, and probably reduced urinary excretion of the metabolites lead to larger total plasma concentrations of ropivacaine and its main metabolites in uremic patients.
PMID: 12538213, UI: 22425376
Anesth Analg 2003 Feb;96(2):555-62, table of contents
Department of Anesthesia, McGill University, Montreal, Quebec, Canada.
Although the nitrogen-sparing properties of epidural block and i.v. glucose on the days after surgical trauma have been well established, their metabolic effects during the acute phase of the stress response remain unclear. Therefore, in this study we investigated the effect of epidural block on glucose and protein kinetics during and immediately after surgery in patients receiving i.v. glucose at 2 mg x kg(-1) x min(-1). Sixteen patients undergoing colorectal surgery received either general anesthesia with epidural block with bupivacaine (EDA; n = 8) or general anesthesia alone (control; n = 8). Glucose and protein kinetics were determined during and 2 h after the operation by stable isotope tracers [6,6-(2)H(2)]glucose and L-[1-(13)C]leucine. Plasma concentrations of glucose, insulin, cortisol, and glucagon were also determined. Epidural block attenuated the perioperative increase in plasma glucose concentration (P < 0.05). The rate of appearance of glucose (R(a) glucose) and endogenous glucose production (EGP) were slower in the EDA group than in control subjects during (R(a) glucose, EDA 13.2 +/- 1.0 versus control 15.3 +/- 1.8 micromol x kg(-1) x min(-1); P < 0.05; EGP, EDA 1.2 +/- 1.2 versus control 3.8 +/- 1.7 micromol x kg(-1) x min(-1); P < 0.05) and after the operation (P > 0.05). Whereas protein breakdown and amino acid oxidation decreased in both groups (P < 0.05), whole-body protein synthesis remained unchanged. Insulin levels increased with both anesthetic techniques (P < 0.05). Intraoperative plasma concentrations of cortisol and glucagon were smaller in the EDA group (P < 0.05). The intraoperative suppression of EGP by exogenous glucose was more pronounced in the presence of epidural block. However, epidural block failed to exert a protein-sparing effect during the acute phase of the stress response in patients receiving i.v. glucose.
PMID: 12538212, UI: 22425375
Anesth Analg 2003 Feb;96(2):493-7, table of contents
Outcomes Research Institute and Department of Anesthesiology, University of Louisville, Louisville, Kentucky 40202, USA.
Minute sphere acupressure has been used for more than 2000 yr and remains popular in Japan. The points most relevant to abdominal surgery are those associated with meridian flows crossing or originating in the abdomen. We tested the hypothesis that minute sphere therapy reduces pain and analgesic requirements after open abdominal surgery. Participating patients were given standardized desflurane and fentanyl anesthetic. On completion of surgery, they were randomly assigned to untreated control or minute sphere acupressure at the Neiguan, Zusanli, Sanyinjiao, and Gongsun points. Each site was covered with bulky gauze dressings so that patients could not determine their assignments. Postoperative pain was treated with IV morphine via a patient-controlled analgesia pump. Our primary a priori end-points were pain and opioid consumption on the first postoperative morning. Data are reported as median (25th percentile, 75th percentile). Fifty-three patients (30 controls and 23 minute spheres) completed the study. Morphine requirements (47 mg [27, 58] vs 41 mg [25, 69]) and pain scores (29.5 mm [16, 59] vs 40 mm [22, 58]) were similar in the control and acupressure groups. These data provide an 80% power for detecting a 50% difference in morphine consumption at an alpha of 0.05. Minute sphere treatment at the Neiguan, Zusanli, Sanyinjiao, and Gongsun points thus failed to provide analgesia after abdominal surgery. Minute sphere therapy is a form of acupuncture. We tested whether minute spheres placed on three acupressure points relevant to abdominal surgery reduced pain and morphine requirements after abdominal surgery. Treatment and control patients received a similar covering. Neither pain nor morphine requirements were different between the groups.
PMID: 12538202, UI: 22425365
Anesth Analg 2003 Feb;96(2):481-6, table of contents
Department of Anaesthesiology and Intensive Care Medicine, Justus-Liebig-University, Giessen, Germany. reginald.matejec@chiru.med.uni-giessen.de
The function of beta-endorphin immunoreactive material (IRM) released under perioperative conditions remains to be clarified. In 17 patients undergoing orthopedic surgery, we determined beta-endorphin IRM in venous blood plasma and in cerebrospinal fluid (CSF) before surgery (t(A)); after termination of surgery and general anesthesia, but still under spinal anesthesia (t(B)); on occurrence of postoperative pain (t(C)); and 1 day after the operation (t(D)). Pain severity was rated by the patients by using a visual analog scale. Patients felt postoperative pain (t(C)), but they felt no pain at times t(A), t(B), and t(D). beta-Endorphin IRM plasma levels before surgery (t(A)) or with postoperative pain (t(C)) proved to be significantly higher than levels determined just after surgery, but still under spinal anesthesia (t(B)), or those determined 1 day after the operation (t(D)); beta-endorphin IRM plasma levels at times t(A) and t(C) correlated positively with postoperative pain severity (t(C)). beta-Endorphin IRM CSF levels after surgery, but still under spinal anesthesia (t(B)), were significantly higher than levels determined at times t(A), t(C), or t(D). No correlation was found between beta-endorphin IRM CSF levels and pain severity. In conclusion, postoperative pain severity appears to be related to beta-endorphin IRM levels in plasma before surgery as well as with postoperative pain; the analgesic significance of this material remains to be elucidated.
PMID: 12538200, UI: 22425363
Anesth Analg 2003 Feb;96(2):432-4, table of contents
Section of Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan. hkohase.anph@tmd.ac.jp
We developed an orotracheal intubation device equipped with a charge couple device (CCD) camera, providing a wide field of vision. We used this device to perform endotracheal intubations in 62 anesthetized patients undergoing dental treatment and oral surgery. The time required to perform an endotracheal intubation with this system was examined. The use of this system is described below. The wand with the CCD camera was inserted into the oropharyngeal cavity. The oropharynx, including the epiglottis and glottis, could be visualized on the monitor screen. The tube introducer was inserted into the trachea through the vocal cords via the side tube of the wand. The wand with the CCD camera was withdrawn, leaving the tube introducer in the trachea. The endotracheal tube was then inserted into the trachea by using the tube introducer as a guide. The time required for the procedure was determined. The mean total time for the procedure was 41.2 s (maximum, 155 s; minimum, 14 s). There were no significant differences in this procedure when the patients were grouped according to the Cormack and Lehane classification. There was no failure to intubate using this system. Because the device can extensively visualize not only the larynx, glottis, and vocal cords, but also the movement of the tube introducer, on the monitor screen via the CCD camera, endotracheal intubation can be easily performed while the vocal cords are visualized on the monitor screen.
PMID: 12538191, UI: 22425354
Anesth Analg 2003 Feb;96(2):414-7, table of contents
Department of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France. x-capdevila@chu-montpellier.fr
PMID: 12538188, UI: 22425351
Anesth Analg 2003 Feb;96(2):396-9, table of contents
Department of Anaesthesia and Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong. reginachoi@hotmail.com
We conducted a prospective, randomized, double-blinded trial comparing preoperative application of EMLA cream and sodium chloride solution dorsal penile block (n = 31) with placebo cream and bupivacaine dorsal penile nerve block (n = 32) for postcircumcision analgesia. Pain was assessed using modified Children's Hospital of Eastern Ontario Pain Scale and the duration of block by the time to requirement of first dose of postoperative analgesic. There was no difference in Children's Hospital of Eastern Ontario Pain Scale between the two groups, but bupivacaine dorsal penile nerve block resulted in longer analgesia (P = 0.003). There were no local or systemic complications related to either technique, and there was a very small incidence of vomiting. We conclude that preoperative application of EMLA cream is an effective and simple method to produce postcircumcision analgesia with a very small incidence of adverse effects.
PMID: 12538184, UI: 22425347
Anesth Analg 2003 Feb;96(2):392-5, table of contents
Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia 30322, USA. keith_brosius@emoryhealthcare.org
We compared two available oral formulations of midazolam with respect to sedation score and plasma midazolam levels in pediatric surgical patients 2-10 yr old. The commercially available oral syrup was compared with a mixture of the IV midazolam preparation in Syrpalta syrup at an equivalent concentration of 2 mg/mL. ASA status I-II patients were randomly assigned to receive 0.5 mg/kg of either the commercial syrup (Group 1) or the prepared mixture (Group 2) as anesthetic premedication. Observer's Assessment of Alertness/Sedation scores were obtained by a blinded observer at 15 and 30 min after drug administration. Plasma midazolam levels were acquired exactly 45, 60, and 90 min after administration. Group 2 patients had a significantly lower median Observer's Assessment of Alertness/Sedation score (Group 1, 17; Group 2, 15) at 30 min (P < 0.03) and significantly higher mean plasma midazolam levels at all three acquisition times (mean +/- SD) (45 min: 63.1 +/- 23.9 ng/mL, Group 2; 43.4 +/- 19.6 ng/mL, Group 1; 60 min: 45.8 +/- 18.2 ng/mL, Group 2; 30.8 +/- 17.9 ng/mL, Group 1; 90 min: 28.9 +/- 12.6 ng/mL, Group 2; 21.0 +/- 8.9 ng/mL, Group 1) (P < 0.02). We conclude that IV midazolam mixed in Syrpalta syrup yields more reliable sedation and correspondingly higher plasma levels than an equivalent dose of the commercially formulated and marketed preparation.
PMID: 12538183, UI: 22425346
Anesth Analg 2003 Feb;96(2):383-6, table of contents
Department of Anesthesia, Deutsches Herzzentrum Berlin, Berlin, Germany. koster@dhzb.de
PMID: 12538181, UI: 22425344
Anesth Analg 2003 Feb;96(2):356-62, table of contents
Department of Anesthesiology and CCM, University of Pittsburgh School of Medicine, Pennsylvania, USA
When reducing fresh gas flows, the course of the vaporizer dial settings required to maintain a constant end-expired concentration of a potent inhaled anesthetic becomes more dependent on the uptake pattern of the inhaled anesthetic. However, the uptake pattern of potent inhaled anesthetics during prolonged procedures remains poorly quantified. Therefore, we determined isoflurane and desflurane uptake (V(iso) and V(des), respectively) during liver resection (LR, n = 17) and orthotopic liver transplantation (OLT, n = 18) using a liquid injection closed-circuit anesthesia technique maintaining the end-expired concentration at 0.8% and 4.5%, respectively. Individual and average uptake curves were fit to a series of mathematical functions and compared with the square root of time and four-compartment models. Cumulative doses of isoflurane and desflurane after 1 and 3 h in the LR group and after 1, 3, and 8 h in the OLT group were correlated with demographic variables and each patient's average cardiac output and cardiac index. Average uptake was best described by a biexponential fit: V(iso) (LR) = 1.5 x (1 - e(-t x 0.525)) + 16.4 x (1 - e(-t x 0.00506)) (R(2) = 0.9996); V(iso) (OLT) = 1.4 + 3.1 x (1 - e(-t x 0.472)) + 26.7 x (1 - e(-t x 0.00307)) (R(2) = 0.9994); V(des) (LR) = 2.7 x (1 - e(-t x 0.763)) + 28.7 x (1 - e(-t x 0.00568)) (R(2) = 0.9984); and V(des) (OLT) = 1.4 x (1 - e(-t x 0.472)) + 26.7 x (1 - e(-t x 0.00307)) (R(2) = 0.9994). Uptake showed significant interindividual variability, and correlations between uptake variables and patient characteristics were inconsistent. The rate of uptake decreased more slowly then predicted by the uptake models. Because neither existing models nor patient characteristics accurately predict uptake in the individual patient, anesthesia techniques involving the use of low fresh gas flows will continue to have to rely on drug monitoring. However, the slowly decreasing rate of uptake during prolonged procedures suggests that the number of vaporizer adjustments to keep the end-expired concentration constant should be limited.
PMID: 12538177, UI: 22425340
Anesth Analg 2003 Feb;96(2):351-5, table of contents
Klinik fur Anasthesiologie und Intensivmedizin, Universitatsklinikum Essen, Essen, Germany. juergen.lutz@uni-essen.de
Living related liver donation for liver transplantation in adults including its risks is receiving increased attention. We present data from 44 liver donors focusing on transfusion requirements and avoidance of heterologous transfusion. The volume of blood transfused (both autologous from preoperative donation and heterologous) was assessed including that derived from intraoperative isovolemic hemodilution, cell-saver salvaged, and retransfused blood. Hemoglobin concentration and central venous pressure were measured at specified time points before and during surgery. Intraoperative blood loss was calculated and correlated to the duration of parenchymal transsection, liver volume resected, and central venous pressure. There were no specific anesthesia-evoked complications. In 4 donors, major bleeding (>2000 mL) occurred. Blood loss averaged 902 +/- 564 mL (SD), yielding a minimal mean hemoglobin concentration of 8.1 +/- 1.2 g/dL. One donor received 3 U of heterologous blood and 30 donors received autologous blood from their preoperative donation. An average of 592 +/- 112 mL of blood derived from perioperative acute isovolemic hemodilution was retransfused as was 421 +/- 333 mL of washed red cells from the cell-saving system. Avoidance of heterologous blood transfusion, application of blood-saving techniques, and efficient pain management are crucial for adult living liver donors. Transfusion of banked blood can be avoided in most patients when intraoperative cell salvage, preoperative autologous blood donation, and intraoperative hemodilution are combined.
PMID: 12538176, UI: 22425339
Anesth Analg 2003 Feb;96(2):344-50, table of contents
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA. nuttall,gregory@mayo.edu
Heparin-induced thrombocytopenia with thrombosis (HITT) type II is a life-threatening complication of heparin therapy that most often occurs after 5-10 days of exposure to heparin. Anticoagulation is a significant concern for patients with HITT type II being prepared for cardiac surgery requiring cardiopulmonary bypass (CPB). We report a case series of 12 patients with a history HITT type II who underwent CPB and cardiac surgery. Six patients did not express the antibody that mediates HITT type II immediately before surgery. Heparin was used as the anticoagulant for the duration of CPB only, and all these patients did well without thrombotic complications. Six patients expressed the antibody that mediates HITT type II immediately before surgery. Hirudin was used as the anticoagulant for CPB in these patients. The ecarin clotting time was used to guide hirudin therapy during CPB. The patients receiving hirudin did well, but they had a large amount of bleeding, required transfusions of multiple allogeneic blood products, and had a frequent rate of reexploration of the mediastinum after CPB.
PMID: 12538175, UI: 22425338
Anesth Analg 2003 Feb;96(2):315-8
PMID: 12538170, UI: 22425333
Eur J Anaesthesiol 2002 Jun;19(6):447-51
Hospital Governador Celso Ramos, Department of Anaesthesiology, Florianopolis, SC, Brazil. grof@th.com.br
BACKGROUND AND OBJECTIVE: The epidural and subarachnoid spaces should be identified at the first attempt, since multiple punctures increase the risk of postdural puncture headache, epidural haematoma and neural trauma. The study aimed to describe the predictors of successful neuraxial blocks at the first attempt. METHODS: After institutional Review Board approval, 1481 patients undergoing spinal or epidural anaesthesia were prospectively enrolled. For each block we recorded: gender, age, height, weight, body habitus, anatomical landmarks (palpability of the spinous processes), spinal anatomy, patient positioning, premedication, needle type and gauge, approach, spinal level of the block, and the provider's level of experience. Retrieval of cerebrospinal fluid or loss of resistance to saline or air identified the subarachnoid and epidural spaces, respectively. The outcome variable was the first attempt success or failure (whether or not the needle was correctly located with one skin puncture and produced adequate surgical anaesthesia). Backward stepwise logistic regression tested its association with the other variables. RESULTS: The first-attempt rate of success was 61.51%. Independent predictors (Odds ratio, 95% confidence limits) were the quality of anatomical landmarks (1.92 (1.57; 2.35)), the provider's level of experience (1.24 (1.15; 1.33)) and the adequacy of patient positioning (3.84 (2.84; 5.19)). CONCLUSIONS: The successful location of the subarachnoid or the epidural space at the first attempt is influenced by the quality of patients' anatomical landmarks, the adequacy of patient positioning and the provider's level of experience.
PMID: 12094920, UI: 22089352
Neurosci Lett 2003 Mar 6;338(3):229-232
Klinik fur Anaesthesiologie, der Universitat Wurzburg, Josef-Schneider Strasse 2, 97080, Wurzburg, Germany
Primary cultures of rat hippocampal neurons were loaded with the Ca(2+)-indicator fluo-3 and studied with a confocal laser microscope. In Mg(2+)-free medium the cultures showed spontaneous synchronized calcium oscillations. These oscillations derived from excitatory signal transmission by N-methyl-D-aspartate and (+/-)-alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid/kainate receptors and were modulated by gamma-aminobutyric acid(A) receptors. The oscillations were dose-dependently depressed by adenosine (IC50=2 &mgr;M) or by 2-chloro-N6-cyclopentyladenosine a specific adenosine A1 receptor agonist (IC50=40 nM). These effects were reverted by 8-cyclopentyl-1,3-dipropylxanthine (DPCPX), a specific adenosine A1 receptor antagonist. The volatile anesthetic isoflurane also depressed these spontaneous calcium oscillations in a dose dependent manner (IC50=0.25 MAC, Minimum Alveolar Concentration). The isoflurane-induced inhibition was partly reversed in 29-38% of the neurons by DPCPX, indicating that the anesthetic activates this receptor possibly by increasing the extracellular concentration of adenosine.
PMID: 12581838