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Anaesthesia 2003 Mar;58(3):294
University Hospital of Wales, Cardiff, CF14 4XW, UK E-mail: hallje@cf.ac.uk
[Medline record in process]
PMID: 12603479, UI: 22491395
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Anaesthesia 2003 Mar;58(3):291-2
Falkirk & District General Hospital, Falkirk, UK E-mail: ian.broome@fvah.scot.nhs.uk
PMID: 12603475, UI: 22491391
Anaesthesia 2003 Mar;58(3):290-1
Swindon, SW6 6PB, UK E-mail: dmjackson@doctors.org.uk
PMID: 12603473, UI: 22491389
Anaesthesia 2003 Mar;58(3):288-9
Royal Victoria Infirmary, Newcastle-upon Tyne, E1 4LP, UK E-mail: vbythell@aol.com
PMID: 12603468, UI: 22491384
Anaesthesia 2003 Mar;58(3):233-42
Professor of Applied Psychology, Research Fellow, Senior Lecturer, Senior Honours Student, Department of Psychology, University of Aberdeen, King's College, Aberdeen, AB24 2UB, UK Consultant Anaesthetist, Aberdeen Royal Infirmary, Aberdeen, UK.
A questionnaire survey was conducted with 222 anaesthetists from 11 Scottish hospitals to measure their attitudes towards human and organisational factors that can have an impact on effective team performance and consequently on patient safety. A customised version of the Operating Room Management Attitude Questionnaire (ORMAQ) was used. This measures attitudes to leadership, communication, teamwork, stress and fatigue, work values, human error and organisational climate. The respondents generally demonstrated positive attitudes towards the interpersonal aspects of their work, such as team behaviours and they recognised the importance of communication skills, such as assertiveness. However, the results suggest that some anaesthetists do not fully appreciate the debilitating effects of stress and fatigue on performance. Their responses were comparable with (and slightly more favourable than) those reported in previous ORMAQ surveys of anaesthetists and surgeons in other countries.
PMID: 12603453, UI: 22491369
Anaesthesia 2003 Mar;58(3):217-22
Department of Anaesthesiology and General Intensive Care, Department of Neurosurgery, University of Vienna, Wahringer Gurtel 18-20, 1090 Vienna, Austria.
We compared systemic (aortic) blood flow and cerebral blood flow velocity in 30 patients randomly allocated to receive either propofol or sevoflurane anaesthesia. Cerebral blood flow velocity (CBFv) was measured in the middle cerebral artery using transcranial Doppler. Systemic blood flow velocity (SBFv) was measured in the aorta using transthoracic Doppler sonography at the level of the aortic valve. Bispectral index (BIS) was used to measure the depth of anaesthesia. Measurements were made in the awake patient and repeated during propofol or sevoflurane anaesthesia, with BIS measurements of 40-50. The effects of SBFv on CBFv were estimated by calculating the cerebral/systemic blood flow velocity-index (CsvI). A CsvI value of 100 indicating a 1 : 1 relationship between CBFv and SBFv. The results demonstrated that propofol anaesthesia produced a significantly greater reduction in CsvI than did sevoflurane anaesthesia [propofol: 60 (19); sevoflurane: 83 (16), p = 0.009, t-test]. This suggests a direct reduction in CBFv independent of SBFv during propofol anaesthesia. The greater reduction of CBFv occurring during propofol anaesthesia may be due to lower cerebral metabolic demand compared with sevoflurane anaesthesia at comparable depths of anaesthesia.
PMID: 12603451, UI: 22491367
Anaesthesia 2003 Mar;58(3):207-16
Senior Research Fellow, Fellow, Association of Anaesthetists of Great Britain and Ireland and Senior Lecturer Department of Anaesthetics and Intensive Care Medicine, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN, UK.
Twelve volunteers known to have airways that responded adversely to 2.0 MAC desflurane were recruited. Each volunteer inhaled three single breaths of each of 0.5, 1.0 and 2.0 MAC of sevoflurane, halothane, isoflurane, desflurane and balance air, with breaths of air between, whilst breathing nasally through a face mask attached to one of three filters that provided three different levels of humidification. The incidence of any adverse airway events was recorded. The anaesthetic inhaled significantly affected the incidence of adverse airway events (p < 0.001), with the least to most irritant being sevoflurane, halothane, isoflurane and desflurane. Increasing the concentration of anaesthetic also significantly increased the incidence of adverse airway events (p < 0.001). The filter used, and hence the level of humidification, did not affect the incidence of adverse airway events (p = 0.09), but repeated exposure caused a significant reduction in the incidence of adverse airway events (p < 0.001).
PMID: 12603450, UI: 22491366
Anesth Analg 2003 Mar;96(3):915-6
Department of Anaesthesia and Intensive Care and Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
PMID: 12598301, UI: 22486066
Anesth Analg 2003 Mar;96(3):911-2
Lucerne, Switzerland. Gent, Belgium. Mannheim, Germany. Department of Anaesthesiology and Intensive Care Medicine, Marienkrankenhaus Soest, Widumgasse 5, Germany. Department of Intensive Care Medicine, Swiss Paraplegic Centre Nottwil, Switzerland.
PMID: 12598292, UI: 22486057
Anesth Analg 2003 Mar;96(3):910; author reply 910
Publication Types:
PMID: 12598290, UI: 22486055
Anesth Analg 2003 Mar;96(3):907
Erasmus MC, University Medical Center Rotterdam.
PMID: 12598286, UI: 22486051
Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Cologne, Germany. Department of Neurology, Isala Klinie, Zwolle, The Netherlands.
PMID: 12598285, UI: 22486050
Anesth Analg 2003 Mar;96(3):903-6
Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas.
PMID: 12598283, UI: 22486048
Anesth Analg 2003 Mar;96(3):881-4
Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan.
We examined whether the concentration of hyperbaric lidocaine affected the regression of motor block when the dose of lidocaine was kept constant at 30 mg. We also examined the spread, duration, and regression of sensory block. Sixty-five patients (ASA physical status I or II), scheduled for elective perineum or lower limb surgery, were enrolled in this study. Patients received spinal anesthesia with 1 mL of 3% lidocaine or 3 mL of 1% lidocaine. Adequate level of block was obtained for surgery in 63 of 65 patients. Whereas the administration of 3 mL of hyperbaric 1% lidocaine solution produced a level of sensory block similar to that produced by the administration of 1 mL of hyperbaric 3% lidocaine solution in spinal anesthesia, the administration of 3 mL of hyperbaric 1% lidocaine solution resulted in shorter times to full motor recovery and to urination and produced less motor block compared with 1 mL of hyperbaric 3% lidocaine solution. Two patients receiving 1% lidocaine and four patients receiving 3% lidocaine required IV ephedrine because of hypotension. Our results showed the clinical advantages of hyperbaric 1% lidocaine spinal anesthesia compared with hyperbaric 3% lidocaine spinal anesthesia for surgery of short duration. IMPLICATIONS: When the dose of lidocaine was kept constant at 30 mg, hyperbaric 1% lidocaine solution resulted in shorter times for recovery from motor block and to urination than did hyperbaric 3% lidocaine solution. Levels of sensory block were similar. Therefore, the more dilute lidocaine for spinal anesthesia may be suitable for day-care surgery and short duration surgery.
PMID: 12598278, UI: 22486043
Anesth Analg 2003 Mar;96(3):819-25
Department of Anesthesiology, Jefferson Medical College, Philadelphia, Pennsylvania [Formerly: US Army Medical Research Institute of Chemical Defense (USAMRICD).
IMPLICATIONS: The 1995 Tokyo subway strike proved nerve gas to be a fearsome terrorist weapon of mass destruction. Because the clear liquid is easily hidden until released, rescuers must aid nonbreathing casualties near instantly. Anesthesiologists are uniquely qualified to train these rescue squads and to manage nerve gas victims in the hospital.
PMID: 12598268, UI: 22486033
Anesth Analg 2003 Mar;96(3):802-12, table of contents
Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0591, USA. aaboulei@utmb.edu
Productivity measurements based on "per operating room (OR) site" and "per case" are not influenced by staffing ratios and have permitted meaningful comparisons among small samples of both academic and private-practice anesthesiology groups. These comparisons have suggested that a larger sample would allow for clinical groups to be compared using a number of different variables (including type of hospital, number of OR sites, type of surgical staff, or other organizational characteristics), which may permit more focused benchmarking. In this study, we used such grouping variables to compare clinical productivity in a broad survey of academic anesthesiology programs. Descriptive, billing, and staffing data were collected for 1 fiscal or calendar year from 37 academic anesthesiology departments representing 58 hospitals. Descriptive data included types of surgical staff (e.g., academic versus private practice) and hospital centers (e.g., academic medical centers and ambulatory surgical centers [ASCs]). Billing and staffing data included total number of cases performed, total American Society of Anesthesiologists units (tASA) billed, total time units billed (15-min units), and daily number of anesthetizing sites staffed (OR sites). Measurements of total productivity (tASA/OR site), billed hours per OR site per day (h/OR/d), surgical duration (h/case), hourly billing productivity (tASA/h), and base units/case were compared. These comparisons were made according to type of hospital, number of OR sites, and type of surgical staff. The ASCs had significantly less tASA/OR site, fewer h/OR/d, and less h/case than non-ASC hospitals. Community hospitals had significantly less h/OR/d and h/case than academic medical centers and indigent hospitals and a larger percentage of private-practice or mixed surgical staff. Academic staffs had significantly less tASA/h and significantly more h/case. tASA/h correlated highly with h/case (r = -0.68). This study showed that the hospitals at which academic anesthesiology groups provide care are not all the same from a clinical productivity perspective. By grouping based on type of hospital, number of OR sites, and type of surgical staff, academic anesthesiology departments (and hospitals) can be better compared by using clinical productivity measurements based on "per OR site" and "per case" measurements (tASA/OR, billed h/OR/d, h/case, tASA/h, and base/case). IMPLICATIONS: Organizational factors, including type of hospital, number of operating rooms, and type of surgical staff, influence the clinical productivity of academic anesthesiology departments. Reporting quartile data by focused grouping variables allows anesthesiology groups to compare their clinical productivity with groups practicing in similar clinical settings.
PMID: 12598266, UI: 22486031
Anesth Analg 2003 Mar;96(3):765-8
Department of Anesthesiology, Sapporo Medical University School of Medicine. Division of Anesthesia, Obihiro Kosei Hospital, Japan.
We investigated the effect of IV droperidol on the bispectral index (BIS) in conscious and propofol-sedated patients during spinal anesthesia. Thirty minutes after the induction of spinal anesthesia, 20 patients were given 2 mg of droperidol IV without administration of other sedatives (conscious group). Another group of patients were sedated with a propofol infusion to maintain BIS at 60 +/- 5 and were administered IV saline (placebo group; n = 20), droperidol 1 mg (dro-1 group; n = 20), or droperidol 2 mg (dro-2 group; n = 20) in a randomized order and in a double-blinded fashion. Although BIS remained the same in the conscious and placebo groups, it significantly decreased after administration of droperidol in the dro-1 and dro-2 groups. The decrease in BIS was significantly larger in the dro-2 group than in the dro-1 group. These results suggest that an antiemetic dose of droperidol enhances the hypnotic effect of propofol in a dose-dependent manner during spinal anesthesia. IMPLICATIONS: An antiemetic dose of IV droperidol causes a decrease in the bispectral index in patients sedated with propofol during spinal anesthesia. We conclude that droperidol may enhance the hypnotic effect of propofol.
PMID: 12598260, UI: 22486025
Anesth Analg 2003 Mar;96(3):755-6
Department of Anesthesiology and Intensive Care, Hopital de l'Hotel-Dieu, Lyon. Laboratory of Glycobiology, Unite INSERM 346, Centre Hospitalier Lyon Sud, Pierre-Benite, France.
IMPLICATIONS: This study suggests that lidocaine can induce apoptosis (detected by dual staining with Annexin V and propidium iodide) on T-cell line cultures in a time-dependent manner. This was not observed with ropivacaine.
PMID: 12598258, UI: 22486023
Anesth Analg 2003 Mar;96(3):720-5
Waikato Clinical School, Waikato Hospital, Hamilton, New Zealand.
It is unclear whether opioid-induced changes in electroencephalogram (EEG) or auditory evoked potentials (AEPs) reliably correspond with consciousness. We examined the correlation between 1) the clinically assessed state of consciousness, 2) implicit and explicit memory (by use of word pairs), and 3) various measures of EEG and AEP-bispectral index (BIS), A-Line ARX AEP index, spectral entropy, and entropy of the singular value decomposition (SVDEN; a measure of the complexity of the EEG). We studied 21 women during a two-stage awakening (sevoflurane washout followed by remifentanil washout) after anesthesia for gynecological surgery. All were amnesic, and 19 were unresponsive to verbal command with remifentanil alone. In six patients, BIS decreased paradoxically as the remifentanil concentration decreased; this was caused by a low-amplitude EEG, which was misinterpreted by the Aspect algorithm as burst suppression. Most of the EEG/AEP variables were sensitive to the decrease in sevoflurane and the recovery of consciousness, but not to the effects of decreasing remifentanil concentrations. SVDEN was the only variable that demonstrated significant increases for both the sevoflurane and remifentanil washout phases. With the prediction probability statistic during remifentanil washout, SVDEN = 0.79, spectral entropy = 0.81, A-Line ARX AEP index = 0.63, and BIS = 0.58. Entropy measures appear to be worthy of further clinical evaluation in a larger series of patients. SVDEN may be a useful variable for assessing anesthetic and analgesic effects on the central nervous system. IMPLICATIONS: During the recovery phase from a remifentanil-based anesthetic, the bispectral index is not reliably predictive of the depth of consciousness, because of suppression ratio artifacts. Entropy measures of the electroencephalogram show promise, but there is still no gold standard to estimate anesthetic depth.
PMID: 12598252, UI: 22486017
Anesth Analg 2003 Mar;96(3):701-5
Department of Anesthesia and Perioperative Care, University of California, San Francisco. Department of Anesthesiology, Texas Tech University Health Science Center, Lubbock.
IMPLICATIONS: Although sevoflurane is less pungent than desflurane at larger concentrations, neither anesthetic seems to irritate the airway when administered at the smaller concentrations often used during maintenance of anesthesia. Both anesthetics may be delivered effectively via a laryngeal mask airway, with minimal evidence of airway irritation.
PMID: 12598249, UI: 22486014
Anesth Analg 2003 Mar;96(3):694-5
Department of Pediatric Anesthesiology, Children's Memorial Hospital, Northwestern University's Feinberg School of Medicine, Chicago, Illinois.
IMPLICATIONS: We report our experience with ketorolac/lidocaine IV regional anesthesia (Bier block) (IVRA) in two adolescents with complex regional pain syndrome 1. IVRA resulted in complete resolution of symptoms.
PMID: 12598246, UI: 22486011
Anesth Analg 2003 Mar;96(3):686-91
Departments of Anesthesiology, Nursing, and. Pediatrics, Children's Memorial Hospital at Northwestern University Medical School, Chicago, Illinois.
Extensive clinical experience and many studies support the use of IV patient-controlled analgesia (IV PCA) and regional anesthesia techniques for the treatment of postoperative pain in children. In contrast, little has been reported about the ability of children to use patient-controlled epidural analgesia (PCEA) or about the efficacy of this technique. We report a descriptive analysis of prospectively recorded data in 128 children (132 procedures) in whom PCEA was used for acute postoperative pain control. Satisfactory analgesia was obtained in 119 patients (90.1%) for up to 103 h with no episodes of desaturation and without clinical evidence of toxicity or serious adverse effects. Analgesia was satisfactory with the initial settings in 89 patients; in 38 others, this was achieved with changes in PCEA settings or solution. Five patients were switched to IV PCA because of inadequate analgesia. Eight patients with satisfactory analgesia were converted to IV PCA because of adverse effects. Children as young as 5 yr had the cognitive ability to understand and the willingness to use PCEA, consistent with reported use of IV PCA. Careful attention should be paid to the total hourly local anesthetic dose to avoid exceeding the recommended limits. Our prospectively collected data demonstrate that PCEA provides satisfactory analgesia with a small incidence of adverse side effects in children and should be considered along with other strategies in pediatric postoperative pain management. IMPLICATIONS: A descriptive analysis of prospectively recorded data in 132 children receiving patient-controlled epidural analgesia for postoperative pain relief demonstrates satisfactory analgesia without serious toxicity or side effects in children as young as 5 yr. This modality should be considered as another strategy in pediatric postoperative pain management.
PMID: 12598244, UI: 22486009
Anesthesiology 2003 Mar;98(3):797-8
PMID: 12606935, UI: 22494341
Anesthesiology 2003 Mar;98(3):796-7
Medical College of Wisconsin, Milwaukee, Wisconsin. cknapp@mcw.edu
PMID: 12606934, UI: 22494340
Anesthesiology 2003 Mar;98(3):795-6
*Hadassah University Hospital, Jerusalem, Israel. gozaly@md2.huji.ac.il
PMID: 12606933, UI: 22494339
Anesthesiology 2003 Mar;98(3):793-5
*Hospital Santa Creu i Sant Pau, Barcelona, Spain. hlitvan@hsp.santpau.es
PMID: 12606932, UI: 22494338
Anesthesiology 2003 Mar;98(3):791-792
* Associate Professor, section sign Professor and Director of Intensive Care Unit, parallel Professor and Chairman, Department of Anesthesia, Teikyo University, School of Medicine, Tokyo, Japan. dagger Research Fellow, Department of Molecular Imaging and Radiotherapy, Chiba University, Chiba, Japan. double dagger Research Fellow, #Head, Department of Clinical Imaging, National Institute of Radiological Studies, Chiba, Japan.
[Record supplied by publisher]
PMID: 12606930
Anesthesiology 2003 Mar;98(3):763-73
* Clinical Associate Professor, Department of Anesthesiology, Faculty Associate, Department of Biomedical History and Ethics.
PMID: 12606924, UI: 22494330
Anesthesiology 2003 Mar;98(3):712-718
* Research Fellow, Department of Anesthesiology, Advocate Illinois Masonic Medical Center, and Department of Anesthesiology, University of Illinois College of Medicine. dagger Fellow, Department of Internal Medicine, Section of Cardiology, Advocate Illinois Masonic Medical Center. double dagger Chair, Department of Anesthesiology, Advocate Illinois Masonic Medical Center. Clinical Professor, Department of Anesthesiology, University of Illinois College of Medicine. section sign Chair, Department of Pathology, Advocate Illinois Masonic Medical Center. Clinical Professor, Department of Clinical Pathology, University of Illinois College of Medicine. parallel Director of Research Laboratory, Department of Anesthesiology, Advocate Illinois Masonic Medical Center. Professor, Departments of Anesthesiology and Physiology and Biophysics, University of Illinois College of Medicine.
BACKGROUND Volatile anesthetics can precondition the myocardium against functional depression and infarction following ischemia-reperfusion. Neutrophil activation, adherence, and release of superoxide play major roles in reperfusion injury. The authors tested the hypothesis that pretreatment of neutrophils with a volatile anesthetic, simulated preconditioning, can blunt their ability to cause cardiac dysfunction.METHODS Studies were performed in 60 buffer-perfused and paced isolated rat hearts. Left ventricular developed pressure served as an index of myocardial contractility. Polymorphonuclear neutrophils and/or drugs were added to coronary perfusate for 10 min, followed by 30 min of recovery. Platelet-activating factor was used to stimulate neutrophils. Pretreatment of neutrophils consisted of incubation with 1.0 minimum alveolar concentration (MAC) isoflurane or sevoflurane for 15 min, followed by washout. Additional studies were performed with 0.25 MAC isoflurane. Effects of superoxide dismutase were compared to those of volatile anesthetics. Superoxide production was measured by spectrophotometry. Neutrophil adherence to coronary vascular endothelium was estimated from the difference between neutrophils administered and recovered in coronary venous effluent.RESULTS Activated neutrophils caused marked, persistent reduction (> 50%) in left ventricular developed pressure. Isoflurane and sevoflurane at 1.0 MAC and superoxide dismutase abolished this effect. Isoflurane and sevoflurane reduced superoxide production of activated neutrophils by 29% and 33%, respectively, and completely prevented the platelet-activating factor-induced increases in neutrophil adherence. Isoflurane at 0.25 MAC blunted, but did not abolish, the neutrophil-induced decreases in left ventricular developed pressure.CONCLUSION Neutrophils pretreated with 1.0 MAC isoflurane or sevoflurane lost their ability to cause cardiac dysfunction, while those pretreated with a concentration of isoflurane as low as 0.25 MAC were partially inhibited. This action of the volatile anesthetics was associated with reductions in superoxide production and neutrophil adherence to the coronary vascular endothelium. Our findings suggest that inhibitory actions on neutrophil activation and neutrophil-endothelium interaction may contribute to the preconditioning effects of volatile anesthetics observed during myocardial ischemia-reperfusion.
PMID: 12606916
Anesthesiology 2003 Mar;98(3):658-669
*Consultant, dagger Resident, Department of Anesthesia, double dagger Professor, Department of Plastic and Reconstructive Surgery, University of Berne, Inselspital, Berne, Switzerland. section sign Professor and Chairman, Department of Anesthesia and Intensive Care Medicine, Landspitali University Hospital, Reykjavik, Iceland.
BACKGROUND Hypoperfusion of the intestinal mucosa remains an important clinical problem during sepsis. Impairment of the autoregulation of microcirculatory blood flow in the intestinal tract has been suggested to play an important role in the development of multiple organ failure during sepsis and surgery. The authors studied microcirculatory blood flow in the gastrointestinal tract in anesthetized subjects during early septic shock.METHODS Eighteen pigs were intravenously anesthetized and mechanically ventilated. Regional blood flow in the superior mesenteric artery was measured with ultrasound transit time flowmetry. Microcirculatory blood flow was continuously measured with a six-channel laser Doppler flowmetry system in the mucosa and the muscularis of the stomach, jejunum, and colon. Eleven pigs were assigned to the sepsis group, while seven animal served as sham controls. Sepsis was induced with fecal peritonitis, and intravenous fluids were administered after 240 min of sepsis to alter hypodynamic sepsis to hyperdynamic sepsis.RESULTS In the control group, all monitored flow data remained stable throughout the study. During the hypodynamic phase of sepsis, cardiac output, superior mesenteric artery flow, and microcirculatory blood flow in the gastric mucosa decreased by 45%, 51%, and 40%, respectively, compared to baseline ( < 0.01 in all). Microcirculatory blood flow in the muscularis of the stomach, jejunum, and colon decreased by 55%, 64%, and 70%, respectively ( < 0.001 in all). In contrast, flow in the jejunal and colonic mucosa remained virtually unchanged. During the hyperdynamic phase of sepsis, there was a threefold increase in cardiac output and superior mesenteric artery flow. Blood flow in the gastric, jejunal, and colonic mucosa also increased (22%, 24%, and 31% above baseline, respectively). Flow in the muscularis of the stomach returned to baseline, while in the jejunum and colon, flow in the muscularis remained significantly below baseline (55% and 45%, respectively, < 0.01).CONCLUSIONS It appears that in early septic shock, autoregulation of microcirculatory blood flow is largely intact in the intestinal mucosa in anesthetized pigs, explaining why microcirculatory blood flow remained virtually unchanged. This may be facilitated through redistribution of flow within the intestinal wall, from the muscularis toward the mucosa.
PMID: 12606910
Anesthesiology 2003 Mar;98(3):639-642
* Assistant Professor, double dagger Research Resident, section sign Consultant, parallel Chief of Department, Department of Anesthesiology and Critical Care Medicine, The Leopold-Franzens University. dagger Research Associate, Department of Medicine, Division of Physiology, University of California, La Jolla, California.
BACKGROUND Sevoflurane, an inhalational anesthetic frequently administered to infants, prolongs the QT interval of the electrocardiogram in adults. A long QT interval resulting in fatal arrhythmia may also be responsible for some cases of sudden death in infants. As the QT interval increases during the second month of life and returns to the values recorded at birth by the sixth month, we evaluated the effect of sevoflurane on the QT interval during and after anesthesia in this particular population.METHODS In this prospective two-group trial we examined pre-, peri-, and postoperative electrocardiograms of 36 infants aged 1 to 6 months scheduled for elective inguinal or umbilical hernia repair. Anesthesia was induced and maintained with either sevoflurane, or the well-established pediatric anesthetic halothane. Heart rate corrected (c) QTc and JTc interval (indicator of intraventricular conduction delays) were recorded from electrocardiograms before and during anesthesia, and at 60 min after emergence from anesthesia.RESULTS Prolonged QTc was observed during sevoflurane anesthesia (mean [+/-SD], 473 +/- 19 ms, < 0.01). Sixty minutes after emergence from anesthesia, QTc was still prolonged (433 +/- 15 ms) in infants treated with sevoflurane compared with those treated with halothane (407 +/- 33 ms, < 0.01). Analogous differences were found for the JTc interval.CONCLUSIONS Despite a shorter elimination time than better known inhalational anesthetics, sevoflurane induction and anesthesia results in sustained prolongations of QTc and JTc interval in infants in the first 6 months of life. Electrocardiogram monitoring until the QTc interval has returned to preanesthetic values may increase safety after sevoflurane anesthesia.
PMID: 12606907
Anesthesiology 2003 Mar;98(3):621-627
* Assistant Professor of Anesthesia, section sign Professor of Anesthesiology, Chairman of the Department of Anesthesiology and Intensive Care Medicine, University of Bonn. dagger Staff Anesthesiologist, Inselspital Bern, Switzerland. double dagger Postgraduate Fellow, Stanford University School of Medicine. parallel Staff Anesthesiologist, Palo Alto VA Health Care Center, and Assistant Professor of Anesthesia, Stanford University School of Medicine. # Staff Anesthesiologist, Palo Alto VA Health Care Center, and Professor of Anesthesia, Stanford University School of Medicine.
BACKGROUND Several studies relating electroencephalogram parameter values to clinical endpoints using a single (mostly hypnotic) drug at relatively low levels of central nervous system depression (sedation) have been published. However, the usefulness of a parameter derived from the electroencephalogram for clinical anesthesia largely depends on its ability to predict the response to stimuli of different intensity or painfulness under a combination of a hypnotic and an (opioid) analgesic. This study was designed to evaluate the predictive performance of spectral edge frequency 95 (SEF95), BIS, and approximate entropy for the response to increasingly intense stimuli under different concentrations of both propofol and remifentanil in the therapeutic range.METHODS Ten healthy male and ten healthy female volunteers were studied during coadministration of propofol and remifentanil. After having maintained a specific target concentration for 10 min, the depth of sedation-anesthesia was assessed using the responsiveness component of the Observer's Assessment of Alertness/Sedation (OAA/S) rating scale, which was modified by adding insertion of a laryngeal mask and laryngoscopy. The electroencephalogram derived parameters approximate entropy, bispectral index, and SEF95 were recorded just before sedation level was assessed.RESULTS The prediction probability values for approximate entropy were slightly, but not significantly, better than those for bispectral index, SEF95, and the combination of drug concentrations. A much lower prediction ability was observed for tolerance of airway manipulation than for hypnotic endpoints.CONCLUSION Approximate entropy revealed informations on hypnotic and analgesic endpoints using coadministration of propofol and remifentanil comparable to bispectral index, SEF95, and the combination of drug concentrations.
PMID: 12606904
Anesthesiology 2003 Mar;98(3):609-14
* Associate Professor, dagger Clinical Nurse Specialist.
BACKGROUND Participation of children in clinical research requires not only parental permission but also the assent of the child. Although there is no fixed age at which assent should be sought, investigators should obtain assent from children considered able to provide it. This study was designed to determine children's understanding of the elements of disclosure for studies in which they had assented to participate.METHODS The study population included 102 children aged 7-18 yr who had given their assent to participate in a clinical anesthesia or surgical study. Children were interviewed using a semistructured format to determine their understanding of eight core elements of disclosure for the study to which they had agreed to participate. Two independent assessors scored the children's levels of understanding of these elements.RESULTS The children's perceived level of understanding of the elements of disclosure was significantly greater than their measured understanding (7.0 +/- 2.4 5.3 +/- 2.7, 0-10 scale; < 0.0001). Complete understanding of the elements of disclosure for all children ranged from 30.4 to 89.4%. Children aged more than 11 yr had significantly greater understanding compared with younger children, particularly with respect to understanding of the study protocol, the benefits, and the freedom to withdraw.CONCLUSIONS Children approached for their assent to participate in a clinical anesthesia or surgery study have limited understanding of the elements of disclosure and their role as a research participant, particularly if they are aged less than 11 yr.
PMID: 12606902, UI: 22494308
Anesthesiology 2003 Mar;98(3):603-8
*Associate Professor, dagger Clinical Nurse Specialist.
BACKGROUND Central to the tenet of informed consent is the quality of disclosure of information by the investigator and the understanding thereof by the research subject or his or her surrogate. This study was designed to measure parents' understanding of the elements of informed consent for clinical studies in which their children had been approached to participate.METHODS The study sample consisted of 505 parents who had been approached for permission to allow their child to participate in a clinical anesthesia or surgery study. Regardless of whether the parent consented (consenters, n = 411) or declined (nonconsenters, n = 94) to their child's participation in a study, they were interviewed to determine their understanding of 11 elements of consent. Two independent assessors who were familiar with the study protocols scored the parents' levels of understanding.RESULTS Parents perceived their overall understanding of the elements of consent as high (8.7 +/- 1.6; 0-10 scale); however, this represented a significant overestimation compared with the assessors' measures of parental understanding (7.3 +/- 1.8; < 0.0001). Furthermore, consenters had greater understanding than nonconsenters (7.6 +/- 1.6 6.1 +/- 1.9; < 0.001). Several predictors of understanding were identified, including whether the parent consented, education level, clarity of disclosure, child in previous study, age of parent, parent listened to disclosure, and degree to which parent read the consent document. The day on which consent was sought had no impact on the level of understanding.CONCLUSIONS Parents approached for permission to allow their child to participate in a research study had less than optimal understanding of the elements of consent. As such, investigators must make every effort to enhance understanding and ensure that parents have sufficient information to make informed decisions regarding their child's participation in research studies.
PMID: 12606901, UI: 22494307
Anesthesiology 2003 Mar;98(3):599-600
PMID: 12606899, UI: 22494305
Anesthesiology 2003 Mar;98(3):5A-6A
PMID: 12606897, UI: 22494303
Anesthesiology 2003 Feb;98(2):591
PMID: 12552228, UI: 22437811
Anesthesiology 2003 Feb;98(2):590-1
PMID: 12552227, UI: 22437810
Anesthesiology 2003 Feb;98(2):588; author reply 588-90
PMID: 12552226, UI: 22437809
Anesthesiology 2003 Feb;98(2):587-8
PMID: 12552225, UI: 22437808
Anesthesiology 2003 Feb;98(2):586
PMID: 12552224, UI: 22437807
Anesthesiology 2003 Feb;98(2):581-5
Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA. rweller@wfubmc.edu
PMID: 12552223, UI: 22437806
Anesthesiology 2003 Feb;98(2):579-81
Department of Rehabilitation, Taipei Veterans General Hospital, and National Yang-Ming University, Japan.
PMID: 12552222, UI: 22437805
Anesthesiology 2003 Feb;98(2):574-5
Department of Anaesthesia, St. Vincent's University Hospital, Dublin, Ireland. crowesuzanne@hotmail.com
PMID: 12552219, UI: 22437802
Anesthesiology 2003 Feb;98(2):516-20
Department of Anesthesiology, Heinrich-Heine-University Dusseldorf, Germany.
BACKGROUND: The inadvertent intravascular injection of a local anesthetic during epidural anesthesia is an uncommon but potentially serious complication. Epinephrine, the most commonly used marker, does not provide sufficient sensitivity to exclude intravascular injection in all patient populations. The dye indocyanine green (ICG) has been proposed as an alternative marker. It has been demonstrated that ICG could be used to detect intravascular injections with a simple transcutaneous spectrophotometric technique. Although the safety of intravenous ICG is well documented, its neurotoxic potential requires careful study given the probability of inadvertent intrathecal injection during test injections used to verify epidural catheter placement. METHODS: In this study, the authors investigated the neurophysiologic effects of clinically relevant concentrations of ICG (range, 28.6-286 microm) on single myelinated and unmyelinated dorsal root axons in rats by measuring effects on impulse generation and conduction. RESULTS: In contrast to the apparent absence of toxicity when injected intravenously, ICG applied to intact dorsal roots at concentrations likely to be encountered with an epidural test dose produced long-lasting conduction block (21 of 26 axons) or spontaneous bursting activity (7 of 26 axons) in myelinated and unmyelinated dorsal root axons. CONCLUSION: Given this apparent neurotoxicity, ICG should not be used when intrathecal or nerve root injection is possible.
PMID: 12552213, UI: 22437796
Anesthesiology 2003 Feb;98(2):495-8
Hospital das Clinicas, Department of Biomechanics, Medicine and Rehabilitation, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Brazil.
BACKGROUND: The purpose of this study was to determine whether combination of 1-5 microg intrathecal neostigmine would enhance analgesia from a fixed intrathecal dose of morphine. METHODS: A total of 60 patients undergoing gynecologic surgery were randomized to one of five groups. Patients received 15 mg bupivacaine plus 2 ml of the test drug intrathecally (saline, 100 microg morphine, or 1-5 microg neostigmine). The control group received spinal saline as the test drug. The morphine group received spinal morphine as test drug. The morphine + 1 microg neostigmine group received spinal morphine and 1 microg neostigmine. The morphine + 2.5 microg neostigmine group received spinal morphine and 2.5 microg neostigmine. Finally, the morphine + 5 microg neostigmine group received spinal morphine and 5 microg neostigmine. RESULTS: The groups were demographically similar. The time to first rescue analgesic (minutes) was longer for all patients who received intrathecal morphine combined with 1-5 microg neostigmine (median, 6 h) compared with the control group (median, 3 h) (P < 0.02). The morphine group (P < 0.05) and the groups that received the combination of 100 microg intrathecal morphine combined with neostigmine (P < 0.005) required less rescue analgesics in 24 h compared with the control group. The incidence of perioperative adverse effects was similar among groups (P > 0.05). CONCLUSIONS: The addition of 1-5 microg spinal neostigmine to 100 microg morphine doubled the duration to first rescue analgesic in the population studied and decreased the analgesic consumption in 24 h, without increasing the incidence of adverse effects. The data suggest that low-dose spinal neostigmine may improve morphine analgesia.
PMID: 12552210, UI: 22437793
Anesthesiology 2003 Feb;98(2):485-94
Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.
BACKGROUND: The objectives of this study were to compare the incidence, onset, duration and pain scores of transient neurologic symptoms (TNS) with 1% versus 5% hyperbaric lidocaine in spinal anesthesia for short urological procedures in a large prospective study. This study would also evaluate patient satisfaction, and impact of TNS on functional recovery to assess the clinical significance of TNS. METHODS: This was a multicenter, double-blind, randomized controlled trial. Four hundred fifty-three patients undergoing short transurethral procedures were randomized to receive 1% or 5% hyperbaric lidocaine. Eighty milligrams of 1% or 5% hyperbaric lidocaine was administered. During the first 3 days after surgery, the presence of TNS, its intensity and duration, and patient functional level were recorded. An intention-to-treat analysis was used. RESULTS: There was no difference in the incidence of TNS (21% vs. 18%) between 1% versus 5% lidocaine. Patients with TNS had significantly higher pain scores (5.3 +/- 3 vs. 2.3 +/- 3) than patients without TNS during the first 24 h. This difference in pain scores persisted until 72 h postoperatively. There was a significant difference in the daily activities functional scores (2.2 +/- 1 vs. 1.4 +/- 0.8) of TNS non-TNS patients during the first 24 h postoperatively. CONCLUSIONS: There was no difference in the incidence of TNS between the 1% versus 5% spinal lidocaine groups. Pain scores were higher in patients with TNS than those who did not have TNS. During the first 48 h postop, a small proportion of patients who had TNS experienced functional impairment of walking, sitting, and sleeping.
PMID: 12552209, UI: 22437792
Anesthesiology 2003 Feb;98(2):349-53
Department of Anesthesiology, Toronto Western Hospital, University of Toronto, Ontario, Canada. david.wong@uhn.on.ca
BACKGROUND: A correctly performed cricothyroidotomy may be lifesaving in a cannot-ventilate, cannot-intubate situation. However, many practicing anesthesiologists do not have experience with cricothyroidotomy. The purpose of this study was to determine the minimum training required to perform cricothyroidotomy in 40 s or less in mannequins. METHODS: After informed consent, participants were shown a demonstration video and asked to perform 10 consecutive cricothyroidotomy procedures on a mannequin using a preassembled percutaneous dilational cricothyroidotomy set. Each attempt was timed from skin palpation to lung insufflation. Cricothyroidotomy was considered successful if it was performed in 40 s or less, and the cricothyroidotomy time was considered to have plateaued when there were no significant reductions in cricothyroidotomy times in three consecutive attempts. RESULTS: One hundred two anesthesiologists participated in the study. There was a significant reduction of cricothyroidotomy times over the 10 attempts (P < 0.0001) and between three consecutive attempts until the fourth attempt (P < 0.03). The cricothyroidotomy times plateaued by the fourth attempt, while the success rate plateaued at the fifth attempt (94, 96, 96, and 96% at the fourth, fifth, sixth, and seventh attempts, respectively). CONCLUSION: Practice on mannequins leads to reductions in cricothyroidotomy times and improvement in success rates. By the fifth attempt, 96% of participants were able to successfully perform the cricothyroidotomy in 40 s or less. While clinical correlates are not known, the authors recommend that providers of emergency airway management be trained on mannequins for at least five attempts or until their cricothyroidotomy time is 40 s or less. The most appropriate retraining intervals have yet to be determined for optimal cricothyroidotomy skill retention.
PMID: 12552192, UI: 22437775
Anesthesiology 2003 Feb;98(2):323-8
Department of Anesthesiology, Division of Biostatistics, Nashville, TN 37232, USA.
BACKGROUND: The formulation of sulfite-containing propofol (SCP) has not been thoroughly investigated in patients with the extensive smoking history for the effects on the total respiratory system resistance after tracheal intubation. However adverse effects, including acute asthma and bronchospasm, have been reported with several other parenteral formulations of drugs containing sulfite as preservative. Therefore, the aim of this prospective randomized and double blind study was to investigate the effects of EDTA-containing propofol (ECP) and SCP on total respiratory system resistance (Rrs) in patients with the prolonged smoking history and undergoing propofol-based total intravenous anesthesia with tracheal intubation. METHODS: 40 patients scheduled for general anesthesia were enrolled into the study. Anesthesia was induced with either 2 mg/kg ECP, or 2 mg/kg SCP followed by vecuronium (0.1 mg/kg) to ensure complete neuromuscular relaxation for the time of the study. Maintenance anesthesia was continued with propofol infusion at 0.15 mg/kg/min for the first 15 min after intubation. Total respiratory system resistance (Rrs), was measured continuously for 10 min postintubation. RESULTS: The analysis of repeated Rrs measurements taken every minute for 10 min postintubation revealed trend consisting of higher Rrs in the SCP group when compared to the ECP group. The statistical analysis of the data performed using repeated measures analysis of covariance demonstrated statistically significant effect (P < 0.05) of the treatment group factor (SCP vs. ECP) and the time factor (time after intubation) on the postintubation Rrs. CONCLUSION: The total respiratory system resistance measured repeatedly for 10 min after tracheal intubation in patients with smoking history is significantly elevated after induction with SCP than after induction with ECP. The preservative used for propofol formulation may alter the effects of propofol on the total respiratory system resistance in smokers.
PMID: 12552188, UI: 22437771
Anesthesiology 2003 Feb;98(2):299-305
Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Japan. tkazama@hama-med.ac.jp
BACKGROUND: The relationship between patient characteristics and anesthesia induction dose at a high administration rate is unclear. This study was designed to investigate the relation between induction dose and patient characteristics and to compare it to the predicted induction dose using the previously reported pharmacokinetic model. METHODS: Diluted propofol (0.5 mg/ml) dose required to reach loss of consciousness, when infused at an infusion rate per lean body mass (LBM) of 150 mg x kg(-1) x h(-1) (high rate), was determined in 82 patients, ages 10-85 yr. Cardiac output, blood volume, central blood volume (CBV), and hepatic blood flow were measured with indocyanine green pulse spectrophotometry. Stepwise multiple linear regression models were used to investigate the relations between the patient characteristics and induction dose. These were compared with our previously reported parameters at the rate of 40 mg x kg(-1) x h(-1) (low rate) and with predicted induction doses with two previously reported pharmacokinetic models. RESULTS: Significant factors for predicting the induction dose at a high rate were age, LBM, and CBV. Induction dose with one pharmacokinetic model was 1.5 times that of the measured one and the other was half that of the measured one at a high rate. At a low rate, one pharmacokinetic model provided an accurate induction dose. CONCLUSIONS: The prediction of induction dose from physiologic characteristics of patients provides reasonable accuracy at both high and low administration rates of propofol. A previously reported pharmacokinetic model that incorporated patient characteristics provides the same accurate induction dose at a low rate.
PMID: 12552185, UI: 22437768
Ann Fr Anesth Reanim 2002 Dec;21(10):825-6
PMID: 12534127, UI: 22422047
Ann Fr Anesth Reanim 2002 Dec;21(10):816-9
Departement d'anesthesie-reanimation A, hopital Lapeyronie, 34000 Montpellier, France. sandrine-lopez@chu-montpellier.fr
Upper limb peripheral nerve blocks offer many advantages but they are not widely used in prehospital care. We report the case of a multitroncular block at the elbow made by the emergency department team out of the hospital after a major hand trauma. A successful axillary brachial plexus block was done two hours later, without any problem. This case report allows us to discuss about different analgesia techniques useful in prehospital care.
PMID: 12534124, UI: 22422044
Ann Fr Anesth Reanim 2002 Dec;21(10):812-5
Departement urgences anesthesie-reanimation, hopital d'instruction des armees Desgenettes, 69003 Lyon, France. RGFatF1@aol.com
The development of an acute respiratory distress syndrome following hip surgery in elderly patients is suggestive of thromboembolism in most instances. However, we must keep in mind the possibility of rarer complications, which can remain undiagnosed because they are hidden by prominent abnormal behaviours, which can develop following any type of anaesthesia. We report the case of a patient who developed a confusion following an orthopaedic surgery under spinal anaesthesia; this confusion concealed a penetration syndrome resulting from accidental inhalation of a dental crown. Because this patient was old and had previously developed chronic lung disorders, we selected a spinal anaesthesia for performing the surgery; these underlying respiratory disorders worsened the clinical consequences of the inhalation. The dental crown was removed under general anaesthesia with spontaneous ventilation using a bronchoscope after an unsuccessful attempt with a fibrescope due to the size of the foreign body.
PMID: 12534123, UI: 22422043
Ann Fr Anesth Reanim 2002 Dec;21(10):807-11
Service d'anesthesie reanimation chirurgicale, Hotel-Dieu, centre hospitalier universitaire, 44093 Nantes, France. jeanmarc.malinovsky@chu-nantes.fr
We described a case of discitis and meningitis following spinal anaesthesia for transurethral resection of the prostate. The patient received antibiotics for a month before surgery, because of Klebsiella prostatitis. Spinal anaesthesia was performed in L3-L4 interspace by using 22G Quincke needle. Bacteriaemia occurred during the first postoperative hours. Ten days after spinal anaesthesia, patient suffered from lumbar pain, exacerbated by vertebral percussion, and motor weakness within lower limb, which was marked on right side. MRI examination showed L3-L4 discitis with psoas abcess in regard, and epiduritis marked around L3 right spinal root. CSF examination confirmed meningitis but no bacteria was found. Antibiotics were administered over a 6 weeks period, and then patient discharged from hospital without neurological sequellae. Infectious discitis related to disk puncture during spinal anaesthesia and postoperative bacteriaemia was likely in our patient.
PMID: 12534122, UI: 22422042
Ann Fr Anesth Reanim 2002 Dec;21(10):779-806
Institut national d'etudes demographiques (Ined), unite de recherche mortalite, sante, epidemiologie, 133, boulevard Davout, 75980 Paris, France. pontone@ined.fr
OBJECTIVES: Fears related to the future of anaesthesia manpower in France have led the French College of Anaesthesiologists (Cfar) and the French Society of Anaesthesia and Intensive Care (Sfar), in scientific partnership with the National Institute for Demographic Studies (Ined), to set-up a national survey among French anaesthetists (MAR) practicing in France, to describe their demographic evolution and to analyse their professional activities. METHODS: The survey was based on a personal questionnaire, filled by each individual, approved by the National Commission on Informatics and Freedoms (CNIL). The survey was conducted in November 1998, in the 1484 hospitals, public (590) and private (894) where anaesthetics are performed, under the control of local and regional referents. RESULTS: The anaesthesiologists positions count gave a total of 9741 positions shared between 5694 in public practice (58%), 3569 in private practice (37%) and 478 in private hospitals taking part to the national health service-PSPH (5%). The evaluation of the number of anaesthesiologists from the number of positions has made necessary a methodology of rectification of the survey to take in account the lack of response and the multiple sites of activity. The survey allows an evaluation of around 8876 physicians practising anaesthesia and intensive care in France at the beginning of 1999, among them 216 overseas. This census is in concordance with the count made by the Medical Council--Ordre des medecins--which published a number of 8716 anaesthesiologists in France, and 234 overseas, at the 1st January 1999, corresponding to a total of 8950. The annual demographic growth has felt from 9% per year, before 1989, to reach the level zero, in 1999. The masculinisation of the speciality is growing with a proportion of 35.7% of females, as well as ageing, the overage of age increasing from 42.8 in 1989 to 45.9 years in 1999. The pyramid of ages does not correspond to a growing population but to ageing people due to a decrease of the youngest classes. The medical density of 14.75 anaesthesiologists for 100,000 inhabitants in 1999, compared to 12.9 in 1989, is slightly above the European average, but the geographic distribution is very unequal between north and south, the large cities, centre of a university hospital, and the smaller one even if a reduction of differences is observed. The study and the analysis of professional activities bring important data to take in account side of demographic evolution. CONCLUSION: The demographic evolution must integrate non-only the reduction of the entries in the speciality, of the retirements, but also the sociological evolutions linked to the working time reduction. The solutions face to the promised shortcut of manpower consist of a reorganisation of the structures, a new definition of tasks and managements, without the possibility to avoid and adjustment of the anaesthesiologists population.
PMID: 12534121, UI: 22422041
Ann Fr Anesth Reanim 2002 Dec;21(10):760-6
Departement d'anesthesie et de reanimation, CHU de Nice, hopital Saint-Roch, 5, rue Pierre-Devoluy, BP 1319, 06006 Nice, France. stephanegindre@yahoo.fr
OBJECTIVES: Rapid sequence intubation (RSI) with the association of etomidate and succinylcholine is the French "Gold standard" for urgent "full stomach" endotracheal intubations. The aim of this study is to assess the fentanyl as a co-induction agent to take over the sedation between the RSI and the keeping of sedation, which is a critical period in which harmful neuro-vegetatives events, and awakening signs are frequently seen. STUDY DESIGN: Randomized, double blind controlled prospective study, after acceptation by the local ethical committee. PATIENTS AND METHODS: Three groups of patients undergoing RSI in the intensive care unit and by the out-of-hospital medical team were compared: group A patients received fentanyl 3 micrograms kg-1 during RSI, before paralysis was induced. Group B patients received the same dose of fentanyl immediately after endotracheal intubation. Group C patients did not received fentanyl (control group). Outcome measures were awakening signs arrival (respiratory movements, eyes opening, spontaneous limb movements), Ramsay score assessment, and haemody namics. Attempt at intubation and vomiting incident were also measured. Discrete data were compared by chi-2 analysis, continuous data were compared with two-way analysis of variance. A p value < 0.05 was the significant threshold. RESULTS: Thirty-six patients were enrolled and completed the study. All the included patients presented awakening signs. The use of fentanyl did not prevent the recourse of other sedative medications. Ten minutes after endotracheal intubation, significant differences has been noticed for the awakening signs arrival between fentanyl groups (A: 42% and B: 36%) and control group (C: 77%). The Ramsay score evolution follows the same variation. All the patients were intubated on the first attempt, there was no vomiting incident noticed. CONCLUSION: The use of fentanyl, as a co-induction agent with etomidate and succinylcholine during RSI, allows a significant delay of the awakening signs arrival and attenuate the neurovegetative response during the minutes after endotracheal intubation after RSI, without deleterious haemodynamic effects.
PMID: 12534118, UI: 22422038
Br Dent J 2002 Oct 26;193(8):427-8
PMID: 12516662, UI: 22404370
Br J Anaesth 2003 Feb;90(2):257; author reply 257-8
PMID: 12538392, UI: 22425691
Br J Anaesth 2003 Feb;90(2):247-50
Department of Anaesthesia, University Hospital/Kantonsspital Basel, Switzerland.
There are many causes for headaches after childbirth. Even though postdural puncture headache (PDPH) has to be considered in a woman with a history of difficult epidural anaesthesia, pre-eclampsia should always be excluded as an important differential diagnosis. We report a case with signs of late-onset pre-eclampsia where administration of an epidural blood patch (EBP) was associated with eclampsia. A hypothetical causal relationship between the EBP and seizures was discarded on the basis of evidence presented in this report.
PMID: 12538386, UI: 22425685
Br J Anaesth 2003 Feb;90(2):244-7
Department of Anaesthesia, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK. jez@drhaines.freeserve.co.uk
We describe a case of pulmonary oedema occurring at 37 weeks gestation, following the attempted removal of a cervical suture under general anaesthesia. The use of an ultrasound technique to demonstrate the patient's fluid status is described. Signs of amniotic fluid embolism and how it exerts its influence on the circulation are discussed.
PMID: 12538385, UI: 22425684
Br J Anaesth 2003 Feb;90(2):235-7
Department of Anesthesiology, Lahey Clinic, 41 Mall Road, Burlington, MA 01805, USA. michael.s.stix@lahey.org
BACKGROUND: The depth of insertion of the ProSeal laryngeal mask airway (PLMA) is unknown. We measured depth of insertion in satisfactorily positioned PLMAs. METHODS: All women received size 4 masks and men size 5 masks. We measured the position of the integral bite block in relation to the upper incisors documented in patients over a 6-month period. Depth of insertion was scored by dividing the integral bite block into quarters. Satisfactory positioning of the ProSeal itself was determined by (i) positive 'suprasternal notch test', (ii) no venting via the drain tube during maximal lung inflation, and (iii) an unobstructed airway. RESULTS: We studied 274 patients (147 women and 127 men). The midway point of the bite block was proximal to the incisors (e.g. within the oropharynx) in 78% of women (95% CI 71-85%) and 92% of men (95% CI 87-97). The standard deviation for the depth distribution in women was 0.8 cm and for men was 1.0 cm. CONCLUSIONS: Usually most of the integral bite block lies within the oropharynx. It was never normal for the entire bite block to stick out of the mouth (4 SD from the mean for both men and women). The position of the integral bite block relative to the upper incisors gives valuable information during assessment of PLMA position.
PMID: 12538382, UI: 22425681
Br J Anaesth 2003 Feb;90(2):183-8
Department of Anaesthesia, University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium. karel.vermeyen@uza.be
BACKGROUND: We aimed to evaluate whether area under the curve (AUC) analysis of pharmacodynamic data can be used to compare pharmacokinetic models taken from the literature, during a target controlled infusion (TCI) of rocuronium. METHODS: Seventy-two patients scheduled for orthopaedic surgery received a TCI of rocuronium (Stanpump) based on one of four pharmacokinetic models: those described by Szenohradszky, Alvarez-Gomez, Wierda, and Cooper. The resulting theoretical plasma concentration versus time curve was calculated for all patients based on all four pharmacokinetic models. Predicted effect versus time curves were calculated following the pharmacokinetic-pharmacodynamic link model (Sheiner and colleagues). Neuromuscular block was evaluated acceleromyographically. The difference between the area under the observed effect (AUC(OE)) and predicted effect (AUC(PE)) versus time curves was used for comparison. RESULTS: AUC(PE )differed significantly from AUC(OE) in the Szenohradszky and Alvarez-Gomez models, both with the reference link-pharmacodynamic data and with altered link-pharmacodynamic variables. AUC(PE )and AUC(OE) were comparable for the Wierda and Cooper models. The mean AUC(OE) was 25.1 (SD 11.9)% block x h. AUC(PE)-AUC(OE) was significantly larger in the Szenohradszky model when compared with all other pharmacokinetic models. This difference remained when link or pharmacodynamic variables were modified. The smallest AUC(PE)-AUC(OE) difference was found with the Wierda model. CONCLUSION: It was possible to use AUC analysis for identification of the pharmacokinetic model that best predicted the pharmacodynamic characteristics of our patients.
PMID: 12538375, UI: 22425674
Br J Anaesth 2003 Feb;90(2):142-7
Department of Anesthesiology, Tokushima University School of Medicine, 3-18-15 Kuramoto, Tokushima 770-8503, Japan. kawahito@clin.med.tokushima-u.ac.jp
BACKGROUND: Many authors report a high incidence of cardiac events during carotid endarterectomy. The aim of the present study was to evaluate the usefulness of dynamic continuous on-line vectorcardiography for monitoring the occurrence of myocardial ischaemia during carotid endarterectomy. METHODS: We studied 21 patients undergoing carotid endarterectomy. Patients underwent general anaesthesia with isoflurane or sevoflurane. The vectorcardiogram was monitored continuously during carotid endarterectomy. Electrodes were placed according to the previously described lead system and connected to a computerized system for on-line vectorcardiography. Two trend variables were recorded: the QRS vector difference, which reflects changes in the shape of the QRS complex; and the ST vector magnitude, which represents deflection of the ST segment from the isoelectric level. The ST segment deflection was measured 60 ms after termination of the QRS complex. RESULTS: Vectorcardiography was successfully recorded in all 21 patients. Three patients showed intraoperative vectorcardiogram abnormalities. In one of these three patients, both ST vector magnitude and QRS vector difference increased after induction of anaesthesia and ST vector magnitude returned to baseline after administration of nitroglycerin. In the other two patients, both ST vector magnitude and QRS vector difference gradually increased after cross-clamping of the internal carotid artery and ST vector magnitude returned to baseline after unclamping. QRS vector difference remained elevated for several hours in all three patients. CONCLUSIONS: Monitoring ST vector magnitude and QRS vector difference by vectorcardiography may be useful for identifying myocardial ischaemia during carotid endarterectomy.
PMID: 12538368, UI: 22425667
Br J Anaesth 2003 Feb;90(2):127-31
University of Glasgow, Department of Anaesthesia, Glasgow Royal Infirmary, 10 Alexandra Parade, Glasgow G31 2ER, UK.
BACKGROUND: Many anaesthetists are deterred from using total i.v. anaesthesia because of uncertainty over the concentration of propofol required to prevent awareness. We predicted blood and effect-site concentrations of propofol at two clinical end-points: loss of consciousness and no response to a painful stimulus. METHODS: Forty unpremedicated Caucasian patients were anaesthetized with i.v. propofol delivered by a Diprifusor target-controlled infusion (TCI). Bispectral index (BIS) and auditory evoked potential index (AEPex) were measured and blood and effect-site propofol concentrations were predicted. Logistic regression was used to estimate population values for predicted blood and effect-site propofol concentrations at the clinical end-points and to correlate these with BIS and AEPex. RESULTS: The effect-site EC(50) at loss of consciousness was 2.8 micro m ml(-1) with an EC(05) and an EC(95) of 1.5 and 4.1 micro m ml(-1), respectively. The predicted EC(50) when there was no response to a tetanic stimulus was 5.2 micro m ml(-1) with an EC(05) and an EC(95) of 3.1 and 7.2 micro m ml(-1), respectively. CONCLUSIONS: Unconsciousness and lack of response to a painful stimulus occur within a defined range of effect-site concentrations, predicted by Diprifusor TCI software.
PMID: 12538366, UI: 22425665
Eur J Anaesthesiol 2002 Aug;19(8):614-5; author reply 615
PMID: 12200954, UI: 22189793
Eur J Anaesthesiol 2002 Aug;19(8):585-8
Leicester Royal Infirmary, University Department of Anaesthesia, Critical Care and Pain Management, University Hospital of Leicester NHS Trust, Leicester, UK. jt23@le.ac.uk
BACKGROUND AND OBJECTIVE: Cognitive dysfunction has been reported after general anaesthesia, but its assessment is time consuming and difficult to evaluate. This pilot study assessed the feasibility of using the Sustained Attention to Response Test to assess 35 ASA I-II adults (mean age 31.6 yr) undergoing day case surgery under general anaesthesia, and 25 ASA I-II adults (mean age 47.8 yr) undergoing day case surgery under local anaesthesia. METHODS: The Sustained Attention to Response Test was performed before surgery and repeated 2 h after surgery. RESULTS: When patients repeated the test after surgery under local anaesthesia, the number of incorrect responses increased, but reaction times decreased (P < 0.05). Following general anaesthesia, the number of incorrect responses increased (P < 0.05), but reaction times remained unchanged. CONCLUSIONS: The Sustained Attention to Response Test is simple to administer and may be a useful tool when comparing different anaesthetic techniques and their effects on postoperative deficits in sustained attention.
PMID: 12200948, UI: 22189787
J Cardiovasc Pharmacol 2003 Mar;41(3):452-9
In a normal volume state, surgical stress decreases rather than increases nitric oxide (NO) production in the vascular system. In our studies, the effect of minor and major surgical stress and three different degrees of volume expansion on systemic and splanchnic circulatory parameters and on the NO dependence of the circulation have been investigated. When the degree of volume expansion was increased, cardiac output and organ blood flow increased without significant change in vascular resistances. Major surgical stress reduced the increase in cardiac output and organ blood flow elicited by the volume expansion. NO synthase (NOS) inhibition significantly increased blood pressure and total peripheral resistance (TPR) and decreased cardiac output in all groups of animals. As the degree of volume expansion was increased, the NO dependence of the circulation in the surgically less- and more-stressed animals was inversely influenced in some cases. With the three degrees of volume expansion (20, 40, and 60 ml/kg), the NOS inhibition increased the TPR from 30.7 R/kg +/- 1.90 to 73.6 R/kg +/- 5.00, from 20.7 R/kg +/- 1.43 to 66.7 R/kg +/- 3.88, and from 19.9 R/kg +/- 1.25 to 49.1 R/kg +/- 3.84 in the surgically less-stressed animals and from 38.6 R/kg +/- 2.14 to 59.8 R/kg +/- 5.62, from 31.9 R/kg +/- 2.70 to 81.7 R/kg +/- 9.89, and from 29.1 R/kg +/- 2.49 to 91.1 R/kg +/- 6.36 in the surgically more-stressed animals. Volume expansion increases the NO dependence of the vascular resistance in the surgically more-stressed animals but decreases it in the surgically less-stressed animals.
PMID: 12605024, UI: 22492579