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Desflurane-remifentanil-nitrous oxide anaesthesia for abdominal surgery: optimal concentrations and recovery features.
Billard V, Servin F, Guignard B, Junke E, Bouverne MN, Hedouin M, Chauvin M.
Institut Gustave Roussy Villejuif, CHU: Bichat Paris, A Pare Boulogne, Brabois Nancy, and Glaxo Smith Kline, Marly le-Roi, France.
Background: Intraoperative combinations of volatile and opioid agents are used to achieve unconsciousness, hypnotic sparing, haemodynamic stability and uneventful recovery. This study describes the influence of different remifentanil concentrations on these variables when combined with desflurane during abdominal surgery. Methods: Sixty-one healthy adult patients were randomly allocated to one of five predefined remifentanil target concentrations (3, 5, 7, 10 or 15 ng ml(-1)). Anaesthesia was titrated to maintain mean blood pressure (MBP), heart rate (HR) and BIS trade mark within predetermined values by adjusting desflurane delivery. Postoperative analgesia using propacetamol and morphine was initiated 30-45 min before skin closure, and continued using morphine PCA. Results: Desflurane requirements adjusted to both BIS and haemodynamics were not significantly modified by the remifentanil concentration (median Fet(DES) 2.7% before incision, 2.5% intraoperatively, and 2.2% during closure), resulting in a calculated drug consumption of 0.22-0.25 ml min(-1) (with 1.5 l min(-1) fresh gas flow). High remifentanil concentration decreased MBP and HR, and reduced the duration of tachycardia, but increased the duration of hypotension. The optimal balance was obtained with a remifentanil concentration of 5-7 ng ml(-1) for intubation, 3 ng ml(-1) until incision, 10 ng ml(-1) during intra-abdominal surgery and 5-7 ng ml(-1) during closure. Post-operative morphine requirements were not significantly modified by intraoperative remifentanil concentrations (median 30 mg/24 h, range [2-88]). Conclusion: Remifentanil target concentrations from 3 to 15 ng ml(-1) had little influence on desflurane requirements or postoperative morphine consumption, but markedly modified intraoperative haemodynamic stability, suggesting that the target concentration should closely follow the successive noxious stimulations.
PMID: 14982571 [PubMed - in process]
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Anaesthesiological airway management in Denmark: Assessment, equipment and documentation.
Mellado PF, Thunedborg LP, Swiatek F, Kristensen MS.
Department of Anaesthesia, The Abdominal Centre, Section 2043, Copenhagen University Hospital, Rigshospitalet, Denmark.
Background: Failed intubation remains one cause of anaesthesia-related morbidity and mortality. In a recent survey in Denmark, 20% of respondents reported preventable mishaps in airway management. Methods: Assessment of the airway, and its documentation, as well as the availability of various equipment to manage a difficult airway, and the existence of a failed intubation plan were surveyed by mailing a questionnaire to the clinical directors of all 69 anaesthesia departments in Denmark. Results: Fifty-six departments (81%) returned the questionnaire. Pre-operative airway evaluation is performed in 90% of the departments. The tests included the mouth-opening test (77%), Mallampati score (48%), lower jaw protrusion (34%), neck mobility (63%), the measurement of the thyromental (11%) and sternomental distance (4%). The result of the tests are documented by 38% of the departments in the anaesthetic chart (96%), in the record (54%), on a card given to the patient (23%), in a letter sent to the patient's general practitioner (2%) or in a database (13%). The patients are personally informed in 82% of the departments. Only 54% of the departments have a failed intubation plan readily available. Conclusion: The preoperative assessment of the airways and its documentation is still unsatisfactory, as is communicating with the patient after a case of a difficult/impossible intubation. The adoption of internationally recognized recommendations might improve airway management and teaching to the best standard possible in the already well-equipped Danish anaesthetic departments.
PMID: 14982570 [PubMed - in process]
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Accuracy in estimating the correct intervertebral space level during lumbar, thoracic and cervical epidural anaesthesia.
Lirk P, Messner H, Deibl M, Mitterschiffthaler G, Colvin J, Steger B, Rieder J, Keller C.
Department of Anaesthesiology and Critical Care Medicine, University of Innsbruck, Innsbruck, Austria.
Background: Even in the absence of factors concealing anatomical landmarks, high failure rates in correctly determining a given lumbar interspace have been reported. Methods: Therefore, it was the aim of the present study to compare the assessed and factual level (determined by computed tomography) of epidural puncture in attending a regional anaesthesia cadaver workshop. Eighty-two anaesthetists performed 117 punctures. Results: Vertebral interspaces between T8-L4 were correctly identified more often than those between C3-T5 (P < 0.05). Identification of an arbitrarily chosen vertebral interspace was excellent in both the cervical/high thoracic and thoracic/lumbar regions. Conclusion: As previously conjectured only for the lumbar region, we could confirm the tendency of anaesthetists to perform neuraxial puncture more cranially than expected also for the thoracic and cervical regions. The large majority of punctures (93.7%) was performed within one interspace of the predicted level.
PMID: 14982569 [PubMed - in process]
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Inclusion of epinephrine to hyperbaric tetracaine and the supine position enhance the cephalad spread of spinal anaesthesia compared with hyperbaric teracaine alone in the lithotomy position.
Inoue S, Kawaraguchi Y, Kitaguchi K, Furuya H.
Department of Anaesthesiology, Nara Medical University, Kashihara, Nara, Japan.
Background: Intrathecal epinephrine can produce prolongation of duration of spinal anaesthesia by reducing vascular absorption of the local anaesthetics. The patient's positioning can change the cephalad spread of hyperbaric local anaesthetics by affecting the lordosis of the vertebral canal. These factors combined are expected to affect the cephalad spread of sensory block levels. The purpose of this study was to investigate whether combined use of epinephrine with hyperbaric tetracaine in the supine position can enhance the cephalad spread of sensory block levels compared with hyperbaric tetracaine alone in the lithotomy position. Methods: ASA physical status I or II 48 urological (lithotomy group) and 48 orthopaedic patients (supine group) scheduled to undergo elective surgical procedures in the lithotomy or supine position under spinal anaesthesia were enrolled. Patients in each group were randomly divided into two subgroups to receive intrathecal 10 mg of hyperbaric tetracaine with or without 0.2 mg of epinephrine (Groups L, LE, S, and SE). The extent of sensory blockade was assessed by loss of cold sensation. After achievement of sensory blockade up to T10, the patients in Groups L and LE were immediately placed in the lithotomy position. Patients in Groups S and SE were maintained in the supine position. Results: The highest sensory blockade in the SE Group was on average statistically significantly higher than in the L Group. The mean time taken to the highest sensory blockade in the SE Group was statistically significantly longer than in Groups L and S. Atropine for bradycardia was used more frequently in the SE Group than in the other groups. Conclusions: Combined use of epinephrine with hyperbaric tetracaine in the supine position can enhance the cephalad spread of sensory block levels compared with hyperbaric tetracaine alone in the lithotomy position.
PMID: 14982568 [PubMed - in process]
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August 26th 1952 at Copenhagen: 'Bjorn Ibsen's Day'; A significant event for Anaesthesia.
Trubuhovich RV.
Department of Critical Care Medicine, Auckland Hospital, Auckland, New Zealand.
PMID: 14982558 [PubMed - in process]
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Isoflurane damage to a Draeger Primus anaesthetic machine.
Vemmer T, Srikiran R, Liban B.
St George's Hospital, London SW17 0QT, UKE-mail: drtvemmer@hotmail.com
PMID: 14984541 [PubMed - in process]
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