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[Tinnitus after anaesthesia]
[Article in German]
Schaaf H, Kampe S, Hesse G.
Tinnitus-Klinik, Arolsen.
Possible connections between different forms of anaesthesia and the occurrence of tinnitus or increasing levels of tinnitus are described. After general anaesthesia no increase in the occurrence or level of tinnitus is to be expected, but there exists a very rare, but specific form of low frequency tinnitus combined with low frequency sensory hearing loss following spinal anaesthesia. Reversible tinnitus and hearing disorders following local anaesthesia normally occur in cases of central nervous system toxicity.
PMID: 15034637 [PubMed - as supplied by publisher]
Tumescent anesthesia: a concern of anesthesiologists.
Tabboush ZS.
Department of Anesthesiology, Kingdom Hospital, Riyadh, Saudi Arabia.
PMID: 15041625 [PubMed - in process]
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Epidural hematoma after spinal anesthesia in a patient with undiagnosed epidural lymphoma.
Gottschalk A, Bischoff P, Lamszus K, Standl T.
Departments of Anesthesiology and. Neurosurgery, University Hospital Hamburg-Eppendorf, Germany.
The incidence of hemorrhagic complications after neuroaxial anesthesia is very infrequent. We report a case of a woman developing epidural bleeding 3 wk after performing an uneventful spinal anesthesia at the lumbar level L3-4 for removal of a wire loop in her left knee. No hemostasis altering medication had been taken before and after spinal puncture. The hematoma presenting at the lumbar level L2-3 had to be removed via laminectomy. Pathological examination of the hematoma revealed a highly vascularized centroblastic non-Hodgkin's lymphoma that was not diagnosed before surgery. The patient did not develop any neurological deficits. IMPLICATIONS: We report a case of a women developing epidural bleeding 3 wk after performing an uneventful spinal anesthesia for removal of a wire loop in her left knee. Pathological examination of the neurosurgically removed hematoma revealed a highly vascularized epidural centroblastic non-Hodgkin lymphoma.
PMID: 15041622 [PubMed - in process]
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Perioperative management with epidural anesthesia for a parturient with superior vena caval obstruction.
Buvanendran A, Mohajer P, Pombar X, Tuman KJ.
Departments of Anesthesiology and. Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois.
Perioperative management of patients with superior vena cava obstruction presents an anesthetic challenge because of severe cardiopulmonary compromise. This is particularly important in the parturient because of increased upper airway edema and inferior vena caval compression. We describe the management of a parturient who presented at 34 wk of gestation with signs and symptoms of superior vena cava obstruction from metastatic breast cancer. The patient was scheduled for a cesarean delivery followed by chemotherapy, as other therapies were deemed excessively risky because of the anatomic characteristics of the large mediastinal mass. This report describes the successful use of regional anesthesia in this setting and discusses the relevant anesthetic and perioperative management considerations for this complex scenario. IMPLICATIONS: Perioperative management of patients with superior vena caval obstruction presents an anesthetic challenge because of the severe cardiopulmonary compromise. This case report describes a parturient who presented for cesarean delivery with superior vena caval obstruction resulting from metastasis from breast cancer.
PMID: 15041617 [PubMed - in process]
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Intrathecal sufentanil and fetal heart rate abnormalities: a double-blind, double placebo-controlled trial comparing two forms of combined spinal epidural analgesia with epidural analgesia in labor.
Van De Velde M, Teunkens A, Hanssens M, Vandermeersch E, Verhaeghe J.
Departments of Anesthesiology and. Obstetrics and Gynecology, University Hospitals Gasthuisberg, Katholieke Universiteit Leuven, Herestraat, Belgium.
Combined spinal epidural analgesia (CSE) for labor pain relief has become increasingly popular. However, the effect of intrathecal sufentanil on the incidence of uterine hyperactivity and fetal heart rate (FHR) abnormalities remains controversial. We hypothesized that the use of intrathecal sufentanil in a dose of 7.5 micro g is more likely to induce a nonreassuring FHR tracing than a small dose of spinal sufentanil combined with bupivacaine or epidural analgesia. Three-hundred parturients were randomized into three groups. In the first group, epidural analgesia was initiated with 12.5 mg of bupivacaine, 12.5 micro g of epinephrine, and 7.5 micro g of sufentanil in a volume of 10 mL (EPD group). In Group 2, initial intrathecal analgesia consisted of 2.5 mg of bupivacaine, 2.5 micro g of epinephrine, and 1.5 micro g of sufentanil (BSE group); in Group 3, spinal analgesia consisted of 7.5 micro g of sufentanil (SUF group). Analgesia was maintained in all groups with patient-controlled epidural analgesia using bupivacaine 0.125%, 1.25 micro g/mL of epinephrine, and 0.75 micro g/mL of sufentanil (bolus, 4 mL; lockout, 15 min). Cardiotocography was monitored continuously 15 min before analgesia and for 60 min after the start of analgesia. The quality of analgesia, labor, and neonatal outcome and side effects were recorded. Twenty-four percent of patients in the SUF group developed FHR abnormalities (bradycardia or late decelerations) during the first hour after initiation of analgesia compared with 12% in the BSE group and 11% in the EPD group. Uterine hyperactivity occurred in 12% of parturients in the SUF group but in only 2% in the other groups. Onset of analgesia was more rapid in both CSE groups as compared with the EPD group. However, 29% of patients in the BSE group developed severe hypotension, requiring IV ephedrine (29% in the BSE group versus 7% and 12% in the EPD and SUF groups, respectively). All these differences reached statistical significance. The present data corroborate previous recommendations of caution when performing CSE using a large dose (7.5 micro g or more) of spinal sufentanil because of the risk of uterine hyperactivity and FHR abnormalities. IMPLICATIONS: Combined spinal epidural analgesia (CSE) produces pain relief during labor. Fetal heart rate changes after CSE using intrathecal sufentanil have been reported. We performed a randomized, blinded trial confirming that fetal heart rate changes are more frequent after CSE using 7.5 micro g of intrathecal sufentanil as compared with other forms of neuraxial labor analgesia.
PMID: 15041616 [PubMed - in process]
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Do anesthesiologists die at a younger age than other physicians? Age-adjusted death rates.
Katz JD.
Yale University School of Medicine, New Haven, Connecticut.
I designed this study to determine whether anesthesiologists are susceptible to premature death. Three specialty groups were studied: anesthesiologists, internists, and all other physicians. Records were examined of all American physicians who died in the years 1989, 1990, 1995, 2000, and 2001, and those who were alive at the end of 1989, 1995, 2000, and 2001. Anesthesiologists had a statistically significant younger mean age at death (crude mortality) (68.98 +/- 15.55 yr) (n = 723) than did internists (74.41 +/- 14.24 yr) (n = 2285) and all other physicians (75.21 +/- 13.3 yr) (n = 18,328) (P < 0.001). However, by factoring in the ages of the living members of the study populations, there was no statistical difference in age-specific mortality. IMPLICATIONS: It has been suggested that one of the potential occupational hazards of the practice of anesthesiology is premature death. This study disproves the notion that anesthesiologists die at a younger age than other physicians.
PMID: 15041608 [PubMed - in process]
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Are patients comfortable consenting to clinical anesthesia research trials on the day of surgery?
Brull R, McCartney CJ, Chan VW, Chung F, Rawson R.
Department of Anesthesia, Toronto Western Hospital, University Health Network, Ontario, Canada.
Consent for clinical anesthesia research trials is often sought on the day of surgery when patients are most anxious and have little privacy or time for reflection. We conducted a retrospective survey of patients' perceptions and concerns regarding consent for clinical anesthesia trials on the day of surgery. Questionnaires were mailed to 175 patients who had participated in 1 of 6 negligible- or minimal-risk clinical anesthesia trials within the preceding year. Seventy-six patients responded (43%). Most patients (80%) reported that they understood the purpose of their trial, did not feel obligated (61%) or pressured (67%) to participate, and were satisfied (mean visual analog scale: 71 mm) with the recruitment and consent process on the day of surgery. Few patients (7%) believed that their well-being was put at risk because of their participation in the trial. IMPLICATIONS: This retrospective survey suggests that patient recruitment and consent for negligible- or minimal-risk clinical anesthesia research trials is appropriate when performed on the day of surgery.
PMID: 15041607 [PubMed - in process]
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Postoperative epidural anesthesia preserves lymphocyte, but not monocyte, immune function after major spine surgery.
Volk T, Schenk M, Voigt K, Tohtz S, Putzier M, Kox WJ.
Departments of Anesthesiology and Intensive Care and. Orthopedic Surgery, University Hospital Charite, Campus Mitte, Humboldt-University, Berlin, Germany.
Extensive spine surgery is associated with postsurgical pain. Epidural pain therapy may reduce postoperative stress responses and thereby influence immune functions. In a randomized, controlled, double-blinded prospective trial, 54 patients received either conventional patient-controlled IV analgesia (PCIA; morphine 3 mg/15 min) or patient-controlled epidural analgesia (PCEA; 0.125% ropivacaine plus sufentanil 1 micro g/mL at a base rate of 12 mL/h and bolus application of 5 mL/15 min). Circulating cytokines, C-reactive protein (CRP), cortisol, and cell-surface receptor expression of immune cells (cluster of differentiation [CD]14, human leukocyte antigen-DR, CD86, CD71, CD3, CD4, CD8, CD16, and CD19) were measured perioperatively to characterize immunological functions. PCEA, compared with PCIA, had no influence on altered levels of circulating cytokines (interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor-alpha, monocyte chemoattractant protein-1, and macrophage inhibitory factor) or indicators of the stress response (CRP and cortisol). Also, no significant difference was found in monocyte numbers or their human leukocyte antigen-DR, CD86, or CD71 expression. In contrast, the postoperative decrease in B lymphocytes and T-helper cells was significant in the PCEA group. Natural killer cells decreased significantly in patients receiving PCEA compared with PCIA. Therefore, postoperative epidural pain therapy has no influence on monocyte functions but reduces natural killer cells and preserves B-cell and T-helper cell populations. Epidural analgesia thus influences the specific rather than the innate immune system and potentially blunts the postsurgical lymphocyte depression, which is relevant for infectious resistance. IMPLICATIONS:Epidural analgesia affects the immune system. Postoperative epidural analgesia, compared with conventional IV opioid therapy, preserves lymphocyte rather than monocyte functions. An improvement of postoperative immune function by epidural analgesia therefore may improve postoperative resistance to infectious complications or to chronic pain states.
PMID: 15041604 [PubMed - in process]
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Unusually low bispectral index values during emergence from anesthesia.
Hagihira S, Okitsu K, Kawaguchi M.
Department of Anesthesiology, Osaka University Graduate School of Medicine, and the. Department of Anesthesiology, Osaka Prefectural Habikino Hospital, Osaka, Japan.
We observed unusually low BIS values during emergence from anesthesia apparently caused by misanalysis (as "suppression") of low voltage electroencephalogram. IMPLICATIONS: When BIS values do not adequately correspond with clinical status, it is necessary to check raw electroencephalogram waveforms to more clearly characterize patient status.
PMID: 15041594 [PubMed - in process]
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Bispectral index as an indicator of seizure inducibility in electroconvulsive therapy under thiopental anesthesia.
Ochiai R, Yamada T, Kiyama S, Nakaoji T, Takeda J.
Department of Anesthesiology, School of Medicine, Keio University, Tokyo, Japan.
The prediction of seizure thresholds in electroconvulsive therapy (ECT) remains problematic. We examined the relationship between bispectral index (BIS) score and seizure duration in ECT performed under thiopental anesthesia in patients receiving their usual regimen of antidepressant medication for its potential as a predictor of seizure inducibility. One-hundred ECT treatments were evaluated in 16 adult patients diagnosed with depression. BIS scores were recorded at the preanesthetic and preictal periods and at recovery from ECT. Seizure duration was defined as the duration of the electroencephalogram seizure pattern. The relationships between preanesthetic and preictal BIS scores and seizure duration were evaluated. Effective seizure threshold was determined by receiver operator characteristic analysis, and the area under the curve (AUC) was calculated for seizure durations of more than 10 s, more than 20 s, and more than 30 s. The relationship between seizure duration and thiopental estimated effect-site and plasma concentrations was analyzed as well. Preictal BIS scores for seizures lasting longer than 30 s were significantly higher than those for seizures lasting <30 s. A preictal BIS score of 55 or more represents a strongly determinant condition for achieving seizures that last longer than 30 s (AUC, 0.937; receiver operator characteristic), as well as for briefer seizures that last more than 20 or 10 s (AUC: 0.938 and 0.959, respectively). There was no significant correlation between seizure duration and the estimated thiopental effect-site or plasma concentration. We conclude that during thiopental anesthesia, the minimum threshold for inducing seizures of any duration correlates with a preictal BIS score of 55. This threshold was independent of antidepressant regimen and thiopental dosage. We suggest that the preictal BIS score is useful in predicting the ictogenic threshold in ECT. IMPLICATIONS: We found that the bispectral index (BIS) score serves as an indicator of seizure inducibility in electroconvulsive therapy (ECT) under thiopental anesthesia and that the relationship between BIS score and seizure duration was not linear, suggesting that the pharmacological mechanisms by which thiopental and propofol suppress ECT seizure activity are different.
PMID: 15041593 [PubMed - in process]
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The Effect of Local Anesthetics on Monocyte mCD14 and Human Leukocyte Antigen-DR Expression.
Kawasaki T, Kawasaki C, Ogata M, Shigematsu A.
Department of Anesthesiology, University of Occupational and Environmental Health, Kitakyushu, Japan.
It has been demonstrated that local anesthetics have several effects on the immune system. Monocytes and macrophages are essential components of the host response to microbial infection; however, the effect of local anesthetics on monocyte surface receptor expression remains unclear. We designed this study to investigate the effects of local anesthetics on monocyte mCD14 and human leukocyte antigen (HLA)-DR expression and lipopolysaccharide (LPS)-induced or staphylococcal enterotoxin B (SEB)-induced tumor necrosis factor (TNF)-alpha production. Blood samples were obtained from 10 healthy volunteers. The effects of local anesthetics on LPS- or SEB-induced TNF-alpha production were determined by using an enzyme-linked immunosorbent assay. After different doses of local anesthetics were added, the blood was stimulated with LPS (10 ng/mL) or SEB (10 micro g/mL) for 4 h. The effects of local anesthetics on monocyte mCD14 and HLA-DR expression were measured by dual monoclonal antibody staining and flow cytometry. Local anesthetics showed no effect on LPS- or SEB-induced TNF-alpha production in human whole blood. Local anesthetics suppressed monocyte HLA-DR expression in a dose-dependent manner (P < 0.05) but had no effect on monocyte mCD14 expression. This study demonstrated that local anesthetics suppress HLA-DR expression on the surface of human monocytes. IMPLICATIONS: Monocyte surface receptors have a crucial role in the host response to microbial infection. We investigated the effects of local anesthetics on monocyte mCD14 and human leukocyte antigen (HLA)-DR expression. Our results show that local anesthetics suppress HLA-DR expression on the surface of human monocytes.
PMID: 15041592 [PubMed - in process]
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Preoperative oral dextromethorphan attenuated tourniquet-induced arterial blood pressure and heart rate increases in knee cruciate ligament reconstruction patients under general anesthesia.
Yamashita S, Yamaguchi H, Hisajima Y, Ijima K, Saito K, Chiba A, Yasunaga T.
Departments of Anesthesia and Critical Care Medicine and. Orthopedics, Iwaki Kyoritsu General Hospital, Iwaki, Fukushima, Japan. Department of Anesthesia, Ryugasaki Saiseikai Hospital, Ryugasaki, Ibaraki, Japan.
The precise mechanism of tourniquet-induced arterial blood pressure increase is unknown. We determined the effect of preoperative oral dextromethorphan (DM) on arterial blood pressure and heart rate changes during tourniquet inflation in knee cruciate ligament reconstruction patients under general anesthesia. Patients in the DM group (n = 38) received oral DM 30 mg, and patients in the control group (n = 38) received oral placebo 2 h before the induction of anesthesia. Anesthesia was maintained with sevoflurane 2.0% and N(2)O in 33% oxygen, and the trachea was intubated until the end of surgery. Arterial blood pressure and heart rate were measured at 0, 30, and 60 min after the start of tourniquet inflation. Systolic arterial blood pressure and heart rate at 60 min in the control group were significantly more than those in the DM group (131.1 +/- 15.8 mm Hg versus 123.6 +/- 15.9 mm Hg [P < 0.05] and 74.1 +/- 11.3 bpm versus 67.8 +/- 8.5 bpm [P < 0.01], respectively). The percentage increase in systolic arterial blood pressure and heart rate in the DM group was also attenuated when compared with that in the control group (P < 0.05). In conclusion, preoperative oral DM 30 mg significantly attenuated arterial blood pressure and heart rate increases during tourniquet inflation under general anesthesia. IMPLICATIONS: We demonstrated that preoperative oral dextromethorphan 30 mg significantly attenuated arterial blood pressure and heart rate increases at 60 min during tourniquet inflation in patients undergoing knee cruciate ligament reconstruction under general anesthesia.
PMID: 15041587 [PubMed - in process]
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A comparison of liver function after hepatectomy in cirrhotic patients between sevoflurane and isoflurane in anesthesia with nitrous oxide and epidural block.
Nishiyama T, Fujimoto T, Hanaoka K.
Department of Anesthesiology, The University of Tokyo, Tokyo, Japan.
In this study, we compared postoperative liver function in patients with liver cirrhosis between isoflurane and sevoflurane anesthesia with nitrous oxide (N(2)O) and epidural block. Forty cirrhotic patients with Child-Pugh Grade A, aged 40 to 70 yr, scheduled for liver segmentectomy, had anesthesia induced with midazolam 0.1 mg/kg and fentanyl 4 micro g/kg. For maintenance, intermittent epidural administration of 1.5% lidocaine 4 to 6 mL and sevoflurane (sevoflurane group) or isoflurane (isoflurane group) with N(2)O 3 L/min in oxygen 3 L/min was used. Aspartate aminotransferase, alanine aminotransferase, total bilirubin, alkaline phosphatase, choline esterase, albumin, prothrombin time, and platelet count were measured before and 1, 3, and 7 days after surgery. Aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase increased significantly, with the peaks at 3 days after surgery in both groups. The increases in these variables were significantly larger in the isoflurane group than those in the sevoflurane group. No patient developed hepatic failure. All increases in liver enzymes were small and of questionable clinical relevance. Whether sevoflurane might be a better anesthetic when combined with N(2)O and epidural block for cirrhotic patients than isoflurane with respect to liver damage remains to be determined. IMPLICATIONS: In cirrhotic patients with Child-Pugh Grade A, isoflurane induced more of an increase in serum concentrations of liver enzymes after surgery than sevoflurane when combined with nitrous oxide and epidural block. However, the increases were small, and there was no clinical liver damage.
PMID: 15041586 [PubMed - in process]
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Warm steaming enhances the topical anesthetic effect of lidocaine.
Arai YC, Ueda W.
Department of Anesthesiology, Kochi Municipal Hospital, and the. Department of Anesthesiology, Clinical Physiology and Pharmacology, School of Nursing, Kochi Medical School, Kochi, Japan.
Warm steaming has been used for hydrating the skin, thereby increasing its permeability. We studied whether skin pretreatment with a steamed towel (at 45 degrees C) for 5 min could enhance the anesthetic effect of a topical lidocaine tape in 14 female volunteers. After each volunteer received the skin pretreatment on one of the forearms, lidocaine tape was applied for 30 min on both the treated and the untreated forearms. Superficial anesthesia was scored by recording the number of painful experience during 5 pinpricks delivered with a 27-gauge needle. To assess anesthesia of the deeper layer, single insertion of a 27-gauge needle to a depth of 3 mm was made and pain was scored by a visual analog scale (VAS). There were significant reductions in the scores of superficial anesthesia (median [range]: treated arm, 2 [0-5], versus untreated arm, 4 [1-5]; P < 0.01) and the VAS scores of deeper insertion (median [range]: treated arm, 4.5 [0-8], versus untreated arm, 8 [2-10]; P < 0.01). In conclusion, the application of a warm steamed towel enhanced the anesthetic effect of a topical lidocaine tape. IMPLICATIONS: We showed that the skin pretreatment with a steamed towel (at 45 degrees C) enhanced the anesthetic effect of a topical lidocaine tape in female volunteers.
PMID: 15041584 [PubMed - in process]
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Modafinil Improves Recovery After General Anesthesia.
Larijani GE, Goldberg ME, Hojat M, Khaleghi B, Dunn JB, Marr AT.
Departments of Anesthesiology and. Psychiatry, University of Medicine and Dentistry of New Jersey, Cooper Health System, Camden, New Jersey, and the. Center for Research in Medical Education, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
Recovery from general anesthesia often involves residual sedation, drowsiness, fatigue, and lack of energy that may last hours to days. Modafinil is a wakefulness-promoting drug approved for patients with excessive daytime sleepiness associated with narcolepsy. We evaluated the effect of single doses of modafinil (200 mg) and placebo in patients recovering from general anesthesia. Thirty-four subjects participated in this prospective, randomized, double-blind study approved by our IRB. Preoperatively, patients were asked to rate various symptoms they had experienced over the previous 24-h using a verbal analog scale (VAS) of 0 to 10 as well as discrete scale when indicated. Postoperatively, once the patient was able to tolerate oral intake and met our institutional discharge criteria, the study drug (modafinil 200 mg or placebo) was administered with a sip of water. Patients were contacted 24 (1) hours after dosing to evaluate postdischarge symptoms. Patients in the placebo group reported significantly more postoperative fatigue (4.8 [3.3] versus 1.4 [1.8]), exhaustion (4.3 [3.3] versus 2.4 [3.1]), or degree of feeling worn out (4.7 [3.6] versus 2.9 [2.4]). Significantly more patients reported moderate to severe fatigue in the placebo group (65% versus 12%). Two major themes of "alertness" and "energy" were expressed by 71% of the patients receiving modafinil versus 18% of those receiving placebo. Patients recovering from general anesthesia can significantly benefit from modafinil. IMPLICATIONS: Modafinil significantly reduces fatigue and improves feelings of alertness and energy in postoperative patients. Patients recovering from general anesthesia can significantly benefit from modafinil administration.
PMID: 15041583 [PubMed - as supplied by publisher]
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A review of intrathecal and epidural analgesia after spinal surgery in children.
Tobias JD.
Departments of Child Health and Anesthesiology and the Division of Pediatric Critical Care/Pediatric Anesthesiology, The University of Missouri, Columbia, Missouri.
In view of the overall experience regarding regional anesthetic techniques to control postoperative pain in infants and children, it is feasible that a similar efficacy and safety profile can be obtained when using such techniques after major orthopedic procedures such as anterior or posterior spinal fusion. I reviewed previous reports regarding the use of neuraxial techniques to provide analgesia after spine surgery in the pediatric population. Variations in both the surgical procedure and the analgesic technique may make the comparison among studies somewhat impractical. Variations of the analgesic technique include 1) the dose of the medications used; 2) the route of delivery (intrathecal or epidural); 3) the mode of delivery (single dose, intermittent bolus dosing, and continuous infusion); 4) the number of epidural catheters used (one versus two); 5) the medications infused (opioids, local anesthetics, or both); 6) the opioid used (morphine, fentanyl, hydromorphone); and 7) the analgesic regimen of the control group (intermittent "as needed" morphine or patient-controlled analgesia). Although limited data are available to document the analgesic superiority of these techniques over parenteral opioids, clinical data offer evidence of other benefits, including decreased intraoperative blood loss and quicker return of gastrointestinal function.
PMID: 15041580 [PubMed - in process]
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The effects of spread of block and adrenaline on cardiac output after epidural anesthesia in young children: a randomized, double-blind, prospective study.
Raux O, Rochette A, Morau E, Dadure C, Vergnes C, Capdevila X.
Departments of Anesthesiology and. Medical Information, CHU Montpellier, France.
Epidural anesthesia is considered to be without significant hemodynamic consequence in young children. However, conversely to adults, few studies have investigated cardiac output. Using transesophageal Doppler monitoring of cardiac output, we prospectively investigated hemodynamic alterations in 48 children (median age, 22.5 mo) receiving sevoflurane general anesthesia combined with caudal or thoracolumbar epidural anesthesia. They were randomly assigned to receive 0.8 mL/kg of plain local anesthetic mixture (lidocaine 1% + bupivacaine 0.25% (50/50) + 1 micro g/mL of fentanyl) or 1 mL/kg of the same mixture with 5 micro g/mL of adrenaline. No significant hemodynamic alteration was elicited in caudal and thoracolumbar groups receiving the plain mixture except a moderate decrease in heart rate. Conversely, a mixture with adrenaline added provoked a significant decrease in mean arterial blood pressure by 14% and 17%, in systemic vascular resistance by 24% and 40%, and an increase in cardiac output by 20% and 34% in caudal and thoracolumbar groups, respectively. The adrenaline effect was greater by the thoracolumbar than the caudal approach. In young children, epidural anesthesia induces an increase in cardiac output only when adrenaline is added to local anesthetics, probably through its systemic absorption from the epidural space. IMPLICATIONS: Epidural anesthesia may induce significant hemodynamic changes, well documented in adults. Using noninvasive hemodynamic monitoring in children, we reported an increase in cardiac output and a decrease in arterial blood pressure only when epinephrine was added to epidurally-injected local anesthetics.
PMID: 15041578 [PubMed - in process]
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The influence of anthracycline therapy on cardiac function during anesthesia.
Huettemann E, Junker T, Chatzinikolaou KP, Petrat G, Sakka SG, Vogt L, Reinhart K.
Departments of Anesthesiology and Intensive Care Medicine and. Pediatrics, University Hospital, Friedrich-Schiller-University, Jena, Germany. Department of Intensive Care, Hippocration General Hospital, Thessaloniki, Greece.
Cardiotoxicity is a well recognized complication of anthracycline (AC) therapy. Subtle abnormalities in myocardial function that become apparent only after exercise may exist in survivors of childhood cancer who have previously received AC, yet have normal resting cardiac function. To evaluate if anesthesia-induced changes in cardiac function differ in pediatric patients with previous AC therapy from healthy children and adolescents, we evaluated in a prospective study 43 patients, of whom 42 were analyzed. Twenty-one patients (AC-group), mean age 9.6 yr (range, 3-16 yr), who had received 193 (30-490) mg/m(2) of AC as a mean cumulative dose with normal resting cardiac function (shortening fraction [SF] 0.34, normal value > 0.30) underwent removal of a Hickman catheter under general anesthesia. Twenty-one patients, mean age 10.9 yr (range, 4-17 yr), who underwent placement of a Hickman catheter before chemotherapy served as the control. All children were premedicated with midazolam 0.5 mg/kg orally. Anesthesia was induced by sodium thiopental (5 mg/kg), fentanyl (3 micro g/kg), and rocuronium (0.6 mg/kg) and maintained with isoflurane (1 MAC) in N(2)O/O(2) (70/30). Before induction (baseline), 5 and 20 min after intubation (T1 and T2), and 20 min after extubation (control), cardiac function was assessed by transthoracic (baseline, control) and transesophageal (T1, T2) echocardiography. Compared with baseline (SF: 34.9 +/- 3.7 [AC], 34.1 +/- 3.7 [C] [not significant]; stroke volume index [SVI] 36 +/- 6 mL/m(2)[AC], 35 +/- 4 mL/m(2)[C] [not significant]; cardiac index [CI] 3.6 +/- 0.6 L/min/m(2)[AC], 3.2 +/- 0.5 L/min/m(2)[C] [not significant]), we found a significant decrease in SF and SVI in both groups at T1 (SF: 26.2 +/- 3.6 [AC] versus 28.6 +/- 3.6 [C] [P < 0.05]; SVI: 26 +/- 4 mL/m(2) [AC] versus 30 +/- 46 mL/m(2) [C] [P < 0.05]) and T2 (SF: 24.1 +/- 3.2 [AC] versus 28.2 +/- 2.5 [C] [P < 0.01], SVI: 26 +/- 6 mL/m(2) [AC] versus 31 +/- 5 mL/m(2) [C] [P < 0.01]), which was significantly greater in the AC group. There were no significant changes of variables of diastolic function (E/A ratio, isovolumetric relaxation time) between both groups. Previous treatment with AC may enhance the myocardial depressive effect of anesthetics even in patients with normal resting cardiac function. IMPLICATIONS: Previous treatment with anthracylines, a group of chemotherapeutic drugs in use for childhood cancer, may enhance the myocardial depressive effect of anesthetics even in children and adolescents with normal resting cardiac function.
PMID: 15041577 [PubMed - in process]
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Cardiac anesthesiology, professionalism and ethics: a microcosm of anesthesiology and medicine.
Lowenstein E.
Department of Anesthesia and Critical Care, Massachusetts General Hospital, and Department of Anaesthesia and Division of Medical Ethics, Harvard Medical School, Boston, Massachusetts.
The granting of professional status to medicine by society at large entails obligations by physicians. Those physicians in the young subspecialty of cardiac anesthesiology have fulfilled these obligations by developing a body of scientific and clinical knowledge and the technical bases to increase survival and decrease morbidity of patients with heart disease undergoing either cardiac or noncardiac surgery. Furthermore, they have contributed effectively to the broad practice of medicine. However, a strong argument can be made that these contributions, though benefiting many individual patients, do not by themselves completely fulfill our obligations. The concept of Civic Professionalism states that our moral responsibilities as physicians must be expanded beyond our immediate patients. Physicians have the obligation to use their knowledge and influence to promote the common good. The Universal Declaration of Human Rights includes access to health care as a basic tenet. The present health care system of the United States excludes many people. Thus, cardiac anesthesiologists have a moral obligation to actively advocate for universal access to health care until it is achieved. Doing so will make the specialty of cardiac anesthesiology an example to the entire profession of medicine. IMPLICATIONS: Cardiac anesthesiologists have contributed to enhanced survival and decreased morbidity of patients with heart disease undergoing surgery. These achievements do not by themselves fulfill the moral obligations incurred by the concept of Civic Professionalism, however. Cardiac anesthesiologists, in common with all physicians, must share the obligation to advocate for the human right of universal access to health care.
PMID: 15041574 [PubMed - in process]
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Analysis of paediatric dental care provided under general anaesthesia and levels of dental disease in two hospitals.
Camilleri A, Roberts G, Ashley P, Scheer B.
Department of Paediatric Dentistry, The Eastman Dental Institute, University College London, 256 Gray's Inn Road, London, UK.
OBJECTIVE: To compare the level of dental disease and the pattern of dental treatment under controlled airway general anaesthesia for ASA I and II children and ASA III and IV children in two hospitals. DESIGN: Prospective analysis. SETTING: Hospital and postgraduate dental teaching institution, UK 1996 - 2000. SUBJECTS AND METHODS: During a four-year period (1996-2000), data were collected on children aged 1 to 16 years who were admitted for treatment of dental caries under general anaesthesia.Outcome measures Levels of dental disease (dmft/DMFT), treatment provided. RESULTS: A total of 515 ASA I and II and 430 ASA III and IV children were treated. The dmft and DMFT values of the ASA I and II children were significantly higher than those of the ASA III and IV children (p = 0.03). A significantly greater number of restorations and fissure sealants were carried out for permanent teeth in ASA III and IV children (p < 0.001). The number of extractions for both primary and permanent teeth was significantly greater in the ASA I and II group (p < 0.05). CONCLUSIONS: The ASA III and IV children had significantly lower levels of dental caries than the ASA I and II children and received a higher level of preventive and restorative care.
PMID: 15039732 [PubMed - in process]
Remifentanil and anaesthesia for carcinoid syndrome.
Farling PA, Durairaju AK.
Department of Anaesthesia, Royal Victoria Hospital, Belfast BT12 6BA, UK.
Carcinoid syndrome creates many challenges during anaesthesia, including hypertension, hypotension and bronchospasm. These challenges are less common and less severe after the routine use of octreotide. We describe the use of remifentanil as part of the anaesthetic management of a 67-yr-old man undergoing resection of a carcinoid tumour of the terminal ileum. The combination of perioperative octreotide administration, intraoperative remifentanil infusion and sevoflurane anaesthesia, with postoperative epidural analgesia proved satisfactory. We review the recent literature and suggest that remifentanil is a useful addition to the armamentarium of the anaesthetist in the management of a patient with carcinoid syndrome.
PMID: 15033895 [PubMed - as supplied by publisher]
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The interaction of anaesthetic steroids with recombinant glycine and GABAA receptors{dagger}
Weir CJ, Ling AT, Belelli D, Wildsmith JA, Peters JA, Lambert JJ.
Department of Anaesthesia, Division of Pathology and Neuroscience, Ninewells Hospital and Medical School, The University of Dundee, Dundee DD1 9SY, UK; Department of Pharmacology & Neuroscience, Division of Pathology and Neuroscience, Ninewells Hospital and Medical School, The University of Dundee, Dundee DD1 9SY, UK.
BACKGROUND: Anaesthetic steroids are established positive allosteric modulators of GABAA receptors, but little is known concerning steroid modulation of strychnine-sensitive glycine receptors, the principal mediators of fast, inhibitory neurotransmission in the brain stem and spinal cord. This study compared the modulatory actions of five anaesthetic pregnane steroids and two non-anaesthetic isomers at human recombinant alpha1 glycine and alpha1beta2gamma2L GABAA receptors. METHODS: Recombinant alpha1 glycine or alpha1beta2gamma2L GABAA receptors were expressed in Xenopus laevis oocytes and agonist-evoked currents recorded under voltage-clamp. Steroid modulation of currents evoked by GABA, or glycine, was quantified by determining the potency (EC50) and maximal effect of the compounds. RESULTS: The anaesthetics minaxolone (EC50=1.3 micro M), Org20599 (EC50=1.1 micro M) and alphaxalone (EC50=2.2 micro M) enhanced currents mediated by GABAA receptors. The anaesthetics also enhanced currents mediated by glycine receptors, although with higher EC50 values (minaxolone 13.1 micro M; Org20599=22.9 micro M and alphaxalone=27.8 micro M). The maximal enhancement (to 780-950% of control) produced by the three steroids acting at the GABAA receptor was similar, but currents evoked by glycine were potentiated with increasing effectiveness by alphaxalone (199%) <Org20599 (525%) <minaxolone (1197%). The anaesthetic isomers, 5alpha-pregnan-3alpha-ol-20-one and 5beta-pregnan-3alpha-ol-20-one (eltanolone) enhanced GABAA receptor-mediated currents with similar potency and efficacy, but only the former enhanced glycine, the latter causing inhibition. The non-anaesthetic steroids 5alpha-pregnan-3beta-ol-20-one and 5beta-pregnan-3beta-ol-20-one modulated neither GABAA, nor glycine, receptors. CONCLUSIONS: The data demonstrate that structure-activity relationships for steroid modulation at glycine and GABAA receptors differ. Comparing the EC50 values reported here with free plasma concentrations during steroid-induced anaesthesia indicates that a selective modulation of GABAA receptor activity is likely to occur in vivo.
PMID: 15033889 [PubMed - as supplied by publisher]
Comment on:
Dose of intrathecal diamorphine for Caesarean section and position for spinal insertion.
Barrett NA, Dob DP, Ball ER, Jones HR.
Publication Types:
PMID: 15002114 [PubMed - indexed for MEDLINE]
Comment on:
How low can we go?
Morley A.
Publication Types:
PMID: 14970145 [PubMed - indexed for MEDLINE]
Comment on:
Post-dural puncture headache.
Sharma R, Bailey A, Bamber J.
Publication Types:
PMID: 14970140 [PubMed - indexed for MEDLINE]
Comment on:
Dose of intrathecal diamorphine for Caesarean section and position for spinal insertion.
Kinsella SM.
Publication Types:
PMID: 14970139 [PubMed - indexed for MEDLINE]
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Alkalinization of intra-cuff lidocaine and use of gel lubrication protect against tracheal tube-induced emergence phenomena.
Estebe JP, Delahaye S, Le Corre P, Dollo G, Le Naoures A, Chevanne F, Ecoffey C.
Service d'Anesthesie Reanimation Chirurgicale 2, Universite de Rennes 1, Rennes, France. jean-pierre.estebe@chu-rennes.fr
BACKGROUND: We sought to determine the benefits of using alkalinized lidocaine 40 mg to fill the cuff of a tracheal tube (ETT) in combination with water-soluble gel lubrication to prevent post-intubation sore throat. METHODS: The work included an in vitro study of the diffusion of alkalinized lidocaine solution through the low-pressure, high-volume cuff of an ETT. We also performed a randomized controlled study (n=20 patients in each group) that included a group who received an alkalinized lidocaine-filled ETT cuff with lubrication of the tube using water-soluble gel (Group G), and two control groups who received an alkalinized lidocaine-filled cuff with ETT lubrication with water (Group W) or an air-filled cuff with ETT lubrication with water (Group C). RESULTS: Water-soluble gel lubrication (Group G) produced a lower incidence of sore throat during the 24-h post-extubation period than lubrication with water alone in the cuffs filled with alkalinized lidocaine (Group W), and compared with the air control group. The ability of lidocaine to pass through the cuff of an ETT when water-soluble gel and/or water alone was used as a lubricant was similar, as determined by lidocaine plasma concentrations (C(max) 45 ng x ml(-1)). Cough and restlessness before tracheal extubation were decreased in patients with the alkalinized lidocaine-filled cuffs compared with the air-filled cuffs. After extubation, nausea, vomiting, dysphonia and hoarseness were greater for patients with air-filled cuffs compared with the lidocaine-filled cuffs. No significant difference between the groups was recorded in arterial blood pressure and heart rate. In vitro data suggest that the lower the NaHCO(3) injection volume, the greater the release of lidocaine across a low-pressure, high-volume cuff. CONCLUSIONS: These data show benefits of using an alkalinized lidocaine-filled ETT cuff in combination with water-soluble gel lubrication in preventing post-intubation sore throat.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14970135 [PubMed - indexed for MEDLINE]
Comment on:
'It ain't what you do; it's the way that you do it.': reducing haemodynamic instability during carotid surgery.
Stoneham MD.
Publication Types:
PMID: 14970131 [PubMed - indexed for MEDLINE]
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Fatal streptococcal necrotizing fasciitis as a complication of axillary brachial plexus block.
Nseir S, Pronnier P, Soubrier S, Onimus T, Saulnier F, Mathieu D, Durocher A.
Service de Reanimation Medicale, Hopital Calmette, CHRU, boulevard du Pr Leclercq, F-59037 Lille cedex, France. s-nseir@chru-lille.fr
A 74-yr-old diabetic woman developed necrotizing fasciitis of the right upper limb after axillary brachial plexus block for carpal tunnel decompression. Clinical signs included oedema, diffuse swelling and bullae; rapidly followed by toxic shock syndrome and multiorgan failure. The patient died 48 h after hospital admission, despite broad-spectrum antibiotics, surgical treatment and supportive measures for the management of shock and multiorgan failure. Cultures yielded group A Streptococcus. Delay in antibiotic and surgical treatment probably affected the outcome. Early diagnosis and treatment are essential to improve the outcome of streptococcal necrotizing fasciitis.
Publication Types:
PMID: 14742341 [PubMed - indexed for MEDLINE]
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High plasma ropivacaine concentrations after fascia iliaca compartment block in children.
Paut O, Schreiber E, Lacroix F, Meyrieux V, Simon N, Lavrut T, Camboulives J, Bruguerolle B.
Department of Paediatric Anaesthesia, Children CHU Timone Hospital, 13385 Marseille Cedex 5, France. olivier.paut@mail.ap-hm.fr
BACKGROUND: The pharmacokinetic profile of local anaesthetics is influenced by the mode of administration. We sought to compare the pharmacokinetics of two doses of ropivacaine after fascia iliaca compartment (FIC) block in children. METHODS: In this prospective, double-blind study, children received an FIC block as a part of their anaesthetic management during elective orthopaedic surgery on the thigh. They were randomized to receive ropivacaine 0.7 ml x kg(-1) using either a 0.375% or 0.5% solution. Venous blood samples were drawn up to 6 h after injection. Plasma concentrations of ropivacaine were measured by gas-liquid chromatography. RESULTS: Six children (10.2 (range 5-15) yr, 35.6 (sd 10) kg were included. FIC block provided satisfactory peroperative pain relief. No signs of toxicity were observed, but high maximal plasma concentrations (C(max) 4.33-5.6 microg ml(-1)), were observed for three of four patients in the ropivacaine 0.5% group. The two patients in the 0.375% group showed values within the safe range (C(max) 0.66 and 0.98 microg ml(-1) respectively). Even though no toxic effects were observed, these results led us to discontinue the study. CONCLUSIONS: The administration of ropivacaine 3.5 mg x kg(-1) can be associated with sustained high plasma concentrations of ropivacaine, outside the tolerable range. In view of these results, we recommend the use of lower ropivacaine dosage during FIC block in children.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14742340 [PubMed - indexed for MEDLINE]
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Analgesia for day-case shoulder surgery.
Wilson AT, Nicholson E, Burton L, Wild C.
Department of Anaesthesia, Leeds General Infirmary, Great George St, Leeds LS1 3EX, UK. awilson@doctors.org.uk
BACKGROUND: Single-shot nerve blocks provide excellent postoperative analgesia for a limited period and are increasingly used in day-case units. They allow early patient discharge following painful operative procedures that would otherwise require overnight hospitalization. We investigated the adequacy of analgesia at home after the block had worn off. METHODS: A prospective audit by telephone 1 week after surgery of 50 consecutive patients who had had a single-shot interscalene block for day-case shoulder arthroscopic surgery. RESULTS: The mean length of adequate sensory block was 22.5 h (9-48 h) after which 20% of patients had a maximum visual analogue scale (VAS) score of 5/5. Most patients did not take analgesics as prescribed and two patients (5.4%) required additional analgesia from their family doctor or accident and emergency department. CONCLUSIONS: We conclude that analgesia at home is often inadequate after painful day-case surgical procedures if single-shot local anaesthetic blockade is used.
PMID: 14742335 [PubMed - indexed for MEDLINE]
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Double-blind randomized controlled trial of caudal versus intravenous S(+)-ketamine for supplementation of caudal analgesia in children.
Martindale SJ, Dix P, Stoddart PA.
Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK.
BACKGROUND: The postoperative analgesic efficacy of S(+)-ketamine after caudal or i.v. administration following sub-umbilical surgery in children was studied to investigate its principal site of analgesic action. METHODS: Sixty children undergoing caudal block during general anaesthesia for hernia repair or orchidopexy were prospectively randomized to one of three groups: the bupivicaine group received plain bupivacaine 0.25% 1 ml x kg(-1); the caudal ketamine group received caudal plain bupivacaine 0.25% 1 ml x kg(-1) with S(+)-ketamine 0.5 mg x kg(-1); the i.v. ketamine group received caudal plain bupivacaine 0.25% 1 ml x kg(-1) plus S(+)-ketamine 0.5 mg x kg(-1) i.v. Postoperative measurements included analgesic requirements and modified objective pain score for the first 24 h. RESULTS: The median time to first analgesia was significantly longer in the caudal ketamine group (10 h) than in the i.v. ketamine (4.63 h) or bupivacaine (4.75 h) groups (P=0.01). Significantly fewer doses of analgesia were required over the first postoperative 24 h by subjects in the caudal ketamine group (median 1) compared with the i.v. ketamine (median 2) or bupivacaine (median 2.5) groups (P<0.05). There was no difference between the groups in the incidence of postoperative nausea and vomiting or psychomotor reactions. CONCLUSIONS: We have demonstrated that the addition of caudal S(+)-ketamine to bupivacaine prolongs the duration of postoperative analgesia. However, the same dose of i.v. S(+)-ketamine combined with a plain bupivacaine caudal provides no better analgesia than caudal bupivacaine alone, indicating that the principal analgesic effect of caudal S(+)-ketamine results from a local neuroaxial rather than a systemic effect.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14742331 [PubMed - indexed for MEDLINE]
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Minimum alveolar concentration (MAC) of xenon in intubated swine.
Hecker KE, Horn N, Baumert JH, Reyle-Hahn SM, Heussen N, Rossaint R.
Department of Anaesthesiology, Klinikum der RWTH Aachen, Pauwelsstr. 30, D-52074 Aachen, Germany. klaus.hecker@post.rwth-aachen.de
BACKGROUND: The minimum alveolar concentration (MAC) is a traditional index of the hypnotic potency of an inhalational anaesthetic. To investigate the anaesthetic as well as the unwanted effects of xenon (Xe) in a swine model, it is useful to know MAC(Xe). METHODS: The study was performed using ten swine (weight 27.8-35.4 kg) anaesthetized with halothane and Xe 0, 15, 30, 40, 50 and 65% in oxygen. With each Xe concentration, various concentrations of halothane were administered in a step-by-step design. For each combination, a supramaximal pain stimulus (claw clamp) was applied and the appearance of a withdrawal reaction was recorded. The MAC(Xe) with halothane was calculated using a logistic regression model. RESULTS: During stable ventilation, haemodynamics and temperature, MAC(Xe) value was determined as 119 vol. % (95% confidence limits 103-135). CONCLUSION: MAC(Xe) in swine was calculated by extrapolation of a logistic regression model. Its theoretical value is 119 vol. %.
PMID: 14742330 [PubMed - indexed for MEDLINE]
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Suppression of insulin signalling by a synthetic peptide KIFMK suggests the cytoplasmic linker between DIII-S6 and DIV-S1 as a local anaesthetic binding site on the sodium channel.
Hirose M, Kuroda Y, Sawa S, Nakagawa T, Hirata M, Sakaguchi M, Tanaka Y.
Acetyl-KIFMK-amide (KIFMK) restores fast inactivation to mutant sodium channels having a defective inactivation gate. Its binding site with sodium channels could be considered to be the cytoplasmic linker (III-IV linker) connecting domains III and IV of the sodium channel alpha subunit. There is a close resemblance of the amino-acid sequences between the III-IV linker and the activation loop of the insulin receptor (IR). This resemblance of the amino-acid sequences suggests that KIFMK may also modulate insulin signalling. In order to test this assumption, we studied the effects of KIFMK and its related (KIYEK, KIQMK, and DIYET) and unrelated (LPFFD) peptides on tyrosine phosphorylation or dephosphorylation of IR in vitro. Purified IR was phosphorylated in vitro with insulin in the presence of various synthetic peptides and lignocaine. The phosphorylation level of IR was then evaluated after SDS-PAGE separation, followed by Western blot analysis with antiphosphotyrosine antibody. KIFMK and KIYEK inhibited insulin-stimulated autophosphorylation of IR. Lignocaine showed similar effects, but at a higher order of concentration. KIYEK and DIYET, but not KIFMK, dephosphorylated the phosphorylated tyrosine residues. The structurally unrelated peptide LPFFD had no effect either on phosphorylation or dephosphorylation of IR. These results indicate that KIFMK, KIYEK, and lignocaine bind with the autophosphorylation sites of IR. The present findings also suggest that KIFMK and lignocaine bind with the III-IV linker of sodium channel alpha subunit.
PMID: 15037518 [PubMed - as supplied by publisher]
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