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Postoperative seizures after sevoflurane anesthesia in a neonate.
Hsieh SW, Lan KM, Luk HN, Jawan B.
PMID: 15101868 [PubMed - in process]
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Trauma in pregnancy: anesthetic management of a parturient with hypotensive shock and trauma to the gravid uterus.
Nelson TW, Kuczkowski KM.
PMID: 15101867 [PubMed - in process]
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Preoperative stellate ganglion blockade prevents tourniquet-induced hypertension during general anesthesia.
Arai YC, Ogata J, Matsumoto Y, Yonemura H, Kido K, Uchida T, Ueda W.
Department of Anesthesiology, Ehime Rosai Hospital, Ehime, Japan.
Background: Prolonged and excessive inflation of pneumatic tourniquets leads to a hyperdynamic circulatory response. Sympathomimetic activity is an important factor in tourniquet-induced hypertension. Stellate ganglion block specifically blunts sympathetic efferent nerves and prevents hypertension induced by sympathomimetic stimulation. The present study was performed to investigate the effects of stellate ganglion block (SGB) on arterial pressure and heart rate during prolonged tourniquet use under general anesthesia. Methods: Twenty patients scheduled for knee arthroscopy were either treated with 10 ml of 1% lidocaine for SGB (SGB group; n = 10), or intramuscular injection (IM group; n = 10) before tourniquet inflation. Comparisons of systolic and diastolic arterial pressure and heart rate were made before and after the induction of anesthesia, 10 min after the lidocaine treatment, every 5 min during the first 60 min after tourniquet inflation, and immediately before and 5 min following deflation. The maximum values of the circulatory variables were compared. Results: Tourniquet inflation caused increases in the circulatory variables in both groups. Systolic arterial pressure in the SGB group was significantly lower than that in the IM group after 55 min of tourniquet inflation. Diastolic arterial pressure also was significantly lower in the SGB group immediately before the deflation. The maximum values of the three hemodynamic variables were significantly lower in the SGB group. Arterial pressure significantly decreased after tourniquet deflation in the IM group. Conclusion: Ipsilateral SGB attenuated the hyperdynamic response mediated by prolonged tourniquet inflation during knee arthroscopy.
PMID: 15101858 [PubMed - in process]
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The comparative hemodynamic effects of intravenous IQB-9302 and bupivacaine in anesthetized rats.
Gallego-Sandin S, Novalbos J, Santos-Ampuero MA, Galvez-Mugica MA, Garcia AG, Abad-Santos F.
Departments of Clinical Pharmacology andAnesthesiology, Hospital Universitario La Princesa, andInstituto Teofilo Hernando, Departamento de Farmacologia y Terapeutica, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain.
Background: The new local anesthetic IQB-9302 is an amide derivative bearing a cyclopropyl group, with remarkable long duration of action and relative low toxicity. In trying to characterize further its safety profile, the current study compared the hemodynamic effects of different concentrations of bupivacaine and IQB-9302 with saline. Methods: Two groups of eight anesthetized Sprague-Dawley rats were given 0.1, 0.3, 1, 3, and 10 mg/kg of intravenous (i.v.) IQB-9302 or bupivacaine at 20-min intervals; control animals received saline only. Arterial blood pressure and heart rate were monitored during the following 20 min. Results: Both bupivacaine and IQB-9302 reduced heart rate: for bupivacaine, -73.8 beats per min (bpm) (SD: 103.8) and -132.5 bpm (SD: 140.7) at 1 and 3 mg/kg, respectively; for IQB-9302, the reduction amounted to -40.8 bpm (SD: 14.2) and -113.5 bpm (SD: 94.2) at 1 and 3 mg/kg, respectively (baseline range, 318.7-438.2 bpm). The two drugs also produced a comparable increase in the mean arterial blood pressure; bupivacaine increased it by 8.7 mmHg (SD: 6.6) and 12.6 mmHg (SD: 15.4) at 1 and 3 mg/kg, respectively, and IQB-9302, 18.7 mmHg (SD: 21.1) and 20.7 mmHg (SD: 20.5) at 1 and 3 mg/kg, respectively (baseline range, 47.4-134.1 mmHg). All rats treated with 10 mg/kg of either drug died after a drop in heart rate and mean arterial blood pressure. Conclusion: IQB-9302 had hemodynamic effects similar to those of bupivacaine in anesthetized rats. The clinical relevance of these effects warrants further investigation.
PMID: 15101857 [PubMed - in process]
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Effects of volatile anesthetics on cardiac ion channels.
Huneke R, Fassl J, Rossaint R, Luckhoff A.
Department of Anesthesiology, University Hospital, Rheinisch-Westfalische-Technische Hochschule (RWTH), Aachen, Germany.
The focus of the present review is on how interference with various ion channels in the heart may be the molecular basis for cardiac side-effects of gaseous anesthetics. Electrophysiological studies in isolated animal and human cardiomyocytes have identified the L-type Ca(2+) channel as a prominent target of anesthetics. Since this ion channel is of fundamental importance for the plateau phase of the cardiac action potential as well as for Ca(2+)-mediated electromechanical coupling, its inhibition may facilitate arrhythmias by shortening the refractory period and may decrease the contractile force. Effective inhibition of this ion channel has been shown for clinically used concentrations of halothane and, to a lesser extent, of isoflurane and sevoflurane, whereas xenon was without effect. Anesthetics furthermore inhibit several types of voltage-gated K(+) channels. Thereby, they may disturb the repolarization and bear a considerable risk for the induction of ventricular tachycardia in predisposed patients. In future, an advanced understanding of cardiac side-effects of anesthetics will derive from more detailed analyses of how and which channels are affected as well as from a better comprehension of how altered channel function influences heart function.
PMID: 15101848 [PubMed - in process]
Tetrodotoxin-induced conduction blockade is prolonged by hyaluronic acid with and without bupivacaine.
Stevens MF, Hoppe M, Holthusen H, Lipfert P.
Klinik fur Anaesthesiologie, Universitatsklinikum Dusseldorf, Postfach 101007, 40001 Germany. markus.stevens@med.uni-duesseldorf.de
BACKGROUND: In isolated nerves, tetrodotoxin (TTX) blocks nerve conduction longer than bupivacaine. In vivo, however, both substances block nerve conduction to an equal duration, presumably because the hydrophilic TTX binds only weakly to the perineural tissue. High molecular weight hyaluronic acid (HA) prolongs the action of local anaesthetics several-fold. We tested whether admixture of HA enhances the binding of TTX to the perineural tissue and thus induces an ultra-long conduction block after a single application. METHODS: In 12 anaesthetized rabbits, the minimal blocking concentrations of TTX, TTX and HA (TTX/HA) and bupivacaine with HA (bupivacaine/HA) were determined by blocking the natural spike activity of the aortic nerve. In 18 other animals, equipotent concentrations of either TTX, TTX/HA or TTX/bupivacaine/HA were applied topically to the aortic nerve. After disappearance of the spike activity, the wound was closed to simulate the clinical situation of a single shot nerve block. The time until recovery of spike activity was determined. The nerves were examined for signs of neurotoxicity 24 h after the application of the drugs. Data are presented as means +/- SD and compared by ANOVA and Student's t-test for unpaired data. RESULTS: The conduction block by TTX/bupivacaine/HA (10.1 +/- 1.9 h) or TTX/HA (9.3 +/- 1.0 h) was significantly longer than that of plain TTX (7.9 +/- 1.0 h). Neurotoxicity was not observed. CONCLUSIONS: Both HA and HA/bupivacaine prolong the TTX-induced conduction blockade of the aortic nerve of rabbits in vivo. No signs of neurotoxicity were observed.
PMID: 14674985 [PubMed - indexed for MEDLINE]
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Bier's block; 100 years old and still going strong!
Brill S, Middleton W, Brill G, Fisher A.
Department of Anesthesiology and Intensive Care, Chaim Sheba Medical Center, Tel. Hashomer, Israel, 52621. s_bril@yahoo.com
In August 1908 Karl August Bier, Professor of Surgery in Berlin, described a new method of producing analgesia of a limb which he named 'vein anesthesia'. Bier first presented his new method of intravenous regional anesthesia (IVRA) at the 37th Congress of the German Surgical Society on 22 April, 1908, only 10 years after his significant communication on spinal anesthesia (1). His method, which now bears his name, consisted of occluding the circulation in a segment of the arm with two tourniquets and then injecting a dilute local anesthetic through a venous cut-down in the isolated segment. Bier had the good fortune to use procaine, the first safe injectable local anesthetic that had been synthesized by Einhorn in 1904.
Publication Types:
- Biography
- Historical Article
Personal Name as Subject:
PMID: 14674982 [PubMed - indexed for MEDLINE]
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Chronic pain following Caesarean section.
Nikolajsen L, Sorensen HC, Jensen TS, Kehlet H.
Department of Anesthesiology, Viborg Hospital, Heibergs Alle 4, DK-8800 Viborg, Denmark. nikolajsen@dadlnet.dk
BACKGROUND: Chronic postoperative pain is a well-recognized problem after various types of surgery such as amputation, thoracotomy, mastectomy, gallbladder surgery and inguinal hernia repair. However, little is known about chronic pain after gynaecologic surgery. Therefore, the aim was to study the incidence of chronic pain after Caesarean section. METHODS: A questionnaire was sent in February/March 2003 to 244 consecutive patients who underwent Caesarean section in a one-year period from 1 October 2001 to 30 September 2002. Patients were asked about duration of postoperative abdominal scar pain, and if pain was still present to describe the frequency and intensity of pain and its impact on daily life. The questionnaire also included questions about the Caesarean section and about pain problems elsewhere. RESULTS: A total of 220 patients (90.2%) answered the questionnaire. The mean follow-up time was 10.2 months (range 6-17.6). Postoperative pain resolved in most patients within 3 months but 27 patients (12.3%) still had pain at the time of the interview. No patients had constant pain, but in 13 of 27 patients (5.9%) pain was present daily or almost daily. Patients with persistent pain (n = 27) had more often undergone general than spinal anaesthesia for the Caesarean section. Frequencies of pain problems elsewhere and recalls of severe acute postoperative pain were also higher among patients with persistent pain. CONCLUSION: Chronic pain after Caesarean section seems to be a significant problem in at least 5.9% of patients.
PMID: 14674981 [PubMed - indexed for MEDLINE]
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The effect of carbon dioxide, respiratory rate and tidal volume on human heart rate variability.
Poyhonen M, Syvaoja S, Hartikainen J, Ruokonen E, Takala J.
Department of Anesthesiology and Intensive Care, Kuopio University Hospital, 70211 Kuopio, Finland.
BACKGROUND: Heart rate variability (HRV) has been used for assessment of depth of anesthesia. Alterations in respiratory rate and tidal volume modulate the sympatovagal neural drive to the heart. The changes in PaCO2 that accompany changes in breathing pattern may, through chemoreceptors in the brainstem, independently influence the autonomic control of the heart and modulate HRV. METHODS: We measured the effects of PaCO2, tidal volume and respiratory rate on HRV during spontaneous and mechanical ventilation in 22 healthy volunteers and in 25 mechanically ventilated anesthetized patients. RESULTS: Adding CO2 to the inspiratory gas increased high frequency (HF) and low frequency (LF) components of HRV in awake volunteers both during spontaneous and mechanical ventilation, while this effect of CO2 was abolished in patients during anesthesia. Increase of tidal volume increased HF component of HRV only in volunteers during spontaneous ventilation. On the other hand, when respiratory rate was reduced, the balance of HF and LF power moved toward LF power in all study groups. Breathing frequency altered HRV independent on PaCO2, tidal volume and the level of consciousness. In contrast, the effect of PaCO2 appeared to be related to normal level of consciousness, suggesting that a cortical modulation of the autonomic nervous activity contributes to the effects of PaCO2 on HRV. CONCLUSIONS: PaCO2, tidal volume and respiratory rate should be controlled when HRV power spectrum is measured in conscious patients or volunteers, while in anesthetized patients small changes in end-tidal CO2 or tidal volume do not modulate HRV if respiratory rate remains unchanged.
Publication Types:
PMID: 14674979 [PubMed - indexed for MEDLINE]
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Haemodynamic effects of volume resuscitation by hypertonic saline-dextran (HSD) in porcine acute cardiac tamponade.
Terajima K, Aneman A, Haljamae H.
Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Goteborg, Sweden.
BACKGROUND: Hypertonic saline-dextran (HSD) has been utilized for small-volume resuscitation in acute circulatory shock. However, HSD has also been reported to induce myocardial depression. The aim of this study was to examine the effects of HSD on cardiac performance and splanchnic perfusion in a low cardiac output model based on experimental cardiac tamponade. METHODS: Seven anaesthetized, mechanically ventilated pigs of both sexes (weight 24 +/- 2 kg, mean +/- SEM) completed a randomized, cross-over protocol. A low cardiac output state was established by intrapericardial infusion of dextran. Animals were resuscitated by bolus infusions (4 ml kg(-1) in 2 min) of either 7.5% hypertonic saline-dextran or Ringer's acetated solution (RAc) and then observed during tamponade (20 min) and following its release (40 min). Central haemodynamics, portal venous (QPV) and renal arterial (QRA) flows were measured together with gastric, jejunal, hepatic and renal laser-Doppler flowmetry. RESULTS: Resuscitation using HSD in a low cardiac output state completely restored QPV and improved gastric, jejunal, hepatic and renal microcirculation as assessed by laser-Doppler flowmetry while no significant effect was observed in QRA. No such beneficial effects could be observed when animals were resuscitated using RAc. The improved haemodynamic state by HSD was maintained following release of cardiac tamponade while perfusion in RAc resuscitated animals returned to baseline or even remained depressed (hepatic and renal microcirculation). No signs of cardiodepression by HSD were observed. CONCLUSION: Resuscitation using HSD in a low cardiac output state restored splanchnic perfusion and microcirculation without any signs of cardiodepression.
PMID: 14674973 [PubMed - indexed for MEDLINE]
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Reduction in the incidence of awareness using BIS monitoring.
Ekman A, Lindholm ML, Lennmarken C, Sandin R.
Department of Anaesthesia and Intensive Care, Regional hospital, Kalmar, and The Karolinska Institute, Stockholm, Sweden.
BACKGROUND: Explicit recall (ER) is evident in approximately 0.2% of patients given general anaesthesia including muscle relaxants. This prospective study was performed to evaluate if cerebral monitoring using BIS to guide the conduction of anaesthesia could reduce this incidence significantly. PATIENTS AND METHODS: A prospective cohort of 4945 consecutive surgical patients requiring muscle relaxants and/or intubation were monitored with BIS and subsequently interviewed for ER on three occasions. BIS values between 40 and 60 were recommended. The results from the BIS-monitored group of patients was compared with a historical group of 7826 similar cases in a previous study when no cerebral monitoring was used. RESULTS: Two patients in the BIS-monitored group, 0.04%, had ER as compared with 0.18% in the control group (P < 0.038). Both BIS-monitored patients with ER were aware during intubation when they had high BIS values (> 60) for 4 min and more than 10 min, respectively. However, periods with high BIS = 4 min were also evident in other patients with no ER. Episodes with high BIS, 4 min or more, were found in 19% of the monitored patients during induction, and in 8% of cases during maintenance. CONCLUSIONS: The use of BIS monitoring during general anaesthesia requiring endotracheal intubation and/or muscle relaxants was associated with a significantly reduced incidence of awareness as compared with a historical control population.
Publication Types:
- Case Reports
- Clinical Trial
PMID: 14674969 [PubMed - indexed for MEDLINE]
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Comfortably numb?
Sebel PS.
Publication Types:
PMID: 14674967 [PubMed - indexed for MEDLINE]
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Tracheal rupture following endotracheal intubation.
Stannard K, Wells J, Cokis C.
Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Wellington Campus, GPO Box X2213, Perth, W.A. 6847.
We describe a case of tracheal rupture diagnosed after an apparently routine endotracheal intubation for otherwise uneventful lower abdominal surgery in a 33-year-old woman. Risk factors for tracheal rupture, presenting symptoms and signs, management of tracheal rupture and methods of airway management during the surgical repair of the tracheal laceration are discussed. In this case, "side-by-side" microlaryngoscopy tubes, one endobronchial and the other with the tip in the upper trachea, placed with fibreoptic assistance were used for airway management during the tracheal repair.
Publication Types:
PMID: 14601288 [PubMed - indexed for MEDLINE]
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Failed extubation of a double-lumen tube requiring a cricoid split.
Probert DJ, Hardman JG.
Department of Anaesthesia and Perioperative Medicine, Royal Brisbane Hospital, Herston Road, Herston, Qld 4029.
Following a five-hour procedure, it was not possible to remove a double-lumen endobronchial tube that had been placed to facilitate the removal of a massive spleen from a 45-year-old female. The tube had been passed easily at the start of surgery, but was firmly stuck at the level of the cricoid at the end of surgery. Surgical removal of the tube by a cricoid split was required 48 hours later. Consideration of previous airway manipulations, careful choice of airway devices and regular checks of airway patency around tracheal tubes during lengthy procedures may prevent similar events in the future.
Publication Types:
PMID: 14601287 [PubMed - indexed for MEDLINE]
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Paraesthesiae during needle-through-needle combined spinal epidural versus single-shot spinal for elective caesarean section.
McAndrew CR, Harms P.
Department of Anaesthesia, Mater Mother's Hospital, Brisbane, Queensland.
The aim of this study was to compare the incidence of paraesthesiae during spinal needle insertion in a needle-through-needle combined spinal-epidural (CSE) versus a single-shot spinal (SSS) technique. Eighty-nine women presenting for elective caesarean section at a tertiary referral obstetric unit were randomized to receive either needle-through-needle CSE or SSS. Equipment used was a 16 gauge/26 gauge combined spinal-epidural kit and a 26 gauge pencil-point spinal needle with introducer (both Sims Portex, Australia) The presence and distribution of paraesthesiae was recorded by an observer at spinal needle insertion and again on day one postoperatively. There were three failures to perform the intended block. One patient was lost to follow-up at postoperative day one. Seventeen of forty-six (37%) women in the needle-through-needle CSE group and four of forty-three (9%) in the SSS group had paraesthesiae upon spinal needle insertion (P < 0.05, Chi-squared test). No patient had persistent neurological symptoms at postoperative day one. We postulate that the higher incidence of paraesthesiae with needle-through-needle CSE may be related to deeper penetration of the subarachnoid space with this technique.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14601273 [PubMed - indexed for MEDLINE]
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A response to 'Checking anaesthetic equipment and the Expert Group on Blocked Anaesthetic Tubing (EGBAT)', Carter J A, Anaesthesia 2004; 59: 105-7.
Marcus R.
Birmingham Children's Hospital Birmingham, UK.
PMID: 15096273 [PubMed - in process]
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A response to 'Improving anaesthetists' communication skills, Harms C, Young J R, Amsler F, Zettler C, Scheidegger D and Kindler C H, Anaesthesia 2004; 59: 166-72.
Cyna A.
Women's and Children's Hospital Adelaide, Australia SA 5006.
PMID: 15096271 [PubMed - in process]
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A response to 'Peri-operative beta-blockade and haemodynamic optimisation in patients with coronary artery disease and decreasing exercise capacity presenting for major non-cardiac surgery' Biccard B M, Anaesthesia 2004; 59: 60-8.
Giles J, Sear J, Foex P.
University of Oxford John Radcliffe Hospital Oxford, UK E-mail: julian.giles@nda.ox.ac.uk
PMID: 15096269 [PubMed - in process]
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A response to 'Advances in neuroanaesthesia', Hirsch N, Anaesthesia 2003; 58: 1162-5.
Levy DM.
Queen's Medical Centre, Nottingham, UK E-mail: dmlevy@nhs.net
PMID: 15096266 [PubMed - in process]
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A response to 'A pilot study of evaluation of cerebral function by S100B protein and near-infrared spectroscopy during cold and warm cardiopulmonary bypass in infants and children undergoing open-heart surgery' Shaaban Ali M, Harmer M, Elliott M, Lloyd Thomas A and Kirkham F, Anaesthesia 2003; 59: 20-6.
Alston RP.
Royal Infirmary of Edinburgh Ediniburgh, UK E-mail: peter.alston@ed.ac.uk
PMID: 15096264 [PubMed - in process]
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A response to 'Cannabis abuse and anaesthesia', Mills P M and Penfold N, Anaesthesia 2003; 58: 1125.
Notcutt W, Rangappa D.
James Paget Hospital Great Yarmouth, UK E-mail: william.notcutt@jpaget.nhs.uk
PMID: 15096263 [PubMed - in process]
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A response to 'Patients ideas of surgical risk', Palmer J, Anaesthesia 2003; 58: 1239.
Whyte E, Ball DR.
Dumfries and Galloway Royal Infirmary Dumfries, UK E-mail: d.ball@dgri.scot.nhs.uk
PMID: 15096261 [PubMed - in process]
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A response to 'Patient safety', Levison A, Anaesthesia 2003; 58: 1236 and 'Sleep deprivation and performance', Price S R, Anaesthesia 2003; 58: 1238.
Arnstein F.
Western General Hospital Edinburgh, UK E-mail: arnie.arnstein@luht.scot.nhs.uk
PMID: 15096260 [PubMed - in process]
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Evidence-based strategies for preventing drug administration errors during anaesthesia.
Jensen LS, Merry AF, Webster CS, Weller J, Larsson L.
Medical Student, Aarhus University, Aarhus, Denmark.
Summary We developed evidence-based recommendations for the minimisation of errors in intravenous drug administration in anaesthesia from a systematic review of the literature that identified 98 relevant references (14 with experimental designs or incident reports and 19 with reports of cases or case series). We validated the recommendations using reports of drug errors collected in a previous study. One general and five specific strong recommendations were generated: systematic countermeasures should be used to decrease the number of drug administration errors in anaesthesia; the label on any drug ampoule or syringe should be read carefully before a drug is drawn up or injected; the legibility and contents of labels on ampoules and syringes should be optimised according to agreed standards; syringes should (almost) always be labelled; formal organisation of drug drawers and workspaces should be used; labels should be checked with a second person or a device before a drug is drawn up or administered.
PMID: 15096243 [PubMed - in process]
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The effect of mechanically-induced cricoid force on lower oesophageal sphincter pressure in anaesthetised patients.
Garrard A, Campbell AE, Turley A, Hall JE.
Department of Anaesthetics and Intensive Care Medicine, University Hospital of Wales, Cardiff, UK.
Summary In the United Kingdom, cricoid force is central to upper airway management in obstetric and emergency anaesthesia. A reduction in oesophageal barrier pressure (OBP) in these patients may increase regurgitation risk. This study investigated whether the application of cricoid force to anaesthetised patients reduced lower oesophageal sphincter pressure (LOSP) and consequently OBP. Anaesthesia was induced in 29 patients using a standard protocol. An oesophageal balloon catheter was inserted and gastric trace identified. The catheter was withdrawn incrementally and pressure readings recorded at each position before and during the application of 30 N cricoid force, with a sudden rise in pressure indicating lower oesophageal sphincter position. Oesophageal barrier pressure was calculated as the difference between LOSP and gastric pressure. Application of cricoid force significantly reduced OBP without influencing gastric pressure (p < 0.001). The use of cricoid force may increase the risk of gastroesophageal reflux in anaesthetised patients.
PMID: 15096237 [PubMed - in process]
[Volatile anesthetics]
[Article in German]
Loscar M, Conzen P.
Klinik fur Anaesthesiologie der Ludwig-Maximilians-Universitat Munchen, Munchen. Monika.Loscar@med.uni-muenchen.de
None of the currently available inhaled anesthetics has all of the properties of an "ideal" inhaled agent. The exceptionally low solubility of desflurane and sevoflurane offers a significantly greater precision of control over maintenance of anesthesia and a potential for a more rapid recovery from anesthesia than other inhaled anesthetics. Sevoflurane appears to offer some advantages regarding cardiovascular stability. Products of metabolism or degradation can be associated with potential organ-specific toxic effects. Renal toxicity is discussed for enflurane and sevoflurane. Breakdown products of volatile agents with carbon dioxide absorbents have to be mentioned especially for sevoflurane (compound A) and desflurane (CO). In contrast to intravenous anesthetics, volatile anesthetics are associated with cardio- and cerebroprotection.
Publication Types:
PMID: 14991199 [PubMed - indexed for MEDLINE]
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[Spinal anesthesia with morphine and clonidine]
[Article in German]
Bang-Vojdanovski B, Gehling M.
Publication Types:
PMID: 14991197 [PubMed - indexed for MEDLINE]
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[Simulator-based modular human factor training in anesthesiology. Concept and results of the module "Communication and Team Cooperation"]
[Article in German]
St Pierre M, Hofinger G, Buerschaper C, Grapengeter M, Harms H, Breuer G, Schuttler J.
Klinik fur Anasthesiologie, Friedrich-Alexander-Universitat, Erlangen. michael.st.pierre@kfa.imed.uni-erlangen.de
BACKGROUND: Human factors (HF) play a major role in crisis development and management and simulator training can help to train HF aspects. We developed a modular training concept with psychological intensive briefing. The aim of the study was to see whether learning and transfer in the treatment group (TG) with the module "communication and team-cooperation" differed from that in the control group (CG) without psychological briefing ("anaesthesia crisis resource management type course"). METHODS: A total of 34 residents (TG: n=20, CG: n=14) managed 1 out of 3 scenarios and communication patterns and management were evaluated using video recordings. A questionnaire was answered at the end of the course and 2 months later participants were asked for lessons learnt and behavioral changes. RESULTS: Good communication and medical management showed a significant correlation (r=0.57, p=0.001). The TG showed greater initiative ( p=0.001) and came more often in conflict with the surgeon ( p=0.06). The TG also reported more behavioral changes than the CG 2 months later. The reported benefit of the simulation was training for rare events in the CG, whereas in the TG it was issues of communication and cooperation ( p=0.001). CONCLUSIONS: A training concept with psychological intensive briefing may enhance the transfer of HF aspects more than classical ACRM.
PMID: 14991191 [PubMed - indexed for MEDLINE]
Prevention of atelectasis formation during the induction of general anesthesia in morbidly obese patients.
Coussa M, Proietti S, Schnyder P, Frascarolo P, Suter M, Spahn DR, Magnusson L.
Department of Anesthesiology, University Hospital, Lausanne, Switzerland.
Atelectasis caused by general anesthesia is increased in morbidly obese patients. We have shown that application of positive end-expiratory pressure (PEEP) during the induction of anesthesia prevents atelectasis formation in nonobese patients. We therefore studied the efficacy of PEEP in morbidly obese patients to prevent atelectasis. Twenty-three adult morbidly obese patients (body mass index >35 kg/m(2)) were randomly assigned to one of two groups. In the PEEP group, patients breathed 100% oxygen (5 min) with a continuous positive airway pressure of 10 cm H(2)O and, after the induction, mechanical ventilation via a face mask with a PEEP of 10 cm H(2)O. In the control group, the same induction was applied but without continuous positive airway pressure or PEEP. Atelectasis, determined by computed tomography, and blood gas analysis were measured twice: before the induction and directly after intubation. After endotracheal intubation, patients of the control group showed an increase in the amount of atelectasis, which was much larger than in the PEEP group (10.4% +/- 4.8% in control group versus 1.7% +/- 1.3% in PEEP group; P < 0.001). After intubation with a fraction of inspired oxygen of 1.0, PaO(2) was significantly higher in the PEEP group compared with the control group (457 +/- 130 mm Hg versus 315 +/- 100 mm Hg, respectively; P = 0.035) We conclude that in morbidly obese patients, atelectasis formation is largely prevented by PEEP applied during the anesthetic induction and is associated with a better oxygenation. IMPLICATIONS: Application of positive end-expiratory pressure during induction of general anesthesia in morbidly obese patients prevents atelectasis formation and improves oxygenation. Therefore, this technique should be considered for anesthesia induction in morbidly obese patients.
PMID: 15105237 [PubMed - in process]
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A survey of orthopedic surgeons' attitudes and knowledge regarding regional anesthesia.
Oldman M, McCartney CJ, Leung A, Rawson R, Perlas A, Gadsden J, Chan VW.
Department of Anaesthesia, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada.
We conducted a survey to explore the surgical attitudes and preferences regarding regional anesthesia among Canadian orthopedic surgeons. Surveys were returned by 468 (61%) of 768 surgeons. Forty-eight percent of respondents directed their patients' choice of anesthetic. Forty percent of surgeons directed their patients to choose regional anesthesia. The principal reasons for favoring regional anesthesia were less postoperative pain (32%), decreased nausea and vomiting (12%), and safety (14%). Reasons for not favoring regional anesthesia were delays in the induction of anesthesia (43%) and an unpredictable success rate (12%). This survey suggests that orthopedic surgeons are supportive of regional anesthesia. Barriers to increased popularity include perceived delays and unreliability. IMPLICATIONS: Orthopedic surgeons understand the benefits of and are supportive of the use of regional anesthesia in their practices. Barriers to increased popularity include perceived operating room delays and lack of reliability.
PMID: 15105236 [PubMed - in process]
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Ultrastructural findings in human spinal pia mater in relation to subarachnoid anesthesia.
Reina MA, De Leon Casasola Ode L, Villanueva MC, Lopez A, Maches F, De Andres JA.
Department of Anesthesiology and Critical Care, Hospital General de Mostoles, Madrid, Spain. miguelangel.rei@terra.es
We examined ultrastructural details such as the cellular component and membrane thickness of human spinal pia mater with the aim of determining whether fenestrations are present. We hypothesized that pia mater is not a continuous membrane but, instead, that there are fenestrations across the pial cellular membrane. The lumbar dural sac from 7 fresh human cadavers was removed, and samples from lumbar spinal pia mater were studied by special staining techniques, immunohistochemistry, and transmission and scanning electron microscopy. A pial layer made by flat overlapping cells and subpial tissue was identified. We found fenestrations in samples from human spinal pia mater at the thoracic-lumbar junction, conus medullaris, and nerve root levels, but these fenestrations did not appear at the thoracic level. We speculate whether the presence of fenestrations in human spinal pia mater at the level of the lumbar spinal cord and at the nerve root levels has any influence on the transfer of local anesthetics across this membrane. IMPLICATIONS: The ultrastructural anatomy of the human pia mater, such as pial cells, membrane thickness, and subpial tissue at different levels of the thoracic and lumbar spinal cord and nerve roots, was studied by special staining techniques, immunohistochemistry, and transmission and scanning electron microscopy. Fenestrations were found in samples at the thoracic-lumbar junction, conus medullaris, and nerve root levels. No fenestrations were found in samples at the thoracic level. At present, we cannot determine the significance of these findings.
PMID: 15105235 [PubMed - in process]
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General anesthesia for cesarean delivery in a patient with paroxysmal nocturnal hemoglobinuria and thrombocytopenia.
Kjaer K, Comerford M, Gadalla F.
Department of Anesthesiology, Weill Medical College of Cornell University, New York, New York 10021, USA. kkjaer@hotmail.com
Pregnancy in patients with paroxysmal nocturnal hemoglobinuria (PNH) increases the risk of complement activation, hemolysis, and thrombosis. We describe the anesthetic management of a patient with PNH who underwent general anesthesia for cesarean delivery. Steroids, heparin, and blood products were administered early to minimize the likelihood of a hematologic emergency. IMPLICATIONS: Pregnancy in patients with paroxysmal nocturnal hemoglobinuria increases the risk of hemolysis, thrombosis, anemia, and thrombocytopenia. We describe the anesthetic management of a patient with paroxysmal nocturnal hemoglobinuria and thrombocytopenia who underwent general anesthesia for cesarean delivery.
PMID: 15105233 [PubMed - in process]
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Electrocerebral silence by intracarotid anesthetics does not affect early hyperemia after transient cerebral ischemia in rabbits.
Joshi S, Wang M, Nishanian EV, Emerson RG.
Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, NY, USA. sj121@columbia.edu
Evidence suggests that early postischemic hyperemia is mediated by both neurological and vascular mechanisms. We hypothesized that if neuronal activity were primarily responsible for reperfusion hyperemia, then electrocerebral silence induced by intracarotid anesthetics (propofol and pentothal) would attenuate the hyperemic response. New Zealand white rabbits were subjected to 10 min of cerebral ischemia using bilateral carotid occlusion and systemic hypotension. Subsequently, carotid occlusion was released, and the mean arterial blood pressure was increased to baseline values. In the control group, intracarotid saline was periodically injected during reperfusion. In the treatment groups, intracarotid propofol or thiopental was administered to maintain electrocerebral silence for 10 min. Physiological data were measured at baseline, during ischemia, and at reperfusion. Satisfactory data were available for 16 of 19 rabbits. Mean arterial blood pressure, end-tidal CO(2), and cerebral blood flows decreased significantly in both groups during carotid occlusion. During early reperfusion, a similar percent increase in cerebral blood flow from baseline values was observed in all 3 groups (192% +/- 76%, 218% +/- 84%, and 185% +/- 101% for saline, propofol, and pentothal, respectively). These results suggest that suppression of neuronal activity during reperfusion does not affect early hyperemia after transient cerebral ischemia. IMPLICATIONS: Intracarotid injection of anesthetic drugs in doses that are sufficient to produce electrocerebral silence do not obtund early cerebral hyperemia after transient cerebral ischemia. This suggests that vascular, not neuronal mechanisms, are primarily responsible for early postischemic cerebral hyperperfusion.
PMID: 15105230 [PubMed - in process]
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Anesthetic management of a patient in prone position with a drill bit penetrating the spinal canal at C1-C2, using a laryngeal mask.
Valero R, Serrano S, Adalia R, Tercero J, Blasi A, Sanchez-Etayo G, Martinez G, Caral L, Ibanez G.
Department of Anesthesiology, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain. rvalero@medicina.ub.es
Airway management in patients with penetrating neck trauma must guarantee cervical spine stability. Moreover, the prone position increases the risk of difficult ventilation and cervical spine injury. A 19-yr-old patient was brought to the emergency room in prone position with a drill bit protruding from the posterolateral aspect of his neck. The bit had entered the spinal canal below the first cervical vertebra, and placed near the odontoid peg. He was referred for surgical removal of the drill. The use of an inhaled induction of anesthesia, avoiding muscle relaxants, and ventilation through a laryngeal mask airway inserted in the prone position seemed to offer a satisfactory approach. IMPLICATIONS: Management of patients with penetrating neck trauma must guarantee cervical spine stability. Moreover, the prone position increases the risk of difficult ventilation and cervical spine injury. Anesthesia may be induced and the airway can be managed with the patient already in the prone position for surgery.
PMID: 15105228 [PubMed - in process]
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Multiple measures of anesthesia workload during teaching and nonteaching cases.
Weinger MB, Reddy SB, Slagle JM.
Department of Anesthesiology, University of California-San Diego and San Diego Center for Patient Safety and Anesthesia Ergonomics Research Laboratory, Veterans Affairs San Diego Healthcare System, 92161-5008, USA. mweinger@ucsd.edu
In this study, we sought to examine several measures of anesthesia provider workload during different phases of anesthesia care and during teaching and nonteaching cases. Clinical work was assessed in real-time during 24 general anesthetics performed by consenting anesthesia providers. Workload was measured using physiological (provider heart rate), psychological (self-assessment and observer rating), and procedural (response latency to an alarm light and workload density) techniques. Clinicians' heart rates, observer and self-reported workload scores, and nonteaching workload density were consistently increased during anesthetic induction and emergence compared with maintenance. In nonteaching cases, workload density correlated with heart rate and with psychological workload. Workload density during teaching cases did not decrease during the induction and was significantly greater than during nonteaching cases. Alarm-light response latency (a measure of clinical vigilance) was significantly prolonged during the teaching compared with nonteaching cases. These results suggest that intraoperative teaching increases the workload of the clinician instructor and may reduce vigilance during anesthesia care. Additionally, multiple workload measures may provide a more comprehensive profile of the work demands of clinical cases. IMPLICATIONS: Psychological, physiological, and procedural workload measures during routine general anesthesia cases documented the increased work demands of induction and emergence. Intraoperative teaching increased workload and decreased vigilance, suggesting the need for caution when educating during patient care.
PMID: 15105224 [PubMed - in process]
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Rapid skin anesthesia using a new topical amethocaine formulation: a preclinical study.
Arevalo MI, Escribano E, Calpena A, Domenech J, Queralt J.
Departament de Fisiologia-Divisio IV, Universitat de Barcelona, Spain.
We developed a fast-acting topical amethocaine emulsion and tested its analgesic activity against heat or mechanically induced pain in a rat paw model. The first experiment was performed in rats made hyperalgesic or allodynic after carrageenan-induced inflammation. Rats were distributed in five subgroups, each receiving topically one of the following: amethocaine microemulsion, amethocaine gel (Ametopgel), EMLA (Eutectic Mixture of Local Anesthetics) cream, amethocaine infiltration, or nothing (controls). The second experiment was conducted on healthy, selected heat- or touch-hypersensitive rats, which were distributed as in the first experiment. Paw withdrawal time from a heat and a mechanical stimulus was used as a pain index. In the first experiment, antihyperalgesic activity appeared at 4.2, 13.8, and 14 min after amethocaine microemulsion, gel, or EMLA cream, respectively. Amethocaine microemulsion was the only topical formulation with an antiallodynic effects, although less than with amethocaine infiltration. In healthy rats (second experiment), all topical formulations produced similar analgesic effects in heat-induced pain of the ipsilateral paw. Activity in the contralateral paw appeared earlier with amethocaine microemulsion, which was also the only one that increased touch-induced withdrawal time in the ipsi- and contralateral paws. Therefore, the microemulsion could be valuable for improving amethocaine skin penetration and thus bringing rapid pain relief. IMPLICATIONS: Topical anesthetics are used in several painful clinical procedures, but they tend to have a slow onset time. A new amethocaine microemulsion with a faster onset of analgesia than commercial formulations was developed and its activity tested in pain states induced by heat or mechanical stimulus in inflamed and healthy rat paws.
PMID: 15105222 [PubMed - in process]
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Comparative evaluation of Narcotrend, Bispectral Index, and classical electroencephalographic variables during induction, maintenance, and emergence of a propofol/remifentanil anesthesia.
Schmidt GN, Bischoff P, Standl T, Lankenau G, Hilbert M, Schulte Am Esch J.
Department of Anesthesiology, University Hospital Eppendorf, Hamburg, Germany. guschmid@uke.uni-hamburg.de
In the present study, we sought to compare the abilities of Narcotrend (NT) with the Bispectral Index (BIS) electroencephalographic system to monitor depth of consciousness immediately before induction of anesthesia until extubation during a standardized anesthetic. We investigated 26 patients undergoing laminectomy. Investigated states of anesthesia were: awake, loss of response, loss of eyelash reflex, steady-state anesthesia, first reaction, and extubation during emergence. NT, BIS, spectral edge frequency, median frequency, relative power in delta, theta, alpha, beta, and hemodynamics were recorded simultaneously. The ability of all variables to distinguish between awake versus loss of response, awake versus loss of eyelash reflex, awake versus steady-state anesthesia, steady-state anesthesia versus first reaction and extubation were analyzed with the prediction probability. Effects of remifentanil during propofol infusion were investigated with Friedman's and post hoc with Wilcoxon's test. Only NT and BIS were able to distinguish all investigated states accurately with a prediction probability >0.95. After start of remifentanil infusion, only hemodynamics changed statistically significantly (P < 0.05). NT and BIS are more reliable indicators for the assessment of anesthetic states than classical electroencephalographic variables and hemodynamics, whereas the analgesic potency of depth of anesthesia could not be detected by NT and BIS. IMPLICATIONS: The modern electroencephalographic monitoring systems Narcotrend and Bispectral Index are more reliable indicators for the assessment of anesthetic states than classical electroencephalographic and hemodynamic variables to predict anesthetic conditions from before induction of anesthesia until extubation during a standardized anesthetic regime with propofol and remifentanil. The analgesic potency of depth of anesthesia could not be detected by Narcotrend and Bispectral Index.
PMID: 15105213 [PubMed - in process]
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The relationship between bispectral index and electroencephalographic parameters during isoflurane anesthesia.
Morimoto Y, Hagihira S, Koizumi Y, Ishida K, Matsumoto M, Sakabe T.
Department of Anesthesiology-Resuscitology, Yamaguchi University School of Medicine, Minami-Kogushi Ube, Yamaguchi, 755-8505, Japan. naa01346@nifty.ne.jp
Bispectral index (BIS) integrates various electroencephalographic (EEG) parameters into a single variable. However, the exact algorithm used to synthesize the parameters to BIS values is not known. The relationship between BIS and EEG parameters was evaluated during nitrous oxide/isoflurane anesthesia. Twenty patients scheduled for elective ophthalmic surgery were enrolled in the study. After EEG recording with a BIS monitor (A-1050) was begun, general anesthesia was induced and maintained with 0.5%-2% isoflurane and 66% nitrous oxide. Using software we developed, we continuously recorded BIS, spectral edge frequency 95% (SEF95), and EEG parameters such as relative beta ratio (BetaRatio), relative synchrony of fast and slow wave (SynchFastSlow), and burst suppression ratio. BetaRatio was linearly correlated with BIS (r = 0.90; P < 0.01; n = 253) at BIS more than 60. At a BIS range of 30 to 80, SynchFastSlow (r = 0.60; P < 0.01; n = 3314) and SEF95 (r = 0.75; P < 0.01; n = 3339) were linearly correlated with BIS. The correlation between BIS and SEF95 was significantly better than the correlation between BIS and SynchFastSlow (P < 0.01). At BIS less than 30, the burst suppression ratio was inversely linearly correlated with BIS (r = 0.76; P < 0.01; n = 65). At BIS less than 80, burst-compensated SEF95 was linearly correlated with BIS (r = 0.78; P < 0.01; n = 3404). In the range of BIS from 60 to 100, BIS can be calculated from BetaRatio. At surgical levels of anesthesia, BIS and SynchFastSlow (a parameter derived from bispectral analysis) or burst-compensated SEF95 (derived from power spectral analysis) are well correlated. However, our results show that SynchFastSlow has no advantage over SEF95 in calculation of BIS. IMPLICATIONS: The relationship between bispectral index (BIS) and electroencephalographic parameters was evaluated during nitrous oxide/isoflurane anesthesia. At surgical levels of anesthesia, BIS and the relative synchrony of fast and slow wave (a parameter derived from bispectral analysis) or burst-compensated spectral edge frequency 95% (a parameter derived from power spectral analysis) are well correlated.
PMID: 15105211 [PubMed - in process]
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The effect of repeated isoflurane anesthesia on spatial and psychomotor performance in young and aged mice.
Butterfield NN, Graf P, Ries CR, MacLeod BA.
Centre for Anesthesia & Analgesia, Department of Pharmacology & Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada. noamb@canada.com
Exposure to general anesthesia may contribute to postoperative cognitive impairment in elderly patients, but the relationship remains poorly understood. We investigated whether aged mice, 18-19 mo, are more susceptible to postanesthetic cognitive impairment than young mice, 3-4 mo, using spatial memory (Barnes maze) and psychomotor (rotarod) tasks. Initially we studied the effect of a single anesthetic episode on asymptotic maze performance. We then tested whether repeated anesthesia would impair spatial memory and psychomotor performance to a greater extent in aged mice. Mice were anesthetized with isoflurane (1.4% atm) for 30 min; controls received 90% oxygen. Anesthesia, administered during the asymptotic period of maze learning, did not impair performance tested the following day (P > 0.05). Repeated anesthesia, 2-3 h after each session, did not impair overall maze or rotarod performance in young or aged mice (P > 0.05). Spatial learning appeared to be facilitated by anesthesia, F(1,204) = 7.97, P < 0.01 for pooled results. Asymptotic performance-when learning had stabilized-remained unimpaired in both the maze and rotarod tasks. These results suggest that an age-related risk of anesthetic-induced impairment appears to be limited to acquisition of a novel motor skill and that anesthesia alone does not lead to prolonged cognitive impairments in aged mice. IMPLICATIONS: This study demonstrates that repeated isoflurane general anesthesia impaired psychomotor performance in aged mice during the initial learning period; however, spatial learning improved and, overall, spatial memory and psychomotor performance were unimpaired. Thus, general anesthesia alone does not appear to result in prolonged cognitive deficits in aged mice.
PMID: 15105206 [PubMed - in process]
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Spinal anesthesia with bupivacaine decreases cerebral blood flow in former preterm infants.
Bonnet MP, Larousse E, Asehnoune K, Benhamou D.
Departement d'Anesthesie Reanimation, Centre Hospitalo-Universitaire de Bicetre, Kremlin Bicetre, France. mariepierre.bonnet@9online.fr
Spinal anesthesia is commonly used in former preterm infants (FPI). In these patients, hypotension induced by spinal anesthesia may impair cerebral blood flow. We measured cerebral blood flow velocity (CBFV) by transcranial Doppler ultrasound to assess the effect of hypotension induced by spinal anesthesia on cerebral hemodynamics. Twelve FPI scheduled for inguinal hernia repair were operated under spinal anesthesia using 1 mg/kg isobaric 0.5% bupivacaine. Systolic, diastolic, and mean middle cerebral artery CBFV were measured at 5 min before and 5 min and 10 min after spinal anesthesia using a transcranial pulsed Doppler ultrasonography. Arterial blood pressure and heart rate were recorded simultaneously. Cerebral arteries resistance index (RI) was calculated as RI = (peak systolic CBFV - end-diastolic CBFV)/peak systolic CBFV. Diastolic CBFV decreased significantly from 30.0 +/- 11.1 cm/s to 20.1 +/- 8.4 cm/s at 5 min and to 20.1 +/- 7.0 cm/s at 10 min. RI increased significantly from 0.7 +/- 0.1 to 0.8 +/- 0.1 at 5 min and 10 min. Systolic, diastolic, and mean arterial blood pressures decreased significantly at the same time intervals. We suggest that in FPI, spinal anesthesia induces a decrease in cerebral blood flow related to changes in arterial blood pressure. Whether these changes have deleterious consequences remains to be determined. IMPLICATIONS: In former preterm infants having spinal anesthesia with bupivacaine, a decrease in cerebral blood flow velocity is displayed by middle cerebral artery transcranial Doppler examination.
PMID: 15105200 [PubMed - in process]
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Trends in the practice of parental presence during induction of anesthesia and the use of preoperative sedative premedication in the United States, 1995-2002: results of a follow-up national survey.
Kain ZN, Caldwell-Andrews AA, Krivutza DM, Weinberg ME, Wang SM, Gaal D.
Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut 06510, USA. kain@biomed.med.yale.edu
Both parental presence during induction of anesthesia and sedative premedication are currently used to treat preoperative anxiety in children. A survey study conducted in 1995 demonstrated that most children are taken into the operating room without the benefit of either of these two interventions. In 2002 we conducted a follow-up survey study. Five thousand questionnaires were mailed to randomly selected physician members of the American Society of Anesthesiologists. Mailings were followed by a nonresponse bias assessment. Twenty-seven percent (n = 1362) returned the questionnaire after 3 mailings. We found that a significantly larger proportion of young children undergoing surgery in the United States were reported to receive sedative premedication in 2002 as compared with 1995 (50% vs 30%, P = 0.001). We also found that in 2002 there was significantly less geographical variability in the use of sedative premedication as compared with the 1995 survey (F = 8.31, P = 0.006). Similarly, we found that in 2002 parents of children undergoing surgery in the United States were allowed to be present more often during induction of anesthesia as compared with 1995 (chi(2) = 26.3, P = 0.0001). Finally, similar to our findings in the 1995 survey, midazolam was uniformly selected most often to premedicate patients before surgery. IMPLICATIONS: Over the past 7 yr there have been significant increases in the number of anesthesiologists who use preoperative sedative premedication and parental presence for children undergoing surgery.
PMID: 15105196 [PubMed - in process]
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Cardiovascular anesthesia: the society of cardiovascular anesthesiologists, its journal, and new opportunities.
Hogue CW Jr, Tuman KJ, Gravlee G.
Dr. Hogue is Assistant Associate Editor, Cardiovascular Anesthesia.
PMID: 15105187 [PubMed - in process]
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Damage to the three-way valves by a clear propofol formulation.
Puri GD, Singh KP.
Publication Types:
PMID: 15041632 [PubMed - indexed for MEDLINE]
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Massive pulmonary embolism after application of an Esmarch bandage.
Lu CW, Chen YS, Wang MJ.
Department of Anesthesia, Far Eastern Memorial Hospital, Taipei, Taiwan. canon@ha.mc.ntu.edu.tw
A 71-yr-old patient who underwent spinal anesthesia for left femoral fracture operation became hypotensive and unconscious after the application of an Esmarch bandage. The transesophageal echocardiography performed during resuscitation revealed pulmonary embolism and acute right ventricular failure. Pulmonary embolectomy with cardiopulmonary bypass was undertaken immediately after the echocardiographic diagnosis. Extracorporeal membrane oxygenation was used after the operation to support the failing right ventricle. The patient was successfully weaned from extracorporeal membrane oxygenation 10 days after the operation. We conclude that transesophageal echocardiography can be very useful in the immediate differential diagnosis of sudden cardiovascular collapse and that extracorporeal membrane oxygenation can be very helpful when acute right ventricular failure follows massive pulmonary embolism. IMPLICATIONS: Transesophageal echocardiography was highly valuable in finding the cause of sudden intraoperative cardiovascular collapse. The use of extracorporeal membrane oxygenation to support the failing right ventricle after emergent pulmonary embolectomy could help to rescue patients with massive pulmonary embolism.
Publication Types:
PMID: 15041624 [PubMed - indexed for MEDLINE]
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Tramadol added to 1.5% mepivacaine for axillary brachial plexus block improves postoperative analgesia dose-dependently.
Robaux S, Blunt C, Viel E, Cuvillon P, Nouguier P, Dautel G, Boileau S, Girard F, Bouaziz H.
Department of Anesthesiology and Critical Care Medicine, Hopital Central, Nancy Cedex, Nimes Cedex 9, France.
Adjuncts to local anesthetics for peripheral plexus blockade may enhance the quality and duration of anesthesia and postoperative analgesia. The analgesic, tramadol, has a unique mechanism of action that suggests efficacy as such an adjunct. It displays a central analgesic and peripheral local anesthetic effect. We designed a prospective, randomized, controlled and double-blind clinical trial to assess the effect of tramadol added to brachial plexus anesthesia. One-hundred patients scheduled for carpal tunnel release surgery under brachial plexus anesthesia were randomized into four groups. All patients received 1.5% mepivacaine 40 mL plus a study solution containing either isotonic sodium chloride (Group P, n = 17), tramadol 40 mg (Group T(40), n = 22), tramadol 100 mg (Group T(100), n = 20) or tramadol 200 mg (Group T(200), n = 20). We evaluated the time of onset of anesthesia, duration of sensory and motor blockade, duration and quality of postoperative analgesia, and occurrence of adverse effects. Onset and duration of sensory and motor blocks were not different among groups. The number of patients requesting analgesia in the postoperative period was significantly less in the 3 tramadol groups compared with the placebo group (P = 0.02); this was also noted with the placebo and T(40) groups compared with the T(200) group. No statistical significance was demonstrated between the placebo and the T(40) group or the T(100) group and the T(200) group. Furthermore, there was a significant trend effect among groups applying the Cochran-Armitage tendency test (P = 0.003), suggesting a dose-dependent decrease for additional postoperative analgesia requirements when tramadol was added. Side effects did not differ among groups, although they were more frequently recorded in the T groups. Our study suggests that tramadol added to 1.5% mepivacaine for brachial plexus block enhances in a dose-dependent manner the duration of analgesia with acceptable side effects. However, the safety of tramadol has to be investigated before allowing its use in clinical practice. IMPLICATIONS: Tramadol's unique mechanism of action suggests efficacy as a local anesthetic adjunct for peripheral plexus blockade. Our study demonstrates that tramadol, added to mepivacaine for brachial plexus anesthesia, extends the duration and improves the quality of postoperative analgesia in a dose dependent fashion with acceptable side effects.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15041620 [PubMed - indexed for MEDLINE]
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The supraclavicular block with a nerve stimulator: to decrease or not to decrease, that is the question.
Franco CD, Domashevich V, Voronov G, Rafizad AB, Jelev TJ.
Department of Anesthesiology and Pain Management, John H Stroger Jr Hospital of Cook County, Chicago, Illinois 60612, USA. carlofra@aol.com
Portable nerve stimulators for nerve blocks have been available for more than 40 yr. It is generally accepted that seeking a motor response at low outputs increases the chances of success. It is customary to start the procedure at a higher current with the goal of finding the nerve. After an adequate response is elicited, the current is decreased before the local anesthetic is injected. However, how low is low enough and, for that matter, how high is too high have not been adequately determined. Our experience seems to indicate that, in the supraclavicular block, the type of response obtained is as important as the output at which it is elicited, provided that this current is not higher than 1 mA. In this context, it is theoretically possible that our initial seeking current of 0.9 mA could be an adequate injection current if it is combined with an appropriate response. We designed this study to test the hypothesis that a response of the fingers in flexion or extension, elicited at 0.9 mA, could be followed immediately by the local anesthetic injection. We did not intend to compare 0.5 and 0.9 mA as minimum stimulating currents but rather as currents able to elicit an unmistakable motor twitch. Sixty patients were randomly assigned to one of two groups. Group 1 (n = 30) was injected with a motor twitch in the fingers that was still visible at 0.5 mA. Group 2 (n = 30) was injected after a similar response to that in Group 1 was elicited, but at the initial output of 0.9 mA, without any further decrease. The blocks were injected with 40 mL of local anesthetic solution. One patient was excluded from the study for failing to meet protocol criteria. The success rate in the remaining 59 patients was 100%; success was defined as complete sensory blockade at the median, ulnar, and radial nerve territories of the hand that was accomplished in <or=30 min from the time of injection and that did not require supplementation or general anesthesia. In fact, all blocks became complete within 22 min of the injection. The onset of anesthesia occurred in 10.9 +/- 5.4 min in the 0.5-mA group and 11.4 +/- 4.8 min in the 0.9-mA group; this difference was not statistically different. The onset of analgesia and the duration of anesthesia were also similar in both groups. There were no complications, and the respondents in both groups graded their experience at a similar level of satisfaction. We conclude that during the performance of a supraclavicular block eliciting a clearly visible response of the fingers at 0.9 mA can be immediately followed by the injection of local anesthetic, because decreasing the output to 0.5 mA does not seem to improve the overall quality of the block as measured by the onset and duration of anesthesia or patient satisfaction. IMPLICATIONS: When nerve blocks are performed with a nerve stimulator, it is customary to reduce the nerve stimulator output to <= 0.5 mA before injecting. Apparently this is not necessary with a supraclavicular block.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15041619 [PubMed - indexed for MEDLINE]
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Bispectral index values at sevoflurane concentrations of 1% and 1.5% in lower segment cesarean delivery.
Chin KJ, Yeo SW.
Department of Obstetric and Gynecological Anaesthesia, KK Women's and Children's Hospital, Singapore. gasgenie@yahoo.co.uk
Inadequate hypnosis in the absence of opioid analgesia may account for the increased incidence of awareness in cesarean delivery. An end-tidal concentration of 0.5 MAC isoflurane in 50% nitrous oxide (N(2)O) during cesarean delivery resulted in bispectral index (BIS) values >60, the threshold below which consciousness is unlikely. Our aim was to determine the BIS values achieved with the equivalent end-tidal concentration of sevoflurane and to determine if a larger concentration would consistently maintain BIS values <60. Twenty ASA physical status I-II parturients were randomized to receive an end-tidal concentration of either 1% sevoflurane or 1.5% sevoflurane delivered in 50% N(2)O throughout surgery. Thiopental 4 mg/kg was used for anesthetic induction. Morphine 0.1-0.15 mg/kg was administered only after delivery. Mean BIS values in the period between skin incision and neonatal delivery were 61 (95% confidence interval, 57-64) in the 1% sevoflurane group, versus 42 (95% confidence interval, 37-47) in the 1.5% sevoflurane group. BIS values were significantly different between groups at skin incision, uterine incision, delivery, and 10 min after delivery, but not thereafter. Indices of maternal and neonatal outcome were similar between groups. IMPLICATIONS: Bispectral index (BIS) values <60 are consistent with a high probability of unconsciousness. An end-tidal concentration of 1.5% sevoflurane maintained BIS values <60 during cesarean delivery, whereas 1% did not. Adverse effects were not seen with the use of larger concentrations of sevoflurane.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15041614 [PubMed - indexed for MEDLINE]
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Patient satisfaction with preoperative assessment in a preoperative assessment testing clinic.
Hepner DL, Bader AM, Hurwitz S, Gustafson M, Tsen LC.
Departments of Anesthesiology, Perioperative and Pain Medicine, Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
Preoperative Assessment Testing Clinics (PATCs) coordinate preoperative surgical, anesthesia, nursing, and laboratory care. Although such clinics have been noted to lead to efficiencies in perioperative care, patient experience and satisfaction with PATCs has not been evaluated. We distributed a one-page questionnaire consisting of satisfaction with clinical and nonclinical providers to patients presenting to our PATC over three different time periods. Eighteen different questions had five Likert scale options that ranged from excellent (5) to poor (1). We achieved a 71.4% collection rate. The average for the subscale that indicated overall satisfaction was 4.48 +/- 0.67 and the average for the total instrument was 4.46 +/- 0.55. Although the highest scores were given for subscales describing the anesthesia, nurse, and lab, only the anesthesia subscale improved with time (P = 0.007). The subscale that involved information and communication had the highest correlation with the overall satisfaction subscale (r = 0.76; P < 0.0001). The satisfaction with the total duration of the clinic visit (3.71 +/- 1.26) was significantly less (P < 0.0001) than the satisfaction to the other items. The authors conclude that the practitioner and functional aspects of the preoperative visit have a significant impact on patient satisfaction, with information and communication versus the total amount of time spent being the most positive and negative components, respectively. IMPLICATIONS: Patient satisfaction can serve as an important indicator of the quality of preoperative care delivered in Preoperative Assessment Testing Clinics (PATC). Information and communication, both from clinical and nonclinical service providers, remain the most important positive components, and the total duration of the clinic visit represents the most negative component, of patient satisfaction in a PATC.
PMID: 15041606 [PubMed - indexed for MEDLINE]
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The efficacy of continuous fascia iliaca compartment block for pain management in burn patients undergoing skin grafting procedures.
Cuignet O, Pirson J, Boughrouph J, Duville D.
Burn Center, Queen Astrid Military Hospital, Military Medical Research Program and Development Committee, Brussels, Belgium. Olivier.Cuignet@smd.be
Postoperative pain from split skin donor sites is often more intense than the pain at the grafted site. In this prospective, randomized, double-blind study we assessed the efficacy of a continuous fascia iliaca compartment block (FICB) in reducing the pain at the thigh donor site. Twenty patients, with a total burn surface area of 16% +/- 13% (mean +/- SD) were randomized 1:1 to receive either ropivacaine 0.2% or saline 0.9%. All patients received a general anesthesic followed by preincision continuous FICB with 40 mL of the randomized solution, then an infusion of 10 mL/h of either ropivacaine or saline until the first dressing change (72 h later). Postoperative analgesia consisted of propacetamol 2g/6h, IV patient-controlled analgesia of morphine chlorhydrate (2 mg/mL), and morphine hydrochlorate 0.5 mg/kg PO once 60 min before first dressing change. The visual analog scale (VAS) scores were compared using the Mann-Whitney U-test preoperatively, 24 and 48 h postoperatively, and during the first dressing change. The cumulative morphine consumption was compared with repeated-measures analysis of variance followed by Scheffe's method if indicated. Patients with continuous FICB had significantly reduced postoperative morphine consumption at all time points (23 +/- 20 versus 88 +/- 29 mg after 72 h, study versus control groups, respectively; P < 0.05). In both groups, VAS scores remained low but were only significantly lower for patients with continuous FICB during the first dressing change (3 [1] versus 7 [3]; median [interquartile range]; P < 0.05). We conclude that continuous FICB is an efficient method for diminishing pain at the thigh donor site. (250 words) IMPLICATIONS:Postoperative pain at the split skin donor sites is often more intense than the pain at the grafted site. This prospective, randomized, double-blind study assessed the efficacy of a continuous fascia iliaca compartment block in reducing the pain at the thigh donor site.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15041602 [PubMed - indexed for MEDLINE]
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Preoperative oral rofecoxib reduces postoperative pain and tramadol consumption in patients after abdominal hysterectomy.
Karamanlioglu B, Turan A, Memis D, Ture M.
Department of Anesthesiology, Trakya University, Medical Faculty, Edirne, Turkey.
We designed this study to determine whether the administration of a preoperative dose of rofecoxib to patients undergoing abdominal hysterectomy would decrease patient-controlled analgesia (PCA) tramadol use or enhance analgesia. Sixty patients were randomized to receive either oral placebo or rofecoxib 50 mg 1 h before surgery. All patients received a standard anesthetic protocol. Intraoperative blood loss was determined. At the end of surgery, all patients received tramadol IV via a PCA-device. Pain scores, sedation scores, mean arterial blood pressure, heart rate, and peripheral oxygen saturation were assessed at 1, 2, 4, 6, 8, 12, and 24 h after surgery. Total and incremental tramadol consumption at the same times was recorded from the PCA-device. Antiemetic requirements and adverse effects were noted during the first postoperative 24 h. Duration of hospital stay was also recorded. The pain scores were significantly lower in the rofecoxib group compared with the placebo group at 6 times during the first 12 postoperative h (P < 0.05). The total consumption of tramadol (627 +/- 69 mg versus 535 +/- 45 mg; P < 0.05) and the incremental doses at 1, 2, 4, 6, 8, and 12 h after surgery were significantly more in the placebo group than in the rofecoxib group. There were no differences between groups in intraoperative blood loss, sedation scores, hemodynamic variables, peripheral oxygen saturation, antiemetic requirements, or adverse effects after surgery. The length of hospital stay was also similar in the groups. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the opioid requirements in patients undergoing abdominal hysterectomy. IMPLICATIONS: This study was designed to determine whether the administration of a preoperative dose of rofecoxib to patients undergoing abdominal hysterectomy would decrease patient-controlled analgesia tramadol use or enhance analgesia. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the opioid requirements in patients undergoing abdominal hysterectomy.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15041595 [PubMed - indexed for MEDLINE]
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Perioperative rofecoxib improves early recovery after outpatient herniorrhaphy.
Ma H, Tang J, White PF, Zaentz A, Wender RH, Sloninsky A, Naruse R, Kariger R, Quon R, Wood D, Carroll BJ.
Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-9068, USA.
Non-opioid analgesics have become increasingly popular as part of a multimodal regimen for pain management in the ambulatory setting. We designed this randomized, double-blind, placebo-controlled study to evaluate the effect of perioperative administration of the cyclooxygenase-2 inhibitor rofecoxib on patient outcome after inguinal herniorrhaphy procedures. Sixty consenting outpatients undergoing elective hernia repair surgery were randomly assigned to one of two treatment groups: control (vitamin C, 500 mg) or rofecoxib (rofecoxib, 50 mg). The first oral dose of the study medication was administered 30-40 min before entering the operating room, and a second dose of the same medication was given on the morning of the first postoperative day. Recovery times, postoperative pain scores, the need for "rescue" analgesics, and side effects were recorded at 1- to 10-min intervals before discharge from the recovery room. Follow-up evaluations were performed at 36 h, 7 days, and 14 days after surgery to assess postdischarge pain, analgesic requirements, resumption of normal activities, as well as patient satisfaction with their postoperative pain management. Rofecoxib significantly decreased the early recovery times, leading to an earlier discharge home after surgery (88 +/- 30 vs 126 +/- 44 min, P < 0.05). When compared with the control group, the patients' median [range] quality of recovery score was also significantly higher in the rofecoxib group (18 [14-18] vs 16 [13-18], P < 0.05). In the predischarge period, a significantly larger percentage of patients required rescue pain medications in the control group (67% vs 37% in the rofecoxib group, P < 0.05). At the 36-h follow-up assessment, rofecoxib-treated patients reported significantly reduced oral analgesic requirements (0 [0-20] vs 9 [1-33] pills, P < 0.05) and lower maximal pain scores, resulting in improved patient satisfaction with their postoperative pain management (3 [1-4] vs 2 [0-3], P < 0.05). However, there were no differences in the times required to resume their activities of daily living. In conclusion, perioperative rofecoxib, 50 mg per os, significantly decreased postoperative pain and the need for analgesic rescue medication, leading to a faster and improved quality of recovery after outpatient hernia surgery. However, perioperative use of rofecoxib failed to improve recovery end points in the postdischarge period. IMPLICATIONS: Rofecoxib (50 mg per os), given before and after surgery, was effective in improving postoperative pain management, as well as the speed and quality of recovery after outpatient inguinal herniorrhaphy. However, it failed to accelerate the postdischarge resumption of normal activities of daily living.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15041582 [PubMed - indexed for MEDLINE]
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Accurate central venous port-A catheter placement: intravenous electrocardiography and surface landmark techniques compared by using transesophageal echocardiography.
Chu KS, Hsu JH, Wang SS, Tang CS, Cheng KI, Wang CK, Wu JR.
Department of Anesthesiology, Kuo General Hospital, Tainan, Taiwan.
Using transesophageal echocardiography (TEE) to locate the tip of central venous catheters inserted via the right subclavian vein, we compared IV electrocardiography (IV-ECG)-guided catheter tip placement with the conventional surface landmark technique. Sixty patients were randomly assigned into two groups. In Group E, the IV-ECG signal was conducted along an NaHCO(3)-filled catheter to facilitate catheter placement. In Group S, surface landmarks on the chest wall were used to determine the appropriate catheter length. The goal was to visualize the catheter tip with TEE at the superior edge of the crista terminalis, which is the junction of the superior vena cava (SVC) and right atrium (RA). The catheter tip position was considered to be satisfactory, as the tip was within 1.0 cm of the upper crista terminalis edge. All 30 Group E patients had satisfactory catheter tip placement when the ECG P wave was at its maximum. In contrast, 16 of the 30 patients in Group S had satisfactory tip positions (P < 0.001). All catheters were repositioned under TEE guidance to adjust the tip to the SVC-RA junction. After the catheter tips were confirmed to be located at the SVC-RA junction, the catheter tips were still visualized in the mid portion of RA in 12 of 60 patients on supine chest radiographs. We concluded that IV-ECG guidance to position a catheter resulted in satisfactory catheter tip placement that is in accordance with TEE views. Catheter placement at the SVC-RA junction with the surface landmark technique was unreliable. IMPLICATIONS: Intravenous electrocardiography guidance to position catheters obtains a satisfactory catheter tip placement that is in accordance with transesophageal echocardiography views. The surface landmark technique does not result in reliable placement at the superior vena cava-right atrium junction.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15041571 [PubMed - indexed for MEDLINE]
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Neither the accuracy nor the precision of thermal dilution cardiac output measurements is altered by acute tricuspid regurgitation in pigs.
Buffington CW, Nystrom EU.
Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA. buffingtoncw@anes.upmc.edu
Whether measurement of cardiac output using the thermal dilution technique (TDCO) is valid in the presence of tricuspid regurgitation (TR) is controversial. We assessed the accuracy and precision of the technique in pigs by comparison with data from an electromagnetic flowmeter on the aorta (EMCO). TR was created with sutures that immobilized the free-wall leaflets of the tricuspid valve, and cardiac output was adjusted with dobutamine to give values comparable to control measurements. TR reduced forward stroke volume from 17.2 to 12.6 mL/beat and caused the right atrium to dilate and pulse in synchrony with the right ventricle. Acute TR did not affect the linear regression relation between TDCO and EMCO and did not alter the correlation coefficient (r = 0.94 during both control and TR). These data demonstrate that acute TR does not affect the accuracy or precision of TDCO in pigs. IMPLICATIONS: Cardiac output is a valuable measurement that guides the medical care of patients with heart and lung disease. This study demonstrates that the thermal dilution technique of determining cardiac output is valid when acute tricuspid valve regurgitation is present in pigs.
PMID: 15041567 [PubMed - indexed for MEDLINE]
Early exploration of diplopia with magnetic resonance imaging after peribulbar anaesthesia.
Taylor G, Devys JM, Heran F, Plaud B.
Department of Anaesthesiology and Intensive Care, Fondation Adolphe de Rothschild, 25-29 rue Manin, F-75019 Paris, France.
We report the cases of five patients who have experienced postoperative diplopia after cataract surgery under peribulbar anaesthesia and in whom orbital Magnetic Resonance Imaging was performed immediately after the diagnosis. In four patients, the imaging study showed a T2 hyper-intensity signal and swelling of one extraocular muscle that was interpreted as oedema. Therefore, these cases were most probably a result of an accidental i.m. injection of local anaesthetics. In the other patient, the imaging study revealed no abnormality.
PMID: 15096444 [PubMed - as supplied by publisher]
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Cardiovascular changes with the laryngeal mask airway in cardiac anaesthesia.
Bennett SR, Grace D, Griffin SC.
Department of Anaesthesia, Castle Hill Hospital, Hull HU16 5JQ, UK.
BACKGROUND: The laryngeal mask airway (LMA) causes fewer haemodynamic changes, particularly in mean arterial pressure (MAP) and heart rate (HR), than tracheal intubation using either laryngoscopy or the intubating LMA. There are no data for patients with coronary artery disease.Method. We studied 27 patients having coronary artery bypass grafting, prospectively randomized to be managed with either the LMA or tracheal intubation using either laryngoscopy or the ILMA. We used invasive monitoring to compare the haemodynamic effects in each group during induction and emergence from anaesthesia. RESULTS: Both methods of intubation caused an increase in MAP compared with the LMA (P<0.05). Mixed venous oxygen saturation increased in the intubated patients but not with the LMA (P<0.05). HR did not change at induction in the LMA group. Changes at extubation were similar in all groups but cardiac index was lower in the LMA group (P<0.05). CONCLUSION: The LMA allows airway management without hypertension and tachycardia and should be considered when anaesthetizing patients with coronary disease.
PMID: 15096442 [PubMed - as supplied by publisher]
Comment on:
Pre-emptive analgesia produced by interscalene blockade. What failed: the block or the methods?
Blumenthal S, Nadig M, Borgeat A.
Publication Types:
PMID: 14649349 [PubMed - indexed for MEDLINE]
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Perioperative intravenous adenosine infusion to extend postoperative analgesia in brachial plexus block.
Apan A, Ozcan S, Buyukkocak U, Anbarci O, Basar H.
Department of Anaesthesiology, Kirikkale University Faculty of Medicine, Kirikkale, Turkey. alpaslanapan@doctor.com
BACKGROUND AND OBJECTIVE: Adenosine infusions have been shown to reduce requirements of anaesthetics, to decrease the need for postoperative analgesics and to attenuate hyperaesthesia related to neuropathic pain. We decided to investigate the effects, beneficial or otherwise, of an adenosine infusion administered during surgery. A brachial plexus block was used to produce anaesthesia for the surgery. METHODS: Sixty adults undergoing upper extremity surgery were included in the study. Brachial plexus block was performed via an axillary approach with lidocaine 1.25% and epinephrine 1/200 000 (40 mL). Patients were randomly assigned to two groups. During surgery, saline (control) or adenosine 80 microg kg min was infused intravenously in a double-blind fashion for 1 h. Visual analogue scores every 4 h, analgesic consumption, time to first spontaneous pain sensation, time to first rescue analgesic and adverse effects were noted during the first 24 h. RESULTS: Vital signs were stable in both groups throughout surgery. During the adenosine infusion, one patient fainted while another complained of palpitations and tightness of the chest; both patients were excluded from further analyses. The time to first sensation of pain was significantly longer in the adenosine group compared to the control group (438 +/- 387 vs. 290 +/- 227 min, P = 0.02). The time to first rescue analgesic, the visual analogue scale scores and analgesic consumption in the postoperative period were similar. CONCLUSIONS: In patients undergoing surgery with an axillary plexus block, a perioperative adenosine infusion prolongs the duration of postoperative analgesia to some extent. However, the time to first rescue analgesic, total analgesic requirements and pain scores were unchanged; the risk of potentially serious adverse effects is high. This therapy cannot be recommended.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14649345 [PubMed - indexed for MEDLINE]
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Improvement in postoperative pain relief by the addition of midazolam to an intrathecal injection of buprenorphine and bupivacaine.
Shah FR, Halbe AR, Panchal ID, Goodchild CS.
Department of Anaesthesiology, B.Y.L. Nair Ch. Hospital and TN. Medical College, Mumbai, India.
BACKGROUND AND OBJECTIVE: Intrathecal injections of the benzodiazepine midazolam have been reported to cause antinociception in animals and pain relief in human beings, including the potentiation of opioid analgesia. This study compared the efficacy of the addition of midazolam to a mixture of buprenorphine and bupivacaine used for spinal anaesthesia. METHODS: The study was prospective, randomized, and observer blinded. It involved 60 patients (30 per group), ASA I and II, age 20-40 yr, undergoing minor and intermediate lower abdominal surgery under spinal anaesthesia. Patients were randomized into two groups: the control group received a spinal injection of hyperbaric bupivacaine (15 mg) plus buprenorphine (0.15 mg) and the experimental group received a spinal injection of the same two drugs and doses but supplemented with intrathecal midazolam (2 mg). RESULTS: The duration of postoperative analgesia in the control group was 9.24 +/- 2.57 h (mean +/- SEM), and 21.33 +/- 12.69 h in the midazolam treated group (P < 0.001). Patients treated with intrathecal midazolam had better pain relief judged by visual analogue score on coughing (P = 0.0013) and a nursing mobility score (P < 0.0001). Adverse effects were minor and their incidence was similar in both groups. CONCLUSIONS: We conclude that intrathecal midazolam 2 mg improves the quality and duration of postoperative pain relief afforded by intrathecal buprenorphine and bupivacaine.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14649343 [PubMed - indexed for MEDLINE]
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The 'TEI-index' is preload dependent and can be measured by transoesophageal echocardiography during mechanical ventilation.
Lutz JT, Giebler R, Peters J.
Klinik fur Anasthesiologie und Intensivmedizin, Universitatsklinikum Essen, Essen, Germany. juergen.lutz@uni-essen.de
BACKGROUND AND OBJECTIVE: The Doppler-derived echocardiographic TEI-index, defined as the sum of the left ventricular isovolumic contraction and isovolumic relaxation times divided by ejection time, quantifies combined systolic and diastolic ventricular functions. The index has been proposed to be independent of arterial pressure and heart rate, implying a broad clinical usefulness. However, it is unclear whether the index is preload independent. We assessed whether and to what degree the TEI-index is altered by left ventricular loading conditions, and the feasibility of measurement by transoesophageal echocardiography during anaesthesia and mechanical ventilation. METHODS: We studied 17 anaesthetized mechanically ventilated patients with coronary artery disease during variations in left ventricular preload evoked by head-up and head-down tilt, respectively. RESULTS: A head-down tilt increasing left ventricular end-diastolic area from 18.8 +/- 4 to 23.7 +/- 4 cm2 (P < 0.05) significantly decreased the TEI-index from 0.5 +/- 0.17 to 0.33 +/- 0.15 (P < 0.05). In contrast, the TEI-index remained unchanged with decreased left ventricular preload (14.4 +/- 3.7 cm2) during head-up tilt. CONCLUSIONS: An increase in preload decreases the TEI-index indicating its sensitivity to acute increases in left ventricular preload. The TEI-index can be measured perioperatively by transoesophageal echocardiography.
Publication Types:
PMID: 14649338 [PubMed - indexed for MEDLINE]
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Levobupivacaine 0.25% compared with ropivacaine 0.25% by the caudal route in children.
Astuto M, Disma N, Arena C.
Policlinico Universitario, Department of Anaesthesia, Catania, Italy. astmar@tiscalinet.it
BACKGROUND AND OBJECTIVE: Levobupivacaine is the most recently introduced local anaesthetic into clinical practice. In a randomized double-blinded study, the onset, intraoperative tolerance, postoperative analgesic effect, motor blockade and any adverse reactions produced by levobupivacaine were compared with ropivacaine. METHODS: Sixty children, ASA I-II, 2-6 yr old, undergoing elective minor surgery, received a single caudal injection of 1 mL kg(-1) of either levobupivacaine 0.25% or ropivacaine 0.25%. Caudal blocks were performed after induction of inhalation general anaesthesia using sevoflurane; anaesthesia was maintained via a laryngeal mask airway using a mixture of sevoflurane, oxygen and air. RESULTS: Onset time, intraoperative tolerance, postoperative analgesic effect and motor blockade were comparable between the two groups. The mean onset of the block was 8.2 +/- 2.2 min for levobupivacaine and 8.5 +/- 3.0 min for ropivacaine (P = 0.66). Additional analgesics during operation were not required in any of the children. No significant difference was found for mean time to requirement of additional analgesia with rectal acetaminophen (paracetamol) (302 +/- 29 min for the levobupivacaine group and 230 +/- 38 min for the ropivacaine group (P = 0.32)). During the first 4 h after placement of caudal block, the pain assessment score (according to the Children Hospital Eastern Ontario Pain Scale) was comparable for the two groups. No motor block was observed in any group on awakening, nor during the observation period. CONCLUSIONS: We conclude that levobupivacaine 0.25% 1 mL kg(-1) provides caudal block of comparable onset and duration, as produced by the same volume and concentration of ropivacaine.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14580053 [PubMed - indexed for MEDLINE]
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Effects of nicardipine and diltiazem on the bispectral index and 95% spectral edge frequency.
Hirota K, Kabara S, Kushikata T, Kitayama M, Ishihara H, Matsuki A.
University of Hirosaki School of Medicine, Department of Anesthesiology, Hirosaki, Japan.
BACKGROUND AND OBJECTIVE: Previous studies have shown that L-type voltage-sensitive Ca2+ channel blocking agents increased and the L-type Ca2+ channel activator Bay K 8644 reduced the general anaesthetic potency in animals. As the bispectral index correlates with the depth of sedation, we examined whether L-type Ca2+ channel blocking agents affect the bispectral index. METHODS: Thirty hypertensive patients (systolic arterial pressure >160 mmHg) presenting for total intravenous anaesthesia with propofol, fentanyl and ketamine were recruited. Bispectral index monitoring was commenced directly the patients arrived in the operating theatre. All patients were given either nicardipine or diltiazem intravenously at the discretion of the anaesthesiologist in charge. RESULTS: Twenty-three and seven patients received nicardipine or diltiazem, respectively. The bispectral index level (mean (95% confidence interval)) did not change with either drug. In the nicardipine group, the bispectral index at 0, 5, 10 and 15 min was 55 (52-58), 55 (51-59), 55 (52-59) and 56 (53-59), respectively. In the diltiazem group, values were 59 (48-71), 60 (51-70), 61 (52-71) and 61 (50-72), respectively. Both L-type Ca2+ channel blocking agents significantly decreased arterial pressure. CONCLUSIONS: Clinical doses of nicardipine and diltiazem do not alter the bispectral index during general anaesthesia.
Publication Types:
PMID: 14580050 [PubMed - indexed for MEDLINE]
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Influence of EEG monitoring on intraoperative stapedius reflex threshold values in cochlear implantation in children.
Schultz B, Beger FA, Weber BP, Niclaus O, Lullwitz E, Grouven U, Schultz A.
Medizinische Hochschule Hannover, Zentrum Anasthesie, Hannover, Germany. ab.schultz@t-online.de
BACKGROUND: Cochlear implantation is a widely used means of treating deafness and severe hearing disorders. The surgical procedure includes inserting the cochlear implant electrode array into the cochlea and embedding the corresponding signal receiver in the mastoid bone behind the ear. Postoperative fitting of the externally worn speech processor is very important for successful use of the cochlear implant. For this purpose, electrically elicited stapedius reflex threshold values can be used. However, stapedius reflex threshold values measured intraoperatively are influenced by anaesthetics. The goal of this retrospective study was to find out whether electroencephalogram (EEG) control of anaesthesia produces more reliable reflex threshold values as a basis for the fitting of the speech processor. METHODS: Three groups of children, after surgery for cochlear implantation, were analysed with regard to the magnitude of intraoperative electrically elicited stapedius reflex threshold values and their deviations from postoperatively determined maximum comfortable levels (group 1: methohexital/remifentanil with EEG monitoring, n = 10; group 2: isoflurane/fentanyl with EEG monitoring, n = 9; group 3: isoflurane/fentanyl without EEG monitoring, n = 11). RESULTS: Children with EEG monitoring had significantly lower electrically elicited stapedius reflex threshold values and also significantly lower differences between intraoperative stapedius reflex threshold values and postoperatively determined maximum comfortable levels. CONCLUSIONS: Electroencephalogram monitoring in cochlear implantation is of considerable value in controlling anaesthesia and improving speech processor fitting based on more reliable intraoperative neurophysiological data.
PMID: 14617120 [PubMed - indexed for MEDLINE]
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The effect of insufflation pressure on pulmonary mechanics in infants during laparoscopic surgical procedures.
Bannister CF, Brosius KK, Wulkan M.
Assistant Professor of Anesthesiology and Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA. carolyn_bannister@emoryhealthcare.org
BACKGROUND: Few studies have reported objective measurements of pulmonary changes under controlled conditions in infants undergoing laparoscopic procedures. We objectively measured the pulmonary effects of laparoscopically-induced pneumoperitoneum in infants less than 1 year of age undergoing surgical procedures under general anaesthesia. METHODS: Nineteen ASA I-II patients less than 1 year of age were enrolled in this direct observational study. Anaesthetic technique included inhalation induction using sevoflurane/O2/air and neuromuscular blockade. Infants were ventilated using 10-15 ml.kg-1 tidal volume at a respiratory rate sufficient to achieve normocarbia [PECO2 4.6-5.8 kPa (35-45 mmHg)]. Opioids and regional anaesthesia techniques were used when appropriate. Peak inspiratory pressure (PIP), expiratory tidal volume (Vt), endtidal carbon dioxide concentration (PECO2) and dynamic compliance (COMPdyn) were recorded at baseline, 5, 10 mmHg and maximal insufflation pressure (Pmax). Pmax was limited to 12 mmHg for infants <5 kg, 15 mmHg for infants >5 kg. At steady state Pmax, ventilator changes were implemented to restore Vt and PECO2 to within 10% of baseline. Each patient served as his own control. RESULTS: At Pmax, average PIP increased 18%, average Vt decreased 33%, average PECO2 concentration increased 13%, average COMPdyn decreased 48%; O2 saturation fell in 41% of patients. Twenty ventilator adjustments were required; one patient experienced no changes in measured pulmonary mechanics, requiring no ventilator changes. CONCLUSIONS: Pulmonary mechanics in infants change significantly during laparoscopic CO2 pneumoperitoneum; the magnitude of change correlates directly with intraperitoneal pressure. Greater than 90% of infants required at least one ventilatory intervention to restore baseline Vt and PECO2.
PMID: 14617119 [PubMed - indexed for MEDLINE]
Comment on:
Instrumentation of the airway in the absence of intravenous access.
Mohiuddinn S, Mayhew JF.
Publication Types:
PMID: 14535926 [PubMed - indexed for MEDLINE]
Comment on:
Airway management without i.v. access-- bad practice or a technique with potential?
Stewart P.
Publication Types:
PMID: 14535925 [PubMed - indexed for MEDLINE]
Comment on:
Postoperative apnoea in an ex-premature infant: is it only related to clonidine?
Hussain AS, Siddiqui MS, Hamdard F, Mayhew JF.
Publication Types:
PMID: 14535920 [PubMed - indexed for MEDLINE]
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Systemic embolism in an infant following haemangioma embolization: a two-step process.
Firth PG, Ahmed MI.
Department of Anesthesia, Tufts Medical School, New England Medical Center, Boston, MA 02111, USA. pfirth@partners.org
A case is presented of therapeutic embolization of a hypervascular hamartoma of the liver, in a term baby. During the procedure signs of pulmonary embolism occurred and the baby subsequently died from myocardial ischaemia. Potential intrathoracic shunts of the newborn together with changes associated with the vascular tumour are thought to have allowed systemic embolization of the embolic material.
Publication Types:
PMID: 14535915 [PubMed - indexed for MEDLINE]
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A long-term continuous infusion via a sciatic catheter in a 3-year-old boy.
Ivani G, Codipietro L, Gagliardi F, Rosso F, Mossetti V, Vitale P.
Department of Anaesthesiology and Intensive Care Regina Margherita Children's Hospital, Turin, Italy. gioivani@libero.it
We describe the case of a 3-year-old boy with a subtotal amputation of the right foot who received treatment for pain via a peripheral catheter positioned at the level of the sciatic nerve (lateral approach).We administered a continuous infusion of 0.2% ropivacaine, 0.4 mg x kg(-1) x h(-1) plus clonidine 0.12 microg x kg(-1) x h(-1) for 21 days. Pain relief was complete and the patient did not require any further rescue analgesia throughout the period even during medications and surgical treatment in our intensive care unit. We discuss the safety and efficacy of the use of a peripheral continuous infusion in children compared with other techniques of analgesia.
Publication Types:
PMID: 14535912 [PubMed - indexed for MEDLINE]
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Validation of a six-graded faces scale for evaluation of postoperative pain in children.
Bosenberg A, Thomas J, Lopez T, Kokinsky E, Larsson LE.
Department of Anaesthesia, University of Cape Town, South Africa.
BACKGROUND: The faces pain scales are often used for self-report assessment of paediatric pain. The aim of this study was to evaluate the validity of a six-graded faces pain scale after surgery by comparing the level of agreement between the children's report of faces pain scores and experienced nurses' assessment of pain by observation of behaviour. The faces pain scores before, at and after administration of analgesics were analysed. The study was performed in two South African hospitals, one with a mainly rural population and the other with an urban population. METHODS: A total of 110 children aged 4-12 years, scheduled for inguinal surgery in the two South African hospitals, were included in the study. The anaesthetic technique was standardized. All patients received a caudal block preoperatively. Postoperative pain assessments were made every hour for 8 h after the caudal block was performed. A designated nurse assessed pain by using a four-graded descriptive scale (no, mild, moderate or severe pain) and thereafter the child reported pain by using the six-graded faces pain scale. RESULTS: A high correlation was found between the two methods of assessment (tau = 0.76, P < 0.0001). The correlation between methods was high in both hospital populations and in all age groups. The weakest correlation was found in children aged 8-12 years (tau = 0.56, P < 0.01). Significantly lower faces pain scores were found after administration of analgesics compared with pain rating before analgesics (P < 0.0001). The proportion of patients with pain scores above 2 decreased from 86% to 31% (P < 0.001). CONCLUSIONS: The findings support this six-graded faces pain scale as a useful and valid instrument for measuring pain in the postoperative period in children aged 4-12 years.
Publication Types:
PMID: 14535910 [PubMed - indexed for MEDLINE]
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Laryngeal mask airway for ventilation during diagnostic and interventional fibreoptic bronchoscopy in children.
Yazbeck-Karam VG, Aouad MT, Baraka AS.
Clinique Dr Rizk, American University of Beirut Medical Center, Beirut, Lebanon.
BACKGROUND: The use of the flexible fibreoptic bronchoscope in infants and children has expanded to include both interventional and diagnostic bronchoscopy. The present report utilizes the laryngeal mask airway (LMATM) for ventilation and anaesthesia administration in children during fibreoptic bronchoscopy using an adult bronchoscope. METHODS: The technique was used in 10 children; their age ranged between 1.2 and 5 years. Six of these children had a history of foreign body aspiration and underwent interventional bronchoscopy, while four children underwent diagnostic bronchoscopy. Anaesthesia was induced by facemask using sevoflurane 6-8% followed by the insertion of a LMA size 2 or 2.5. A swivel adapter connected the proximal end of the LMA to the T-piece anaesthesia system. Anaesthesia was then maintained with spontaneous breathing of sevoflurane 2-4% in oxygen, delivered via the LMA. A flexible adult fibreoptic bronchoscope (outer diameter 4.9 mm) was inserted via the swivel adapter. RESULTS: The procedure could be accomplished successfully in the 10 patients. However, one child developed laryngospasm that was easily relieved by deepening the level of anaesthesia. In a second child hypoxia and hypercarbia occurred and were relieved by intermittent withdrawal of the fibreoptic bronchoscope. CONCLUSIONS: Laryngeal mask airway is a safe and effective adjunct to fibreoptic bronchoscopy under general anaesthesia in children. Its larger internal diameter compared with a tracheal tube permits the use of relatively large fibreoptic bronchoscope without a significant increase in airway resistance.
Publication Types:
PMID: 14535907 [PubMed - indexed for MEDLINE]
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