Order this document
Anaesthesia 2003 Jan;58(1):64-8
Department of Anaesthesiology, Intensive Care and Operating Service, Alice Ho Miu Ling Nethersole Hospital, Tai Po, New Territories, Hong Kong.
We conducted a randomised controlled study to evaluate whether watching video compact discs intra-operatively using a liquid crystal display (LCD) unit decreased anxiety. Forty-four patients undergoing elective surgery under regional anaesthesia were assigned to either the LCD or control group. Anxiety was measured using the Chinese version of the State-Trait Anxiety Inventory (STAI) and visual analogue score (VAS). The mean (SD) anxiety trait scores were 46.15 (6.28) and 46.40 (7.32) in the control and LCD groups, respectively. The state anxiety of the LCD group [35.50 (7.96)] measured immediately postoperatively was significantly lower than the control group [41.50 (9.02); p = 0.03]. The median (range) reduction in VAS anxiety score was not significantly greater in the LCD group [20 (20 to 80) mm] compared with the control group [12.5 (70 to 60) mm]. Watching video intra-operatively reduces patient anxiety as measured by the STAI.
Publication Types:
PMID: 12523327, UI: 22410785
Other Formats:
Anaesthesia 2003 Jan;58(1):60-3
Nuffield Department of Anaesthetics, The John Radcliffe Hospital, Oxford OX3 9 DU, UK.
We conducted a two-part study to assess the practice of withholding neuromuscular blockade until the ability to ventilate the lungs using a bag and face mask (mask ventilation) has been established following induction of anaesthesia. The first part of the study consisted of a postal survey (71% response rate) of 188 anaesthetists in the Oxford region to assess their current practice. Thirty per cent of respondents always checked mask ventilation before administering a neuromuscular blocking drug, whereas 39% of respondents (all them consultants) never did this. A further 31% only did so in the case of known or anticipated difficulty with the airway. In the second part of the study, we measured inspired (V(TI)) and expired (V(TE)) tidal volumes before and after neuromuscular blockade in 30 patients undergoing general anaesthesia. The ratio V(TE)/V(TI) was used as a measure of the efficiency of ventilation. There was no difference in V(TE)/V(TI) before [mean (SD) 0.47 (0.13)] and after [0.45 (0.13)] neuromuscular blockade. We conclude that neuromuscular blockade does not affect the efficiency of mask ventilation in patients with normal airways.
PMID: 12523326, UI: 22410784
Anaesthesia 2003 Jan;58(1):101-2
PMID: 12492694, UI: 22380344
Anaesthesia 2003 Jan;58(1):99-100
PMID: 12492690, UI: 22380340
Anaesthesia 2003 Jan;58(1):92-3
PMID: 12492679, UI: 22380329
Anaesthesia 2003 Jan;58(1):86-7
PMID: 12492671, UI: 22380321
Anaesthesia 2003 Jan;58(1):42-4
Department of Anaesthesiology, J.N. Medical College, AMU, Aligarh, PIN-202002, India.
Sixty adult patients undergoing minor peripheral surgery under general anaesthesia were randomly allocated to receive either the laryngeal mask airway (laryngeal mask airway; size 4 for females and size 5 for males) or the PAXpress (adult size), inserted by a single operator with experience of > 50 insertions of each device. The laryngeal mask airway was correctly placed on the first attempt in 27 patients (90%) compared with 20 patients (67%) when using the PAXpress (p < 0.01). No patient required more than two attempts at insertion and there were no failures with the laryngeal mask airway, compared with four (13%) who needed three attempts and two failures (7%) with the PAXpress (p < 0.001 and p < 0.01, respectively). Mean (SD) total placement time was shorter with the laryngeal mask airway [24.6 (3.1) s] than with the PAXpress[35.4 (2.5) s; p < 0.01]. The most common complication was sore throat, which occurred less frequently with the laryngeal mask airway (8 patients; 26%) than with the PAXpress (15 patients; 53.5%; p < 0.001).
PMID: 12492668, UI: 22380318
Anaesthesia 2003 Jan;58(1):28-35
University of New South Wales, NSW 2217, Australia.
The thienopyridines, ticlopidine and clopidogrel, are antiplatelet drugs. They are prodrugs and are metabolised in the liver to active metabolites that are non-competitive antagonists of the platelet adenosine diphosphate receptor, P2Y12. Inhibition of platelet aggregation by these drugs is delayed until 24-48 h after administration, with maximal inhibition achieved after 3-5 days. Recovery of platelet function after drug withdrawal is slow (7-14 days). Ticlopidine and clopidogrel are effective in preventing atherothrombotic events in cardiovascular, cerebrovascular and peripheral vascular disease. Gastrointestinal side effects and skin rashes are common. However, neutropenia and thrombotic thrombocytopenic purpura are significant and sometimes fatal adverse effects of ticlopidine. Clopidogrel appears to offer several advantages over ticlopidine: a more rapid onset of action and a lower incidence of neutropenia and thrombotic thrombocytopenic purpura.A combination of clopidogrel and aspirin has become standard for antithrombotic therapy in cardiovascular disease. The anaesthetic considerations of patients taking the thienopyridine compounds are discussed.
PMID: 12492666, UI: 22380316
Anesth Analg 2003 Feb;96(2):629-30
Department of Anesthesiology, Faculty of Medicine University of Yamanashi, Yamanashi, Japan.
[Medline record in process]
PMID: 12538229, UI: 22425392
Anesth Analg 2003 Feb;96(2):629
Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital, Cork, Ireland. Department of Anaesthesiology and Intensive Care, University Hospital Muenster, Munster, Germany.
PMID: 12538227, UI: 22425390
Anesth Analg 2003 Feb;96(2):606-10
Department of Anesthesiology, National Defense Medical College, Tokorozawa, Japan.
The Brandt(TM) tube system can limit excessive cuff pressure during nitrous oxide (N(2)O) anesthesia, but there is a lack of data assessing whether the Brandt(TM) tube system avoids cuff deflation after cessation of N(2)O administration. In this study, we recorded air-filled cuff pressures of the Mallinckrodt Brandt(TM) or Hi-Contour(TM) (control) tracheal tubes (Mallinckrodt, Athlone, Ireland) during 67% N(2)O anesthesia and the cuffs were aspirated if the cuff pressure exceeded 22 mm Hg; 180 min later, O(2) was substituted for N(2)O. The cuff pressure of both groups significantly decreased after N(2)O anesthesia but the time required for the cuff pressure to return to the initial pressure was longer in the Brandt group than in the control group (76.5 +/- 35.2 min and 36.5 +/- 18.1 min, respectively; P = 0.03). The incidence of air leaks was more frequent in the control group than in the Brandt group (P = 0.015); changes in intracuff N(2)O were small in the Brandt group (6.6 +/- 1.2% to 3.4 +/- 0.9%) compared with those in the control group (46.2 +/- 3.8% to 18.6 +/- 5.6%). Therefore, the Brandt(TM) tube system attenuates the cuff deflationary phenomenon after N(2)O anesthesia, whereas repeated cuff deflation during N(2)O anesthesia causes cuff deflation after cessation of N(2)O, resulting in a possible risk of air leaks. IMPLICATIONS: We demonstrated that the Brandt(TM) tube system attenuates a decrease in cuff pressure after cessation of nitrous oxide (N(2)O) administration, whereas a method of repeated cuff deflation to avoid excessive pressure during N(2)O anesthesia causes deflationary phenomenon of the cuff after cessation of N(2)O administration, resulting in possible risk of air leaks.
PMID: 12538220, UI: 22425383
Anesth Analg 2003 Feb;96(2):600-5
Department of Anesthesiology, Hospital Torrecardenas, Almeria. Hospital Costa del Sol, Malaga. Hospital Germans Trias i Pujol, Barcelona, Spain.
In this multicenter, randomized study, we compared ease of insertion, postinsertion hemodynamic repercussion, quality of ventilation, and the capacity to achieve a "hands-free" anesthesia delivery between two new devices: the ProSeal(TM) laryngeal mask airway (PLMA) and the Laryngeal Tube((R)) (LT). The incidence of postoperative laryngopharyngeal discomfort was examined after short surgical interventions in spontaneously breathing patients. After induction with fentanyl and propofol, the respective airways were inserted into 70 adult ASA physical status I and II patients (35 patients in each group). First-attempt insertion success rates were more frequent for the PLMA (77% versus 51%; P < 0.05), but success rates were similar (100% versus 97%) after 3 attempts. The anesthesiologists considered that insertion of the PLMA was easier (P < 0.001). Expired tidal volume was larger with the PLMA (404.9 versus 328.4 mL; P < 0.005) and the ability to achieve hands-free ventilation was more frequent with the PLMA (32 versus 21 cases; P < 0.004). Positional maneuvers with the LT to correct ventilation deficiencies were not always completely effective (5 of 13). There were no differences in the incidence of intolerance, sore throat, dysphagia, and/or dysphonia between the two devices. We conclude that the PLMA showed greater ease of insertion and reliability than the LT for use in nonparalyzed anesthetized patients. IMPLICATIONS: In this prospective, randomized study, we found that the ProSeal(TM) laryngeal mask airway was easier to insert and permitted a better delivery of hands-free anesthesia than the Laryngeal Tube((R)). The incidence of postoperative laryngopharyngeal discomfort was similar for both devices.
PMID: 12538219, UI: 22425382
Anesth Analg 2003 Feb;96(2):548-54
Department of Anesthesia, Austin and Repatriation Medical Centre, Melbourne, Australia.
In a primary analysis of a large recently completed randomized trial in 915 high-risk patients undergoing major abdominal surgery, we found no difference in outcome between patients receiving perioperative epidural analgesia and those receiving IV opioids, apart from the incidence of respiratory failure. Therefore, we performed a selected number of predetermined subgroup analyses to identify specific types of patients who may have derived benefit from epidural analgesia. We found no difference in outcome between epidural and control groups in subgroups at increased risk of respiratory or cardiac complications or undergoing aortic surgery, nor in a subgroup with failed epidural block (all P > 0.05). There was a small reduction in the duration of postoperative ventilation (geometric mean [SD]: control group, 0.3 [6.5] h, versus epidural group, 0.2 [4.8] h; P = 0.048). No differences were found in length of stay in intensive care or in the hospital. There was no relationship between frequency of use of epidural analgesia in routine practice outside the trial and benefit from epidural analgesia in the trial. We found no evidence that perioperative epidural analgesia significantly influences major morbidity or mortality after major abdominal surgery. IMPLICATIONS: Secondary analysis of data from a large randomized trial of perioperative epidural analgesia demonstrates no beneficial effect on major postsurgical morbidity or mortality from epidural analgesia.
PMID: 12538211, UI: 22425374
Anesth Analg 2003 Feb;96(2):545-7
Department of Anesthesiology, Pain & Perioperative Medicine, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts.
IMPLICATIONS: The use of central neuraxial anesthesia techniques shortly after an epidural blood patch (EBP) has not been described. The authors discuss the potential concerns and report a unique case of a patient who underwent a cesarean delivery under spinal anesthesia 6 h after an EBP.
PMID: 12538210, UI: 22425373
Anesth Analg 2003 Feb;96(2):513-7
Departments of Anesthesiology, Evanston Northwestern Healthcare, Evanston. Northwestern University Feinberg School of Medicine, Chicago, Illinois.
A decline in the proportion of articles published by American authors in medical journals has been reported. We therefore sought to determine whether the contributions of authors from the United States to the three leading anesthesia journals changed between the years 1980 to 2000. The journals Pain, Anesthesiology, and Anesthesia & Analgesia were selected for evaluation on the basis of their respective impact factors. All clinical studies and basic science studies published in the years 1980, 1985, 1990, 1995, and 2000 were evaluated. The country of origin of the lead author of each article was determined by two of the investigators. chi(2) Tests and least squares linear regression analyses were used to determine associations between the source of publication (United States or abroad) and year of publication. The proportion of American publications in the leading anesthesia specialty journals was found to be decreasing over the period 1980-2000 because of an increase in the rate of publication from abroad that is disproportionate to the increase in the total number of publications in the journals over that time. The reasons for changes in anesthesia-related publications by American authors were not established by this study. The authors speculate that multiple factors are involved, including an increased emphasis on clinical care over research because of economic constraints, American publication in journals other than the leading specialty journals, and the increased quality of submissions from abroad. IMPLICATIONS: In the period 1980-2000, there was an increase in the number of research articles published in the three main anesthesia journals: Anesthesiology, Anesthesia & Analgesia, and PAIN: Despite this increase in research activity, there was a significantly disproportionate decrease in the United States versus non-US authorship.
PMID: 12538205, UI: 22425368
Anesth Analg 2003 Feb;96(2):412-3
Departments of Anesthesia and. Surgery, Children's Hospital. Departments of Anaesthesia and. Surgery, Harvard Medical School, Boston, Massachusetts.
IMPLICATIONS: Conjoined twins have some cross-circulation, which makes general anesthesia for only one patient impossible. Using caudal anesthesia in the awake patient, we were able to provide anesthesia for an inguinal central venous catheter placement in one patient without having to unnecessarily anesthetize the other twin.
PMID: 12538187, UI: 22425350
Anesth Analg 2003 Feb;96(2):400-6
Department of Pediatric Anesthesiology, La Paz Children's University Hospital, Madrid, Spain.
The uptake of sevoflurane and nitrous oxide (N(2)O) was characterized during the mask induction of anesthesia in healthy children. We assessed concentration and second gas effects by determining the influence of two different inspiratory N(2)O concentrations on the rate at which the estimated alveolar concentration (FA) increased to the inspired gas concentration (FI). Eighteen children aged 4-12 yr old were randomly assigned to receive a 6% sevoflurane mixture with either a large or a small N(2)O concentration with balance O(2). End-tidal and inspiratory concentrations of respiratory and anesthetic gases were continuously assessed during the induction. The FA/FI for the small N(2)O was 0.87 +/- 0.09 (mean +/- SD) and increased to 0.92 +/- 0.08 for the large N(2)O (P < 0.01). Both groups differed significantly at 3, 4, and 5 min. The FA/FI for sevoflurane increased but more slowly than for N(2)O. The mean only differed significantly at 3 min. Equilibration between FA and FI for N(2)O and sevoflurane was attained rapidly. Consistent with their respective blood/gas partition coefficients, the FA/FI for N(2)O increased more rapidly than that for sevoflurane. Increasing FI-N(2)O produced a leftward shift in gas equilibration curves. A concentration effect was confirmed with N(2)O and a brief second gas effect, probably explained by the higher solubility of sevoflurane. IMPLICATIONS:The wash-in of sevoflurane and nitrous oxide in healthy children during the mask induction of anesthesia showed a more rapid equilibrium between alveolar and inspired gas concentrations than in adults. Consistent with their respective blood/gas partition coefficients, the alveolar concentration for nitrous oxide increased more rapidly to its inspired concentration than that for sevoflurane. A concentration effect was confirmed with nitrous oxide and a brief, second gas effect, probably explained by the higher solubility of sevoflurane.
PMID: 12538185, UI: 22425348
Anesth Analg 2003 Feb;96(2):336-43
Departments of Anesthesiology and Intensive Care Medicine and. Cardiac Surgery, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany.
In this prospective, randomized study, we compared hemodynamics, oxygenation, possible intraoperative awareness, and costs in 62 patients undergoing first-time elective coronary artery bypass grafting at 2 different levels of anesthesia. Depth of anesthesia was assessed with bispectral index (BIS). All patients were anesthetized with sufentanil/midazolam. The dosage of sufentanil/midazolam was adjusted to achieve a BIS level of 45-55 in 32 patients (Group BIS 50), whereas in 30 patients a BIS level of 35-45 was intended (Group BIS 40). Data were obtained at six different time points before, during, and after surgery. All patients were asked about possible intraoperative awareness on the third postoperative day. There were no significant differences of any hemodynamic or oxygenation variables at any time between the two groups. BIS 40 patients received significantly (P < 0.05) more sufentanil (BIS 40, 888 +/- 211 micro g; BIS 50, 514 +/- 99 micro g) and midazolam (BIS 40, 22.4 +/- 5.6 mg; BIS 50, 16.6 +/- 3.7 mg) than BIS 50 patients. The reduction in anesthetic drugs used saved euro;13.78/US$12.54 per patient (P < 0.05) in Group BIS 50, but one BIS electrode caused additional costs of euro;19.95/US$18.15. Time to extubation was not significantly prolonged in Group BIS 40 (BIS 40, 14.3 +/- 4.6 h; BIS 50, 11.8 +/- 3.8 h). There was no explicit memory during anesthesia in either group. BIS-guided reduction of anesthetic medication saved costs and did not increase the risk of intraoperative awareness. However, total costs were increased by monitoring BIS, because of the BIS electrodes. IMPLICATIONS:Bispectral index (BIS)-guided anesthesia may allow reductions in anesthetic medication and costs without increasing the risk of intraoperative awareness. However, total costs may be increased by monitoring BIS.
PMID: 12538174, UI: 22425337
Anesth Analg 2003 Jan;96(1):304
PMID: 12505976, UI: 22392450
Anesth Analg 2003 Jan;96(1):304-6; author reply 306
PMID: 12505975, UI: 22392449
Anesth Analg 2003 Jan;96(1):298-300, table of contents
Department of Anesthesiology, Hospital de Sant Pau, Barcelona, Spain. mcunzueta@telefonica.net
IMPLICATIONS: We describe a technique of one-lung high-frequency jet ventilation surgery with continuous monitoring of airway pressures that achieves satisfactory operating conditions with less complications than other similar approaches.
PMID: 12505970, UI: 22392444
Anesth Analg 2003 Jan;96(1):290-2, table of contents
Department of Anesthesiology, American University of Beirut Medical Center, Lebanon. ayoub@aub.edu.lb
The advancement of an endotracheal tube (ETT) over a flexible fiberoptic bronchoscope (FOB) is often impeded at the glottis. This is attributed to the creation of a cleft by the difference in the outer diameter of the fiberscope and the internal diameter of the tube. We designed a conical-shaped polyvinyl chloride sleeve to fit the insertion cord. This report compares the ease of advancement of the tube over a sleeved versus a nonsleeved bronchoscope. General anesthesia was induced, and one anesthesiologist introduced the FOB (a 3.8-mm Olympus LF2). Patients were randomly assigned to undergo tracheal intubation with the regular bronchoscope (25 patients) or the sleeved bronchoscope (25 patients). The FOB was advanced to approximately 1 cm above the carina. A blinded operator advanced the tube over the bronchoscope. The ETT was successfully advanced over the nonsleeved bronchoscope into the trachea on the first attempt in 64% of the patients, whereas tracheal intubation succeeded from the first attempt in 96% of patients when the sleeved FOB was used (P < 0.05). Advancement of the ETT over the fiberscope can be facilitated by using a conically shaped sleeve mounted on the insertion cord. IMPLICATIONS: This report shows that a conical sleeve mounted on the insertion cord of a fiberoptic bronchoscope will facilitate advancing the endotracheal tube into the trachea.
PMID: 12505968, UI: 22392442
Anesth Analg 2003 Jan;96(1):273-7, table of contents
Department of Anesthesia, Moorfields Eye Hospital, London, United Kingdom. HeinrichRuschen@yahoo.co.uk
IMPLICATIONS: The use of blunt instead of sharp needles for ophthalmic local anesthesia techniques has reduced the incidence of injury to intra-orbital structures. This case review of complications from blunt needle sub-Tenon's block suggests that sight-threatening or even life-threatening complications can still occur.
PMID: 12505965, UI: 22392439
Anesth Analg 2003 Jan;96(1):263-72
Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington 98111, USA. anessl@vmmc.org
PMID: 12505964, UI: 22392438
Anesth Analg 2003 Jan;96(1):260-2, table of contents
Clinique chirurgicale Bordeaux-Merignac, France. henri.iskandar@wanadoo.fr
Used as the sole analgesic, clonidine produces analgesia after central neural blockade and intraarticular injection but not after axillary block. In this study, we sought to determine whether interscalene clonidine induces analgesia for shoulder arthroscopy. Forty patients scheduled for shoulder arthroscopy were prospectively included in this double-blinded study. Using a nerve stimulator technique, an interscalene catheter was inserted. The patients were randomly divided into two groups. The interscalene group (n = 20) received clonidine 150 micro g in 15 mL of saline through the catheter and 1 mL of subcutaneous saline, and the systemic group (n = 20) received 15 mL of saline through the catheter and clonidine 150 micro g (1 mL) subcutaneously. All patients underwent general anesthesia for surgery. On completion of arthroscopy, all patients received, via a patient-controlled analgesia, on demand a bolus of 8 mL of ropivacaine 0.2% through the catheter with a 1-h lockout period. Postoperative pain was measured every 4 h using the visual analog scale (VAS) for 24 h. Additional postoperative analgesia was available with parenteral nalbuphine if required until VAS < 3. VAS scores in the recovery room were significantly higher in the systemic group compared with the interscalene group (P < 0.0001). Analgesic duration was significantly longer in the interscalene group (P < 0.00001), and ropivacaine consumption was significantly less than in the systemic group (P < 0.0001). No significant difference was observed between groups for nalbuphine consumption. Side effects were comparable in the two groups. IMPLICATIONS: Clonidine administered via an interscalene catheter enhanced analgesia compared with systemic administration. Nevertheless, the adverse effect of clonidine at this dose limits its use for routine management for postoperative analgesia.
PMID: 12505963, UI: 22392437
Anesth Analg 2003 Jan;96(1):247-52, table of contents
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
Continuous axillary brachial plexus block may theoretically increase the risk of neurologic complications because of catheter-induced mechanical trauma or local anesthetic toxicity. In this study, we retrospectively reviewed the frequency of complications using current techniques and applications. There were 405 continuous axillary catheters in 368 patients. A preexisting neurologic condition was present in 41 (10.1%) patients, including 30 patients with a preoperative ulnar neuropathy. In 305 (75.3%) cases, the axillary catheter was placed to facilitate rehabilitation after major elbow surgery. Catheters were typically placed postoperatively, after documentation of the patient's normal neurologic examination. The local anesthetic infusion contained bupivacaine in 355 (88.7%) patients and mepivacaine in 45 (11.1%) patients. The mean infusion rate was 10 +/- 2 mL/h. Catheters remained indwelling for 55 +/- 32 h. In 31 patients, the axillary catheter was replaced because of technical problems or inadequate analgesia. There were 9 complications in 8 patients for an overall frequency of 2.2%. Complications included one each of the following: localized infection (treated with catheter removal and antibiotics), axillary hematoma, and retained catheter fragment requiring surgical excision. In addition, two patients reported signs and symptoms of systemic (preseizure) local anesthetic toxicity. Four (1.0%) patients reported new neurologic deficits postoperatively. In two patients, the neural dysfunction was non-anesthesia related. All four had continuous catheters placed after major elbow surgery. We conclude that the risk of neurologic complications associated with continuous axillary blockade is similar to that of single-dose techniques. IMPLICATIONS: We evaluated the risk of neurologic complications in 368 patients undergoing 405 consecutive continuous axillary blocks. New neurologic deficits were reported in four patients. This series suggests that the risk of neurologic complications associated with continuous axillary block is similar to that of single-dose techniques.
PMID: 12505961, UI: 22392435
Anesth Analg 2003 Jan;96(1):215-9, table of contents
Division of Anesthesiology, Department of APSIC (Anesthesiology, Pharmacology, and Surgical Intensive Care), Geneva University Hospitals, Switzerland. lysakowski.christopher@hcuge.ch
Insertion of a peripheral IV cannula is a common, although painful, procedure. We tested the analgesic efficacy, adverse effects, and cost-effectiveness of a needle-free intradermal drug delivery system (Jet) with lidocaine for the insertion of an IV cannula (18-gauge; dorsum of hand). Four-hundred patients were randomly allocated to one of four groups: (a) no treatment, (b) Jet (J-Tip), National Medical Products Inc, CA; $3.0 per device) with 0.5 mL of saline, (3) Jet with 0.5 mL of lidocaine 1%, and (4) Jet with 0.5 mL of lidocaine 2%. Pain was evaluated using a numerical verbal scale (NVS 0-10). A NVS < or =3 was considered as acceptable in this context. Incremental cost-effectiveness ratios were calculated. Without treatment, 42.4% of patients had a NVS < or = 3, 39.3% with saline, 60.7% with 1% lidocaine (relative risk [RR] compared with no treatment, 0.70; 95% confidence interval [CI], 0.53-0.93), and 86.7% with 2% lidocaine (RR, 0.49; 95% CI, 0.38-0.62). Nineteen and one-half percent of patients had a NVS >3 because of Jet treatment, 13.5% had local hyperemia, and 16.9% had minor local bleeding. Of all Jet treatments, 10.5% were technical failures, and there were 17.6% cannula insertion failures (10.1% without treatment [RR, 1.74; 95% CI, 0.92-3.32]). Compared with no treatment, costs to generate one additional patient with a NVS < or =3 were $23 with lidocaine 1% and $10 with lidocaine 2%. On insertion of an IV cannula on the back of the hand, 58% of patients report at least moderate pain. Lidocaine-Jet is analgesic; there is dose-responsiveness. However, Jet treatment is not painless, and costs incurred to achieve one success compared with doing nothing are not negligible. IMPLICATIONS: Insertion of an IV cannula is painful. Four-hundred patients were randomly allocated to test the analgesic efficacy, adverse effects, and cost-effectiveness of the needle-free intradermal drug delivery system (J-Tip); Jet). Jet with lidocaine is effective, but its application is not painless. Costs to achieve one patient with no more than moderate pain (numerical verbal scale < or =3 of 10) on insertion of an IV cannula are $10.
PMID: 12505955, UI: 22392429
Anesth Analg 2003 Jan;96(1):163-4, table of contents
Department of Anesthesiology, School of Medicine, Sapporo Medical University, Japan. jhattori@sapmed.ac.jp
IMPLICATIONS: Propofol is often used in patients with asthma, but it can induce bronchospasm. We report a patient with sick house syndrome (nonspecific complaints of mucosal irritation, headache, nausea, and chest symptoms) who suffered bronchospasm. This case suggests that propofol is not always a safe anesthetic for patients with asthma, especially drug-induced asthma.
PMID: 12505944, UI: 22392418
Anesth Analg 2003 Jan;96(1):142-7, table of contents
Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Germany. jbruhn@mailer.med.buni-bonn.de
We describe the development and evaluation of a simple slide rule that enables the bedside determination of the infusion rate for a particular target plasma concentration of propofol. The infusion rate to reach this target concentration at time (t) is the product of the target concentration, body weight, and a correction factor that depends on the time elapsed from the start of the initial infusion. Our target-controlled infusion (TCI) slide rule, constructed along this principle, performs the multiplications, analogous to the principle of the classical slide rule, as addition of logarithms. We calculated the percentage deviation of the predicted concentration obtained by STANPUMP versus predicted concentrations obtained using the infusion rates determined from the TCI slide rule. The evaluation using STANPUMP simulations showed, for a constant target concentration of 3 micro g/mL of propofol, a mean deviation of 4.05% (max, 6.97%) in the first 15 min and a mean deviation of 0.5% (max, 2.03%) between 16 and 300 min. The mean deviation after changing the target from 3 micro g/mL to 1, 2, 4, or 5 micro g/mL ranged from 1.15% to 17.76%. This pocket-sized TCI slide rule combines the advantages of minimal financial and technical cost with reasonable accuracy. IMPLICATIONS: We describe the development and evaluation of a simple slide rule that enables the bedside determination of the required infusion rate for a particular target plasma concentration. This pocket-sized target-controlled infusion slide rule combines the advantages of minimal financial and technical cost with reasonable accuracy.
PMID: 12505940, UI: 22392414
Anesth Analg 2003 Jan;96(1):65-7, table of contents
Department of Anesthesiology, Kyoto Prefectural University of Medicine, Japan. kasai@koto.kpu-m.ac.jp
IMPLICATIONS: A child experienced a spinal cord injury by an accidental dural puncture during thoracic epidural anesthesia. A magnetic resonance image was used for diagnosis and treatment.
PMID: 12505925, UI: 22392399
Anesth Analg 2003 Jan;96(1):51-7, table of contents
Department of Anesthesiology, German Heart Center, Munich, Germany. cammerer@dhm.mhn.de
Hemorrhage after cardiopulmonary bypass (CPB) remains a clinical problem. Point-of-care tests to identify hemostatic disturbances at the bedside are desirable. In the present study, we evaluated the predictive value of two point-of-care tests on postoperative bleeding after routine cardiac surgery. Prospectively, 255 consecutive patients were studied to compare the ability of modified thromboelastography (ROTEG) as well as a platelet function analyzer (PFA-100) to predict postoperative blood loss. Measurements were performed at three time points: preoperatively, during CPB, and after protamine administration with three modified thromboelastography and PFA tests. The best predictors of increased bleeding tendency were the tests performed after CPB. The angle alpha is the best predictor (area under the receiver operating characteristic curve 0.69) and, in combination with the adenosine diphosphate-PFA test, the predictive accuracy is enhanced (area under the receiver operating characteristic curve 0.73). The negative predictive value for the angle alpha is 82%, although the positive predictive value is small (41%). Thromboelastography is a better predictor than PFA. In routine cardiac surgery, impaired hemostasis as identified by point-of-care tests does not inevitably lead to hemorrhage postoperatively. However, patients with normal test results are unlikely to bleed for hemostatic reasons. Bleeding in these patients is probably caused surgically. The high negative predictive value supports early identification and targeted treatment of surgical bleeding by distinguishing it from a significant coagulopathy. IMPLICATIONS: Thrombelastography and platelet function analysis in routine cardiac surgery demonstrate high negative predictive values for postoperative bleeding, which supports early identification and targeted treatment of surgical bleeding by distinguishing it from a significant coagulopathy. The positive predictive values are small. The best predictors are thrombelastography values obtained after cardiopulmonary bypass.
PMID: 12505922, UI: 22392396
Anesth Analg 2003 Jan;96(1):33-8, table of contents
Department of Anesthesiology, Pitie-Salpetriere Hospital, Paris, France.
Remifentanil is a potent ultra-short-acting opioid, which permits rapid emergence. However, remifentanil is expensive and may have detrimental effects on hemodynamics in case of overdose. Target-controlled infusion (TCI) permits adapting infusion to pharmacokinetic models. In this prospective randomized study, we compared intra- and postoperative hemodynamics, remifentanil requirement during anesthesia, and postoperative morphine requirement in patients scheduled for carotid surgery, and receiving either continuous IV weight-adjusted infusion of remifentanil (RIVA) or TCI for remifentanil (TCIR). Forty-six patients were enrolled in this study: all were anesthetized by using TCI for propofol. Twenty-three received RIVA (0.5 micro g. kg(-1) x min(-1)) for the induction of anesthesia and endotracheal intubation, with the infusion rate decreased to 0.25 micro g x kg(-1) x min(-1) after intubation, then adapted by step of 0.05 micro g x kg(-1) x min(-1) according to hemodynamics. Twenty-three patients received TCIR (Minto model, Rugloop), with an effect-site concentration at 4 ng/mL during induction, then adapted by step of 1 ng/mL according to hemodynamics. All patients received atracurium and a 50% mixture of N(2)O/O(2). Hemodynamic variables were recorded each minute. The number and duration of hemodynamic events were collected, and total doses of anesthetics (remifentanil and propofol) and vasoactive drugs were noted in both groups of patients. Data were analyzed by using unpaired t-tests. RIVA was significantly associated with more frequent episodes of intraoperative hypotension (16 versus 6, P < 0.001) and more frequent episodes of postoperative hypertension and/or tachycardia requiring more frequent administration of beta-adrenergic blockers (16 vs 10, P < 0.04) in comparison with TCIR. The need for morphine titration was not significantly different between groups. TCIR led to a significantly smaller requirement of remifentanil (700 +/- 290 versus 1390 +/- 555 micro g, P < 0.001) without difference in propofol requirement. This prospective randomized study demonstrated that, during carotid endarterectomy, in comparison with patients receiving remifentanil using continuous RIVA, TCI results in less hypotensive episodes during the induction of anesthesia, in fewer episodes of tachycardia and/or hypertension and a smaller beta-adrenergic blocker requirement during recovery, and a decrease in remifentanil requirement. Recommendations to prefer TCI for remifentanil administration during carotid endarterectomy may be justified. IMPLICATIONS: Remifentanil for intraoperative analgesia in carotid artery surgery is associated with a better stability in perioperative hemodynamics when administered in target-controlled infusion compared with continuous weight-adjusted infusion. This may be related to a smaller requirement of this drug when using target-controlled infusion, as well as a smooth mode of administration.
PMID: 12505919, UI: 22392393
Anesthesiology 2003 Jan;98(1):282; author reply 283
PMID: 12503015, UI: 22390636
Anesthesiology 2003 Jan;98(1):272-4
Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio 43210-1228, USA.
PMID: 12503010, UI: 22390631
Anesthesiology 2003 Jan;98(1):268-70
Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. jngl@partners.org
PMID: 12503008, UI: 22390629
Anesthesiology 2003 Jan;98(1):241-57
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55902, USA. Sprung.juraj@mayo.edu
PMID: 12503003, UI: 22390624
Anesthesiology 2003 Jan;98(1):189-94
Department of Physiology, Institute of Biomedicine, University of Helsinki, Helsinki, Finland. Antti.Pertovaara@utu.fi
BACKGROUND: The authors determined the visceral antinociceptive effect induced by MPV-2426 (fadolmidine), a selective alpha 2 -adrenoceptor agonist, in rats with and without inflammation of the colon. They also determined whether the sympathetic nervous system or intact descending pathways are critical for the alpha 2 -adrenoceptor-induced visceral antinociception. METHODS: Spinal neuronal responses evoked by colorectal distension were recorded in pentobarbitone-anesthetized rats. MPV-2426 was administered onto the spinal cord. Clonidine was used as a reference alpha 2 -adrenoceptor agonist. Inflammation of the colon was induced by turpentine. Sympathectomy was induced by 6-hydroxydopamine. A midthoracic transection of the spinal cord was performed to study the role of descending pathways. RESULTS: Spinal administration of MPV-2426 produced a dose-dependent attenuation of responses evoked by colorectal distension, and this effect was of the same percentual magnitude in inflamed as in noninflamed animals. Clonidine and MPV-2426 induced equipotent visceral antinociception. The effect by spinally administered MPV-2426 was enhanced by a chemical sympathectomy but not influenced by spinal transection. CONCLUSIONS: Spinally administered MPV-2426 produces a dose-dependent visceral antinociception as well in animals with an inflammation of the colon as in controls. The visceral antinociceptive effect induced by spinal MPV-2426 is equipotent to that of spinal clonidine. An intact sympathetic nervous system or intact brainstem-spinal pathway is not critical for the MPV-2426-induced visceral antinociception.
PMID: 12502996, UI: 22390617
Anesthesiology 2003 Jan;98(1):181-8
Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachussets 02115, USA.
BACKGROUND: Adding epinephrine to lidocaine solutions for peripheral nerve block potentiates and prolongs the action, but by incompletely understood mechanisms. In an effort to discriminate the pharmacokinetic from the pharmacodynamic effects of epinephrine, the authors measured the lidocaine content of peripheral nerve over the course of block produced by 0.5% lidocaine, with and without epinephrine, and correlated it with the degree of analgesia. METHODS: Percutaneous sciatic nerve blocks were performed in 18 groups of rats (10 in each) with 0.1 ml of either 0.5% lidocaine or 0.5% lidocaine with epinephrine (1:100,000). Over the full course of nerve block, the authors regularly measured analgesia to toe pinch and then rapidly removed nerves to assay intraneural lidocaine content at 2-120 min after injection. RESULTS: The kinetics of lidocaine's clearance from nerve was composed of a fast-decaying transient superimposed on a very slowly decaying component. The effect of epinephrine on the intraneural lidocaine content was to increase the amount of lidocaine in the slow-decaying component by threefold to fourfold, although the total neural content was not altered by epinephrine for the first 10 min after injection. Epinephrine prolonged blockade by almost fourfold and enhanced the intensity of peak analgesia, as well as the fraction of rats with complete block, almost throughout the 2-120-min period of behavioral observation. CONCLUSIONS: Adding epinephrine to lidocaine solutions increases the intensity and duration of sciatic nerve block in the rat. The early increase in intensity is not matched with an increase in intraneural lidocaine content at these early times, although the prolonged duration of block by epinephrine appears to correspond to an enlarged lidocaine content in nerve at later times, as if a very slowly emptying "effector compartment" received a larger share of the dose. The increase in early analgesia without increased lidocaine content may be explained by a pharmacodynamic action of epinephrine that transiently enhances lidocaine's potency, but also by a pharmacokinetic effect that alters the distribution of the same net content of lidocaine within the nerve.
PMID: 12502995, UI: 22390616
Anesthesiology 2003 Jan;98(1):164-9
Departments of Anesthesiology and Obstetrics and Gynecology, University of Miami School of Medicine, Florida 33136, USA. dbirnbach@med.miami.edu
BACKGROUND: Although rare, infectious sequelae of epidural analgesia can occur. A recently marketed antiseptic solution (DuraPrep) which contains an iodophor in isopropyl alcohol, may provide enhanced and longer-lasting antimicrobial activity and thus be useful in the obstetric setting. The purpose of this study was to evaluate the antisepsis achieved with DuraPrep compared with povidone iodine (PI). METHODS: Sixty women in active labor who requested epidural analgesia were randomly assigned to receive skin preparation with either PI or DuraPrep solution. A total of three cultures were obtained from each subject. The first was obtained just prior to skin disinfection, the second was obtained immediately following antisepsis, and the third was obtained just before removal of the catheter. In addition, the distal tip of the catheter was also submitted for culture. RESULTS: The clinical characteristics and the risk factors for infection were similar in the two groups. The proportion of subjects with positive skin cultures immediately after skin disinfection differed significantly between the PI and DuraPrep groups (30 3%, respectively, P = 0.01). The number of subjects with any positive skin cultures at the time of catheter removal was greater in the PI group as compared to the DuraPrep group (97 50%, respectively, P = 0.0001), as was the number of organisms cultured from skin (log CFU 1.93 +/- 0.40 0.90 +/- 0.23, respectively, P = 0.03). Six catheters, all from the PI group, yielded positive cultures by the roll-plate technique. CONCLUSION: As compared to PI, DuraPrep solution was found to provide a greater decrease in the number of positive skin cultures immediately after disinfection, as well as in bacterial regrowth and colonization of the epidural catheters.
PMID: 12502993, UI: 22390614
Anesthesiology 2003 Jan;98(1):156-63
Department of Anesthesiology and Critical Care Medicine, Orthopedic Surgery, Hadassah Hebrew University Medical Center, Jerusalen, Israel. matoth@cc.huji.ac.il
BACKGROUND: Perioperative myocardial ischemia occurs in 35% of unselected elderly patients undergoing hip fracture surgery. Perioperative epidural analgesia may reduce the incidence of adverse cardiac events. METHODS: The effect of early administration of epidural analgesia during the stressful period, on cardiac events was evaluated in a prospective randomized study in 68 patients with hip fractures who either had known coronary artery disease or were at high risk for coronary artery disease. On admission to the emergency room, patients were assigned to receive a usual care analgesic regimen (intramuscular meperidine, control group, n = 34) or continuous epidural infusion of local anesthetic and opioid (epidural group, n = 34). Monitoring in the preoperative period included a preoperative history and physical examination, daily assessment of cardiac adverse events, serial electrocardiograms, cardiac enzymes, and pain scores. RESULTS: Preoperative adverse cardiac events were significantly more prevalent in the control group compared with the epidural group (7 of 34 0 of 34; = 0.01). Adverse cardiac events included fatal myocardial infarction in three, fatal congestive heart failure in one, nonfatal congestive heart failure in one, and new onset atrial fibrillation in two. The incidence of intraoperative and postoperative adverse cardiac events was similar for the two groups. The significant difference between groups in the incidence of preoperative cardiac events prompted interruption of the study after the planned interim analysis. CONCLUSIONS: The authors' data indicate that compared with conventional analgesia, early administration of continuous epidural analgesia is associated with a lower incidence of preoperative adverse cardiac events in elderly patients with hip fracture who have or are at risk for coronary artery disease. Preoperative epidural analgesia may be advantageous for this surgical population.
PMID: 12502992, UI: 22390613
Anesthesiology 2003 Jan;98(1):143-50
*Consultant, dagger Professor and Chief of Staff, Department of Anesthesiology, University Clinic of Zurich/Balgrist. double dagger AstraZeneca R&D, Sodertalje, Sweden.
BACKGROUND: In this open, randomized study, the pharmacokinetics, clinical efficacy, and safety of a 48-h continuous interscalene infusion of 2 mg/ml ropivacaine for postoperative pain relief were investigated in patients undergoing open major shoulder surgery. METHODS: An initial interscalene block with 30 ml ropivacaine, 7.5 mg/ml (225 mg), was performed. After completion of interscalene block, all patients (n = 24) received general anesthesia, and 6 h after interscalene block, a 48-h continuous interscalene infusion of 12 or 18 mg/h using 2 mg/ml ropivacaine was started. Total and unbound plasma concentrations of ropivacaine and 2.6-pipecoloxylidide (PPX; a major active metabolite) were determined during and up to 6 h after the interscalene infusion. Postoperative pain at rest was assessed by a visual analog scale. Supplementary analgesics and adverse events were recorded. RESULTS: Plasma concentrations of total and unbound ropivacaine were proportional to the total dose. At the end of the interscalene infusion of 9 ml/h, the mean +/- SD plasma concentrations of total and unbound ropivacaine were 1.40 +/- 0.54 and 0.03 +/- 0.01 mg/l, respectively, and of total and unbound PPX were 0.70 +/- 0.38 and 0.30 +/- 0.20 mg/l, respectively. Plasma concentrations of unbound ropivacaine and unbound PPX, added together, remained well below threshold levels for systemic central nervous system toxicity. There were no significant differences between the groups for postoperative pain (median maximum of about 20 mm on the visual analog scale in both groups), analgesic consumption, or quality of pain relief assessed by the patient. No signs or symptoms of systemic local anesthetic toxicity were observed. CONCLUSION: A 48-h continuous interscalene infusion of 6 or 9 ml/h ropivacaine, 2 mg/ml, started 6 h after an initial interscalene block of 30 ml ropivacaine, 7.5 mg/ml, provided satisfactory postoperative pain relief after major shoulder surgery and was well tolerated. Unbound plasma concentrations of ropivacaine and PPX remained well below threshold levels for systemic central nervous toxicity.
PMID: 12502990, UI: 22390611
Anesthesiology 2003 Jan;98(1):82-8
Research Fellow, Klinik fur Anaesthesiologie der Technischen Universitat Munchen, Klinikum rechts der Isar, Germany.
BACKGROUND: Systemic inflammation may be associated with resistance to nondepolarizing neuromuscular blocking drugs, the mechanisms of which are, however, uncharacterized. The authors therefore investigated the pharmacodynamics of atracurium and its relation to the expression of nicotinic acetylcholine receptors and alpha1 -acid glycoprotein in a rat model of systemic inflammation. METHODS: To induce a systemic inflammation, male CD rats received 56 mg/kg corynebacterium parvum intravenously. On days 2, 4, 6, 8, 10, 12, 14, or 16 after infection, neuromuscular transmission was measured. The individual effective dose of atracurium was determined, followed by an atracurium infusion at a rate to establish a steady state neuromuscular block of 50%. Total and unbound plasma concentrations of atracurium for 50% paralysis were measured using high-performance liquid chromatography. Acetylcholine receptors were quantitated using 125I-alpha-bungarotoxin. alpha1 -Acid glycoprotein concentrations in the serum were measured using a competitive chemiluminescence immunoassay. RESULTS: The effective dose of atracurium was increased on days 4, 6, and 8. Total atracurium plasma concentrations at 50% neuromuscular paralysis were increased on days 4, 6, 8, and 10, with a peak at day 8 (8.0 +/- 1.3 micro g/ml) compared with control rats (4.23 +/- 0.82 micro g/ml). The alpha1 -acid glycoprotein concentrations were increased between days 2 and 10, with a peak on day 4 (6.52 +/- 1.45 mg/ml), and recovered to control values (0.61 +/- 0.33 mg/ml) on day 12. Unbound plasma concentrations of atracurium to achieve 50% depression, as well as the expression of acetylcholine receptors, did not differ between groups. CONCLUSION: Resistance to atracurium during corynebacterium parvum-induced systemic inflammation is due to increased drug binding to alpha1 -acid glycoprotein and is unrelated to changes in acetylcholine receptor expression.
PMID: 12502983, UI: 22390604
Anesthesiology 2003 Jan;98(1):46-52
Department of Anesthesiology, University Hospital Center of Charleroi, Belgium. michaela.stadler@chu-charleroi.be
BACKGROUND: It is commonly stated that risk factors for postoperative nausea are the same as for vomiting. The authors designed a prospective study to identify and differentiate the risk factors for postoperative nausea and vomiting in various surgical populations in a clinical audit setting. METHODS: The study included 671 consecutive surgical inpatients, aged 15 yr or more, undergoing various procedures. The study focused on postoperative nausea visual analog scale scores every 4 h and vomiting episodes within 72 h. Both vomiting and retching were considered as emetic events. Patient-, anesthesia-, and surgery-related variables that were considered to have a possible effect on the proportion of patients experiencing postoperative nausea and/or vomiting were examined. The bivariate Dale model for binary correlated outcomes was used to identify selectively the potential risk factors of postoperative nausea and vomiting. RESULTS: Among the 671 patients in the study, 126 (19%) reported one or more episodes of nausea, and 66 patients (10%) suffered one or more emetic episodes during the studied period. There was a highly significant association between the two outcomes. Some risk factors were predictive of both nausea and vomiting (female gender, nonsmoking status, and general anesthesia). History of migraine and type of surgery were mainly responsible for nausea but not for vomiting. The predictive effect of risk factors was controlled for postoperative pain and analgesic drugs. CONCLUSION: This study shows that differences exist in risk factors of postoperative nausea and vomiting. These could be explained by differences in the physiopathology of the two symptoms.
PMID: 12502978, UI: 22390599
Anesthesiology 2003 Jan;98(1):41-5
Anesthesiology and Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA. litmanr@email.chop.edu
BACKGROUND: Knowledge of the influence of age on laryngeal dimensions is essential for all practitioners whose interest is the pediatric airway. Early cadaver studies documented that the larynx is conically shaped, with the apex of the cone caudally positioned at the nondistensible cricoid cartilage. These dimensions change during childhood, as the larynx assumes a more cylindrical shape. The authors analyzed laryngeal dimensions during development to determine if this relationship continues in unparalyzed children in whom laryngeal muscles are tonically active. The authors determined the relationships between the vocal cord, sub-vocal cord, and cricoid ring dimensions and the influence of age on these relationships. METHODS: Infants and children undergoing magnetic resonance imaging with propofol sedation had determinations of the transverse and anterior-posterior (AP) dimensions of the larynx at the most cephalad level of the larynx (vocal cords) and the most caudad level (cricoid). Most patients had an additional measurement (sub-vocal cord) at a level between the vocal cords and the cricoid ring. Relationships were obtained by plotting age against laryngeal dimensions and the ratio of laryngeal dimensions at different levels within the larynx. RESULTS: The authors measured transverse and AP laryngeal dimensions in 99 children, aged 2 months-13 yr. The relationship between the transverse and AP dimensions at all levels of the larynx did not change during development. Transverse and AP dimensions increased linearly with age at all levels of the larynx. In all children studied, the narrowest portion of the larynx was the transverse dimension at the level of the vocal cords. Transverse dimensions increased linearly in a caudad direction through the larynx ( P< 0.001), while AP dimensions did not change relative to laryngeal level. The shape of the cricoid ring did not change throughout childhood. CONCLUSIONS: In sedated, unparalyzed children, the narrowest portions of the larynx are the glottic opening (vocal cord level) and the immediate sub-vocal cord level, and there is no change in the relationships of these dimensions relative to cricoid dimensions throughout childhood.
PMID: 12502977, UI: 22390598
Anesthesiology 2003 Jan;98(1):6-13
Department of Anesthesiology of the University Hospital, RWTH Aachen, Germany. rossaint@post.rwth-aachen.de
BACKGROUND: All general anesthetics used are known to have a negative inotropic side effect. Since xenon does not have a negative inotropic effect, it could be an interesting future general anesthetic. The aim of this clinical multicenter trial was to test the hypothesis of whether recovery after xenon anesthesia is faster compared with an accepted, standardized anesthetic regimen and that it is as effective and safe. METHOD: A total of 224 patients in six centers were included in the protocol. They were randomly assigned to receive either xenon (60 +/- 5%) in oxygen or isoflurane (end-tidal concentration, 0.5%) combined with nitrous oxide (60 +/- 5%). Sufentanil (10 mcirog) was intravenously injected if indicated by defined criteria. Hemodynamic, respiratory, and recovery parameters, the amount of sufentanil, and side effects were assessed. RESULTS: The recovery parameters demonstrated a statistically significant faster recovery from xenon anesthesia when compared with isoflurane-nitrous oxide. The additional amount of sufentanil did not differ between both anesthesia regimens. Hemodynamics and respiratory parameters remained stable throughout administration of both anesthesia regimens, with advantages for the xenon group. Side effects occurred to the same extent with xenon in oxygen and isoflurane-nitrous oxide. CONCLUSION: This first randomized controlled multicenter trial on the use of xenon as an inhalational anesthetic confirms, in a large group of patients, that xenon in oxygen provides effective and safe anesthesia, with the advantage of a more rapid recovery when compared with anesthesia using isoflurane-nitrous oxide.
PMID: 12502972, UI: 22390593
Other Formats: Links:
BMJ 2003 Jan 11;326(7380):62-3
PMID: 12521950, UI: 22409617
Br Dent J 2002 Sep 28;193(6):299-300
PMID: 12412591, UI: 22296305
Br Dent J 2002 Sep 28;193(6):300
PMID: 12374988, UI: 22261796
Br J Anaesth 2003 Feb;90(2):258-9
Northampton, UK Norwich, UK.
PMID: 12538393, UI: 22425692
Br J Anaesth 2003 Feb;90(2):241-3
Department of Anesthesiology, The Ottawa Hospital-Civic Campus and The Adult Congenital Heart Clinic, University of Ottawa, Ottawa, Canada.
Anaesthetic management of Caesarean section in a parturient with severe pulmonary stenosis and aortic regurgitation is described. The valvular sequelae resulted from previous unsuccessful surgical correction (Ross procedure) of congenital aortic stenosis. This case demonstrates the importance of multi-disciplinary assessment and careful anaesthetic planning, to avoid deterioration in perioperative cardiac performance in parturients with complex valvular disease. Br J Anaesth 2003; 90: 241-3
PMID: 12538384, UI: 22425683
Br J Anaesth 2003 Feb;90(2):233-7
Christian-Albrechts-University Kiel, Brunswiker Strasse 10, D-24105 Kiel, Germany. University-Hospital Hamburg Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.
BACKGROUND: Compound A, a degradation product of sevoflurane, has been demonstrated to induce sister chromatid exchanges (SCE) in Chinese hamster ovary cells in vitro as a marker for possible genotoxicity. We investigated the formation of SCE in mitogen-stimulated T-lymphocytes of 40 children undergoing sevoflurane anaesthesia for minor surgical procedures. METHODS: Anaesthesia was induced by inhalation of up to 8% sevoflurane and maintained at 2.5-3% in oxygen/nitrous oxide (65/35%) at a fresh gas flow of 3 litre min(-1). Soda lime (humidity 12-15%) was used as a carbon dioxide absorbent. Blood was drawn directly before induction and after termination of anaesthesia. Twenty-five second division metaphases of mitogen-stimulated T-lymphocytes per blood sample were screened for SCE rates using standard techniques. RESULTS: Average duration of anaesthesia was 49.6 (SD 24.0) min. Before anaesthesia induction, 7.93 (1.23) SCE per metaphase were determined. After sevoflurane anaesthesia [1.40 (0.77) MAC h] 7.92 (1.19) SCE per metaphase were observed. Additionally, no differences were evident between male or female children. CONCLUSION: Short-term administration of sevoflurane anaesthesia did not induce SCE in T-lymphocytes of children. No indication for a possible genotoxic effect has been observed. Br J Anaesth 2003; 90: 233-5
PMID: 12538381, UI: 22425680
Br J Anaesth 2003 Feb;90(2):212-220
Anaesthesiologische Universitatsklinik Freiburg, Hugstetter Strasse 55, D-79106 Freiburg im Breisgau, Germany. Institut fur Experimentelle und Klinische Pharmakologie und Toxikologie der Universitat Freiburg, Hermann-Herder-Strasse 5, D-79104 Freiburg im Breisgau, Germany. Chirurgische Forschung, Chirurgische Universitatsklinik Freiburg, Hugstetter Strasse 55, D-79106 Freiburg im Breisgau, Germany. Klinik und Poliklinik fur Anasthesiologie und Intensivtherapie, Universitat Rostock, Schillingallee 35, D-18055 Rostock, Germany.
[Record supplied by publisher]
BACKGROUND: Perioperative intestinal hypoperfusion is a major contributing factor leading to organ dysfunction. It can be caused by stress as a result of surgical manipulation or hypoxia. Additionally, anaesthesia can affect intestinal oxygenation. This animal study was designed to assess the effects of reduced regional sympathetic nervous activity induced by thoracic epidural anaesthesia on intestinal oxygenation. METHODS: After ethical approval, 16 anaesthetized and acutely instrumented pigs were randomly assigned to two groups (epidural anaesthesia alone vs epidural anaesthesia plus volume loading). The epidural anaesthesia aimed for a T5-T12 block. Measurements were at baseline and after 1 and 2 h. RESULTS: Epidural anaesthesia was associated with a decrease in mean arterial blood pressure and pronounced mesenteric vasodilatation. Mesenteric blood flow did not change. Intestinal oxygen uptake, mucosal tissue oxygen partial pressure and tissue carbon dioxide partial pressure remained unchanged. CONCLUSIONS: Despite marked systemic hypotension, epidural anaesthesia did not affect intestinal oxygenation. There was no benefit obtained from volume loading. Br J Anaesth 2003; 90: 212-20
PMID: 12538379
Br J Anaesth 2003 Feb;90(2):199-211
Departments of Anesthesiology and Pharmacology, Box 50, LC-203A, Weill Medical College of Cornell University, 525 East 68th Street, New York, NY 10021, USA.
BACKGROUND: Current theories favour multiple agent-specific neuronal actions for both general anaesthetics and antiepileptic drugs, but the pharmacological properties that distinguish them are poorly understood. We compared the interactions of representative agents from each class on their putative targets using well-characterized radioligand binding assays. METHODS: Synaptosomes or membranes prepared from rat cerebral cortex were used to analyse drug effects on [(35)S]t-butyl bicyclophosphorothionate ([(35)S]TBPS) binding to the picrotoxinin site of GABA(A) receptors, [(3)H]batrachotoxinin A 20-alpha benzoate ([(3)H]BTX-B) binding to site 2 of voltage-gated Na(+) channels, (+)-[methyl-(3)H]isopropyl 4-(2,1,3-benzoxadiazol-4-yl)-1,4-dihydro-5-methoxycarboxyl-2,6-dimethyl-3-pyridinecarboxylate ([(3)H]PN200-110; isradipine) binding to L-type Ca(2+) channels, and [cyclohexyl-2,3-(3)H](N)glibenclamide ([(3)H]GB) binding to K(ATP) channels. RESULTS: I.V. anaesthetics other than ketamine preferentially inhibited [(35)S]TBPS binding (etomidate approximately alphaxalone > propofol > thiopental > pentobarbital). Volatile anaesthetics inhibited both [(35)S]TBPS and [(3)H]BTX-B binding with comparable potencies (halothane approximately isoflurane approximately enflurane). Antiepileptic drugs preferentially antagonized either [(35)S]TBPS (diazepam > phenobarbital) or [(3)H]BTX-B (phenytoin > carbamazepine) binding. Local anaesthetics (lidocaine, tertracaine) selectively antagonized [(3)H]BTX-B binding. None of the drugs tested were potent antagonists of [(3)H]PN200-110 or [(3)H]GB binding. CONCLUSIONS: Comparative radioligand binding assays identified distinct classes of general anaesthetic and antiepileptic drugs based on their relative specificities for a defined target set. I.V. anaesthetics interacted preferentially with GABA(A) receptors, while volatile anaesthetics were essentially equipotent at Na(+) channels and GABA(A) receptors. Antiepileptic drugs could be classified by preferential actions at either Na(+) channels or GABA(A) receptors. Anaesthetics and antiepileptic drugs have agent-specific effects on radioligand binding. Both general anaesthetics and antiepileptic drugs interact with Na(+) channels and GABA(A) receptors at therapeutic concentrations, in most cases with little selectivity. Br J Anaesth 2003; 90: 199-211
PMID: 12538378, UI: 22425677
Br J Anaesth 2003 Feb;90(2):194-8
Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.
BACKGROUND: Remifentanil is used as an analgesic for different procedures performed during monitored anaesthesia care. Opioid-induced nausea and vomiting can be troublesome. METHODS: This prospective, randomized, double-blind study was performed to evaluate the efficacy of prophylaxis with dolasetron in reducing the frequency of postoperative nausea and duration of discharge time. Forty urological patients, undergoing elective ambulatory extracorporeal shock wave lithotripsy (ESWL) received randomly either dolasetron 12.5 mg i.v. (Group 1) or placebo (Group 2) 10 min before a patient-adapted continuous infusion of remifentanil 0.15-0.4 micro g kg(-1) min(-1) was administered. Frequency and intensity (VAS 0-100 mm) of nausea, retching, and vomiting were assessed by patients and blinded investigators during and after the procedure. RESULTS: Patient characteristics, baseline values, duration of ESWL, and total dose of remifentanil did not differ between groups. The frequency (Group 1/Group 2; 20/55%; P<0.05) and mean (SD) maximal intensity [15 (9)/45 (14) mm; P<0.05] of nausea during 24 h was significantly reduced after dolasetron and discharge times in Group 1 were less than Group 2 [22 (14)/45 (28) min; P<0.05]. Br J Anaesth 2003; 90: 194-8
PMID: 12538377, UI: 22425676
Br J Anaesth 2003 Feb;90(2):189-93
Anaesthesia Unit, Department of Anaesthesia and Critical Care and Ophthalmology Unit, Department of Surgery, Fundacion Hospital Alcorcon, c/ Budapest 1, E-28922 Alcorcon, Madrid, Spain.
BACKGROUND: We studied the incidence and clinical characteristics of persistent diplopia related to anaesthesia for cataract surgery in a general hospital. METHODS: This was a retrospective review of anaesthesia for 3587 cataract surgeries. Of all the cases of diplopia referred to the ocular motility clinic after cataract surgery, those involving anaesthesia-related diplopia lasting longer than 1 month were studied. RESULTS: During the study period, 3450 cataract surgeries were performed by phacoemulsification and 137 by extracapsular extraction. Retrobulbar block was used in 2024 cases, peribulbar block in 98, topical anaesthesia in 1420 and general anaesthesia in 43. Twenty-six cases of persistent diplopia were found (0.72% incidence), nine of which (0.25%) were considered to be related to anaesthetic factors; five of the latter involved the left eye. Five were caused by paresis of the inferior rectus muscle and three by fibrosis. In one patient, the inferior oblique muscle was affected. Anaesthesia was by retrobulbar block in eight cases (0.39%) and by peribulbar block in one. No diplopia was found in patients who had topical or general anaesthesia. Treatment was with surgery in two patients and with prisms in six. One patient continues to be studied. CONCLUSIONS: Persistent diplopia can occur after cataract surgery using retrobulbar block predominantly through direct damage to the inferior rectus muscle. The overall incidence of anaesthesia-related diplopia in this series was 0.25%. Br J Anaesth 2003; 90: 189-92
PMID: 12538376, UI: 22425675
Br J Anaesth 2003 Feb;90(2):179-82
Department of Anaesthesia, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. Quality Control North West, Stepping Hill Hospital, Stockport, UK.
BACKGROUND: Local anaesthetics and opioid mixtures are commonly used to provide anaesthesia or analgesia during the perioperative period. In order to facilitate their preparation and storage it is necessary to establish the stability of such solutions. METHODS: In our study, diamorphine was added to ropivacaine 0.2% 200-ml polybags to give a concentration of 25 micro g ml(-1) and to ropivacaine 1% 50-ml syringes to give a concentration of 45 micro g ml(-1). The polybags and syringes were stored at 40 degrees C, 21 degrees C and 4 degrees C for up to 120 days. Samples were taken during this period for measurement of diamorphine and ropivacaine content and pH of the solutions. RESULTS: We found that the storage temperature and the initial concentration influenced the rate of degradation of diamorphine in both the polybags and the syringes. In the syringes, 10% degradation of diamorphine [T (0.9)] was: 6 days at 40 degrees C, 16 days at 21 degrees C and 30 days at 4 degrees C. In the polybags, diamorphine T (0.9) was 6 days at 40 degrees C, 28 days at 21 degrees C and 70 days at 4 degrees C. CONCLUSIONS: It is feasible to manufacture such solutions in pharmacy aseptic units and to store them for up to 1 month for routine use in epidural infusions. Br J Anaesth 2003; 90: 179-82
PMID: 12538374, UI: 22425673
Br J Anaesth 2003 Feb;90(2):173-8
Second Department of Anaesthesiology, Toho University School of Medicine, 2-17-6 Ohashi, Meguro-ward, Tokyo 153-8515, Japan.
BACKGROUND: Block of the first sacral segment is often delayed in lumbar epidural anaesthesia. The addition of either epinephrine or sodium bicarbonate to the local anaesthetic enhances the efficacy of epidural block. We assessed the block of lumbo-sacral segments in lumbar epidural anaesthesia adding epinephrine and/or bicarbonate to lidocaine. METHODS: Twenty-seven patients undergoing lumbar epidural anaesthesia with lidocaine 2%, 17 ml at L4-5 or L5-S1 were randomly divided into three groups. Plain lidocaine, lidocaine with 1:200 000 epinephrine or lidocaine-epinephrine-bicarbonate was administrated via an epidural catheter. The pain threshold after repeated electrical stimulation was used to assess the sensory block at the L2, S1, and S3 segments. Motor block was evaluated using the Bromage scale. RESULTS: Patient characteristics were comparable between the groups. The pH of lidocaine in the lidocaine-epinephrine-bicarbonate group was significantly higher than that in other groups. Pain thresholds at the S1 and S3 segments in the lidocaine-epinephrine-bicarbonate group were significantly higher than those in the lidocaine-epinephrine group. However, differences in the pain threshold at the L2 segment between groups were insignificant. The time to onset of sensory block at the S1 and S3 in the lidocaine-epinephrine-bicarbonate group was significantly shorter than that in the lidocaine group. Pain threshold by pinprick test was approximately within the 30-50 mA range. CONCLUSION: A combination of lidocaine, bicarbonate, and epinephrine increases the pain threshold over the sacral segments. Br J Anaesth 2003; 90: 173-8
PMID: 12538373, UI: 22425672
Br J Anaesth 2003 Feb;90(2):166-72
Pharmacia, 5200 Old Orchard Road, Skokie, IL 60077, USA. Hessing'sche Orthopedic Clinic, Hessingstr, Augsburg, Germany.
BACKGROUND: This multicentre, double-blind, placebo-controlled study compared the opioid-sparing effectiveness and clinical safety of parecoxib sodium over 48 h, in 195 postoperative patients after routine total knee replacement surgery. METHODS: Elective total primary knee arthroplasty was performed under spinal anaesthesia, with a single dose of spinal bupivacaine 10-20 mg, and intraoperative sedation with midazolam 0.5-1.0 mg i.v., or propofol <6 mg kg(-1 )h(-1). Patients were randomized to receive either parecoxib sodium 20 mg twice daily (bd) i.v. (n=65), parecoxib sodium 40 mg bd i.v. (n=67), or placebo (n=63) at the completion of surgery, and after 12, 24, and 36 h. Morphine (1-2 mg) was taken by patient-controlled analgesia or by bolus doses after 30 min. RESULTS: Patients receiving parecoxib sodium 20 mg bd and 40 mg bd consumed 15.6% and 27.8% less morphine at 24 h than patients taking placebo (both P<0.05). Both doses of parecoxib sodium administered with morphine provided significantly greater pain relief than morphine alone from 6 h (P<0.05). A global evaluation of study medication demonstrated a greater level of satisfaction among patients taking parecoxib sodium than those taking placebo. Parecoxib sodium administered in combination with morphine was well tolerated. However, a reduction in opioid-type side-effects was not demonstrated in the parecoxib sodium groups. CONCLUSION: Parecoxib sodium provides opioid-sparing analgesic effects in postoperative patients. Br J Anaesth 2003; 90: 166-72
PMID: 12538372, UI: 22425671
Br J Anaesth 2003 Feb;90(2):161-5
Department of Anaesthesia, Atkinson Morley's Hospital, Copse Hill, Wimbledon, London SW20 0NE, UK Present address: Department of Anaesthesia, St Mary's Hospital, Praed Street, London, UK.
BACKGROUND: There is an increasing trend towards performing craniotomy awake. The challenge for the anaesthetist is to provide adequate analgesia and sedation, haemodynamic stability, and a safe airway, with an awake, cooperative patient for neurological testing. METHODS: The records of all patients who had awake craniotomy at our institution were reviewed. Patients were divided into three groups according to anaesthetic technique. Patients in Group 1 were sedated throughout the procedure. Patients in Groups 2 and 3 had an asleep-awake-asleep technique. Those in Group 2 were anaesthetized with a propofol infusion and fentanyl, and breathed spontaneously through a laryngeal mask airway (LMA( dagger )). Patients in Group 3 had total i.v. anaesthesia with propofol and remifentanil, and ventilation was controlled using an LMA. We noted the incidence of complications in each group. RESULTS: There were 99 procedures carried out between 1989 and 2002. Group 3 had the fewest complications. No patients in Group 3 developed hypercapnia (E'(CO(2)) >6 kPa), compared with all of the patients in Group 2. Patients in Group 1 had no E'(CO(2)) monitoring, but 7% developed airway obstruction. No patients in Group 3 required additional analgesia for pain, compared with 70% of patients in Group 2. CONCLUSIONS: We have developed a technique for craniotomy, which facilitates awake neurological testing, is safe, and has good patient satisfaction. Br J Anaesth 2003; 90: 161-5
PMID: 12538371, UI: 22425670
Br J Anaesth 2003 Feb;90(2):132-41
Department of Anaesthesiology, Leiden University Medical Centre, PO Box 9600, NL-2300 RC Leiden, The Netherlands.
BACKGROUND: The predictive performance of the available pharmacokinetic parameter sets for remifentanil, when used for target-controlled infusion (TCI) during total i.v. anaesthesia, has not been determined in a clinical setting. We studied the predictive performance of five parameter sets of remifentanil when used for TCI of remifentanil during propofol anaesthesia in surgical patients. METHODS: Remifentanil concentration-time data that had been collected during a previous pharmacodynamic interaction study in 30 female patients (ASA physical status I, aged 20-65 yr) who received a TCI of remifentanil and propofol during lower abdominal surgery were used in this evaluation. The remifentanil concentrations predicted by the five parameter sets were calculated on the basis of the TCI device record of the infusion rate-time profile that had actually been administered to each individual. The individual and pooled bias [median performance error (MDPE)], inaccuracy [median absolute performance error (MDAPE)], divergence and wobble of the remifentanil TCI device were determined from the pooled and intrasubject performance errors. RESULTS: A total of 444 remifentanil blood samples were analysed. Blood propofol and remifentanil concentrations ranged from 0.5 to 11 micro g ml(-1) and 0.1 to 19.6 ng ml(-1) respectively. Pooled MDPE and MDAPE of the remifentanil TCI device were -15 and 20% for the parameter set of Minto and colleagues (Anesthesiology 1997; 86: 10-23), 1 and 21%, -6 and 21%, and -6 and 19% for the three parameter sets described by Egan and colleagues (Anesthesiology 1996; 84: 821-33, Anesthesiology 1993; 79: 881-92, Anesthesiology 1998; 89: 562-73), and -24 and 30% for the parameter set described by Drover and Lemmens (Anesthesiology 1998; 89: 869-77). CONCLUSIONS: Remifentanil can be administered by TCI with acceptable bias and inaccuracy. The three pharmacokinetic parameter sets described by Egan and colleagues resulted in the least bias and best accuracy. Br J Anaesth 2003; 90: 132-41
PMID: 12538367, UI: 22425666
Br J Anaesth 2003 Feb;90(2):118-21
The Northern General Hospital, Herries Road, Sheffield S5 7AU, UK E-mail: richardmarks@doctors.org.uk
PMID: 12538364, UI: 22425663
Eur J Pharmacol 2003 Jan 26;460(1):51-7
Department of Pharmacology, University of Yamanashi Faculty of Medicine, Tamaho-cho, Nakakoma-gun, Yamanashi 409-3898, Japan
Y-27632, (+)-(R)-trans-4-(1-aminoethyl)-N-(4-pyridyl) cyclohexanecarboxamide dihydrochloride monohydrate, is a selective Rho-associated kinase inhibitor, which has been suggested to possess multiple clinical applications based on the in vitro observations. Since information regarding in vivo cardiovascular effects of Y-27632 is still limited, we assessed them using the halothane-anesthetized, closed-chest canine model. Administration of Y-27632 in a dose of 0.01 mg/kg, i.v. significantly decreased total peripheral vascular resistance together with an increase of cardiac output without affecting other cardiovascular parameters. Moreover, additional administration of Y-27632 in a dose of 0.1 mg/kg, i.v. significantly decreased blood pressure and left ventricular end-diastolic pressure, increased the heart rate and cardiac contractility, enhanced atrioventricular conduction and shortened the repolarization process as well as the effective refractory period. These results indicate that Y-27632 exerts a potent arterio-venodilator action with cardiostimulatory effects possibly through the sympathetic reflex in the in vivo canine model.
PMID: 12535859, UI: 22423194
Eur J Pharmacol 2003 Jan 26;460(1):27-35
Centre for Anaesthesia and Pain Management Research, University of Sydney at Royal North Shore Hospital, St. Leonard's NSW, 2065, Australia
The interactions between &mgr;-opioid and N-methyl-D-aspartate (NMDA) receptors have important implications for clinical pain management. We recently examined the pharmacokinetics of ketamine in rats following i.v. infusion of ketamine (racemate, 50 mg/kg/5 min) and found increased central nervous system distribution of ketamine in the presence of low constant plasma alfentanil concentrations ( approximately 50 ng/ml). We now report on the effects of low plasma alfentanil concentrations on the duration of anaesthetic and electroencephalographic (EEG) responses to i.v. infusion of ketamine. Compared to ketamine alone, alfentanil significantly increased both the duration of anaesthesia (by 130%, P=0.00022) and the processed EEG power (&mgr;V(2)/s) (by 48%, P=0.0040). The plasma ketamine concentration producing half-maximal EEG effect was significantly reduced (by 60%, P<0.0001) in the presence of alfentanil. The results indicate that low plasma alfentanil concentrations potentiate the anaesthetic and EEG effects produced by ketamine.
PMID: 12535856