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High success rate and low incidence of headache and neurological symptoms with two spinal needle designs in children.
Kokki H, Turunen M, Heikkinen M, Reinikainen M, Laisalmi M.
Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland. Hannu.Kokki@kuh.fi
BACKGROUND: In children, only a few trials have evaluated the use of spinal needles with special tip designs. In this study, we compared the success rate and incidence of post-dural puncture complaints of two small-gauge spinal needle designs used in children undergoing spinal anaesthesia (SA). METHODS: Three hundred and three children aged 9 months to 17 years presenting for subumbilical surgery were randomly assigned to have a 26G Atraucan (n = 156) or 27G Whitacre (n = 147) spinal needle for SA. The number of attempts to obtain successful cerebrospinal fluid (CSF) return and the success rate of SA were recorded. The first week of recovery was recorded by a diary. RESULTS: Both groups had a similar one-attempt success rate: 80% in the Atraucan group and 81% in the Whitacre group. Failure to obtain CSF occurred in one patient in the Atraucan group and in two patients in the Whitacre group. Paraesthesia was observed more commonly in the Whitacre group (10%) than in the Atraucan group (2%) (P = 0.004). The success rate of SA was 96%, with no differences between the two needles; one child was given general anaesthesia and 11 children (3%) a single dose of supplemental analgesia for the skin incision. Forty-one children (15%) developed a headache, 13 of which were classified as post-dural puncture headache (PDPH), seven cases (5%) in the Atraucan group and six (4%) in the Whitacre group; none of the children required a blood patch. Fifteen children (10%) in the Atraucan group and nine (7%) in the Whitacre group developed low back pain. Two children (1%) in the Atraucan group and four (3%) in the Whitacre group developed transient neurological symptoms (TNSs). CONCLUSION: Both needles were associated with a high success rate and a low incidence of complaints.
Publication Types:
PMID: 16146477 [PubMed - indexed for MEDLINE]
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Blood-borne factors possibly associated with post-operative nausea and vomiting: an explorative study in women after breast cancer surgery.
Oddby-Muhrbeck E, Eksborg S, Helander A, Bjellerup P, Lindahl S, Lonnqvist P.
Division of Anaesthesia and Intensive Care, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden. eva.oddby@ds.se
BACKGROUND: The pathophysiology behind post-operative nausea and vomiting (PONV) is still not fully understood, especially with respect to gender. According to PONV risk scores, female gender is the strongest predictor for PONV. The risk for PONV after general anaesthesia for breast cancer surgery is 50-80%. The aim of the present explorative study was to identify blood-borne factors that might be associated with the development of PONV in women undergoing breast cancer surgery as a basis for further studies. METHODS: Fifty patients were enrolled prospectively in the study. A standardized sevoflurane-based anaesthetic was used. Blood samples for the analysis of vasopressin, gastrin, cholecystokinin, epinephrine, norepinephrine, dopamine, serotonin, platelet count and blood glucose were taken at six pre-determined time points peri-operatively, and PONV was assessed during 24 h. RESULTS: PONV was found in 27 of 47 patients completing the study. Patients with PONV had a larger variability of the platelet count (P = 0.001), a reduced platelet count on the first post-operative day (P = 0.02) and a less pronounced relationship between the platelet count and whole blood serotonin (P = 0.004) compared with non-PONV patients. A lack of a decrease in epinephrine levels in response to the induction of anaesthesia (P = 0.03) and increased levels of vasopressin (P < 0.001), epinephrine (P = 0.005) and blood glucose (P = 0.004) were observed in the early post-operative period in PONV patients. CONCLUSION: Three different platelet-associated factors and an altered epinephrine pattern were found to be associated with the occurrence of PONV after breast cancer surgery.
PMID: 16146474 [PubMed - indexed for MEDLINE]
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Is peri-operative cortisol secretion related to post-operative cognitive dysfunction?
Rasmussen LS, O'Brien JT, Silverstein JH, Johnson TW, Siersma VD, Canet J, Jolles J, Hanning CD, Kuipers HM, Abildstrom H, Papaioannou A, Raeder J, Yli-Hankala A, Sneyd JR, Munoz L, Moller JT; ISPOCD2 Investigators.
Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
BACKGROUND: The pattern of cortisol secretion is influenced by surgery. As cortisol can adversely affect neuronal function, this may be an important factor in the development of post-operative cognitive dysfunction (POCD). We hypothesized that the incidence of POCD would be related to changes in cortisol level. METHODS: We studied 187 patients aged over 60 years undergoing major non-cardiac surgery with general or regional anaesthesia. Saliva cortisol levels were measured pre-operatively and at 1 day, 7 days and 3 months post-operatively in the morning (08.00 h) and in the afternoon (16.00 h) using salivettes. Cognitive function was assessed pre-operatively, on day 7 and at 3 months using four neuropsychological tests. POCD was defined as a combined Z score of greater than 1.96. RESULTS: After surgery, salivary cortisol concentrations increased significantly. POCD was detected in 18.8% of subjects at 1 week and in 15.2% after 3 months. The pre-operative ratios between the morning and afternoon cortisol concentrations (am/pm ratios) were 2.8 and 2.7 in patients with POCD at 1 week vs. those without POCD at 1 week, respectively. The am/pm ratios decreased significantly post-operatively to 1.9 and 1.6 at 1 week, respectively (P = 0.02 for both). In an analysis considering all am/pm ratios, it was found that the persistent flattening in am/pm ratio was significantly related to POCD at 1 week. CONCLUSION: The pattern of diurnal variation in cortisol level was significantly related to POCD. Thus, circadian rhythm disturbance or metabolic endocrine stress could be an important mechanism in the development of cognitive dysfunction after major surgery.
Publication Types:
PMID: 16146456 [PubMed - indexed for MEDLINE]
[Levobupivacaine for regional anesthesia A systematic review.]
[Article in German]
Urbanek B, Kapral S.
Klinik fur Anasthesie und Allgemeine Intensivmedizin, Allgemeines Krankenhaus, Medizinische Universitat, Wien.
Levobupivacaine [S(-)bupivacaine], the levorotatory S-enantiomer of racemic bupivacaine, is commercially available in the U.S. and in most European countries. We performed a systematic review (MEDLINE database) and identified 88 articles on the clinical application of levobupivacaine in more than 3,000 patients. The use of levobupivacaine is described for epidural, caudal, and spinal anesthesia, for peripheral nerve blocks, for ophthalmic and dental anesthesia, for different pediatric indications and for intravenous regional anesthesia. In these regional techniques, levobupivacaine was used for all common indications in a wide range of clinical settings. Epidural levobupivacaine was combined with fentanyl, morphine, sufentanil, epinephrine, and clonidine, spinal levobupivacaine was combined with sufentanil, fentanyl, and epinephrine. In most studies, levobupivacaine was compared to bupivacaine and/or ropivacaine.
PMID: 16341730 [PubMed - as supplied by publisher]
Emerging techniques in the management of acute pain: epidural analgesia.
Viscusi ER.
Department of Anesthesiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 19107-5092, USA. eugene.viscusi@jefferson.edu
Epidural analgesia, often using opioids intraoperatively and postoperatively, is widely accepted as a valuable modality for perioperative pain management. In this review I present data from meta-analyses and recently published trials that evaluate the perioperative use of opioids administered epidurally or parenterally (as-needed or by patient-controlled analgesia) and their effect on outcome. Published effects of perioperative epidural techniques on cardiac and pulmonary function are reviewed. Clinical and practical issues associated with epidural anesthesia and analgesia include the existence of analgesic gaps (often related to technical difficulties with the pump or use of an indwelling catheter), the occurrence of hypotension, and compatibility with anticoagulation therapy. A new treatment option, a single epidural injection of morphine for continuous perioperative analgesia (DepoDur; Endo Pharmaceuticals Inc, Chadds Ford, PA), may reduce some of these problems. Data from recent clinical studies are presented.
Publication Types:
PMID: 16334490 [PubMed - indexed for MEDLINE]
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Subdural hematoma following accidental dural puncture.
Cohen S, Shorshtein A, Blanchfield P.
Publication Types:
PMID: 16244048 [PubMed - indexed for MEDLINE]
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Comment on:
Supplementation of intrathecal bupivacaine with clonidine in ex-premature neonates.
Aouad MT, Hajj RE.
Publication Types:
PMID: 16244041 [PubMed - indexed for MEDLINE]
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Continuous maxillary and mandibular nerve block for perioperative pain relief: the excision of a complicated pleomorphic adenoma.
Kumar A, Banerjee A.
Department of Anaesthesiology and Critical Care, UCMS and GTB Hospital, Delhi, India. prof_ashok@rediffmail.com
A 68-yr-old hypertensive patient with ischemic heart disease and intractable atrial fibrillation with stable hemodynamics and poor chest compliance underwent pleomorphic adenoma of the parotid gland using regional anesthesia with continuous propofol sedation. Continuous maxillary and mandibular nerve blocks were performed and excision was performed with complete intraoperative and postoperative pain relief without compromising the patient's hemodynamic variables.
Publication Types:
PMID: 16244026 [PubMed - indexed for MEDLINE]
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An in vitro comparison of the electrical conducting properties of multiport versus single-port epidural catheters for the epidural stimulation test.
Tsui BC, Sze CK.
Department of Anesthesiology and Pain Medicine, 8-120 Clinical Sciences Building, University of Alberta, Edmonton, Alberta, Canada T6G 2G3. btsui@ualberta.ca
Effective conduction of electricity through a catheter is essential for the success of the epidural stimulation test. In this in vitro study we examined the electrical conductivity of single and multiport epidural catheters (with and without embedded metal elements) after being primed with normal saline. Seven different types of 19-gauge catheters (n = 5), either single-port or multiport catheters, with or without embedded metal elements, were studied. The proximal end of each epidural catheter was connected to the cathode of a nerve stimulator via an electrode adapter. The catheter, primed with normal saline, was placed at the bottom of a syringe filled with 5 different volumes of saline (1, 2, 3, 4 and 5 mL) and attached to an electrode adapter. The voltage of the peripheral nerve stimulator was measured using an oscilloscope. The electrical resistance between the proximal and distal end of the catheter was calculated using Ohm's Law. In catheters without metal elements the electrical resistances were too high to be measured. In catheters that had metal elements, the mean electrical resistances of the same catheter design (single-port or multiport) were similar. However, the electrical resistances of the multiport metal reinforced epidural catheters were significantly lower (P < 0.05) than the single-port metal coil reinforced epidural catheters. The volume of saline in the syringe had no impact on the measured electrical resistances. This study suggests that multiport metal reinforced epidural catheters have low electrical resistances and, thus, are a reasonable alternative to single-port catheters for transmitting sufficient current for performing the epidural stimulation test. On the other hand, epidural catheters without metal elements (single-port or multiport) are not suitable for performing the stimulation test.
PMID: 16244025 [PubMed - indexed for MEDLINE]
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Intraarticular bupivacaine-clonidine-morphine versus femoral-sciatic nerve block in pediatric patients undergoing anterior cruciate ligament reconstruction.
Tran KM, Ganley TJ, Wells L, Ganesh A, Minger KI, Cucchiaro G.
Children's Hospital of Philadelphia, Room, 9th Floor, 34th St. and Civic Center Blvd., Philadelphia, PA 19104, USA.
We hypothesized that combined femoral-sciatic nerve block (FSNB) offers better analgesia with fewer side effects than intraarticular infiltration (IA) in children undergoing anterior cruciate ligament (ACL) reconstruction. Thirty-six children undergoing ACL reconstruction were randomized to FSNB or IA. FSNB patients had FSNB with bupivacaine (0.125%)-clonidine (2 microg/kg), whereas IA patients received bupivacaine (0.25%)-clonidine (1 microg/kg)-morphine (5 mg). Postoperatively, analgesia was provided with patient-controlled analgesia and rescue morphine. Patient demographics were similar. FSNB patients required less intraoperative fentanyl (50 +/- 40 microg versus 80 +/- 50 microg; P = 0.04). Visual analog scale score for FSNB was smaller than IA in the recovery room (1.8 +/- 3 versus 5.4 +/- 3; P = 0.0002) and during the first 24 h (1.6 +/- 1 versus 2.9 +/- 2; P = 0.01)). FSNB morphine use in the first 18 h was less (7 +/- 13 mg versus 21 +/- 21 mg; P = 0.03). Fewer FSNB patients vomited (11% versus 50%; P = 0.03). IA patients required morphine patient-controlled analgesia sooner. After ACL reconstruction in children, FSNB with bupivacaine-clonidine provides better analgesia with fewer side effects than IA with bupivacaine-clonidine-morphine.
Publication Types:
PMID: 16243985 [PubMed - indexed for MEDLINE]
Comment on:
Why does prophylactic epidural blood patch fail to demonstrate efficacy in preventing post-dural puncture headache in parturients after dural puncture?
Pruszkowski O, Goncalves O, Lentschener C, Mignon A.
Publication Types:
PMID: 16192788 [PubMed - indexed for MEDLINE]
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Arterial and venous pharmacokinetics of ropivacaine with and without epinephrine after thoracic paravertebral block.
Karmakar MK, Ho AM, Law BK, Wong AS, Shafer SL, Gin T.
Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital. karmakar@cuhk.edu
BACKGROUND: Animal and volunteer studies indicate that ropivacaine is associated with less neurologic and cardiac toxicity than bupivacaine. Ropivacaine may offer advantages when used for thoracic paravertebral block. This study was designed to describe the pharmacokinetics of ropivacaine after thoracic paravertebral block. METHODS: Twenty female patients undergoing elective unilateral breast surgery were randomly assigned to receive a single bolus thoracic paravertebral injection of 2 mg/kg ropivacaine, with or without 5 mug/ml epinephrine. Simultaneous arterial and venous blood samples were obtained for plasma ropivacaine assay. Data were analyzed with NONMEM, using two possible absorption models: conventional first-order absorption and absorption following the inverse gaussian density function. RESULTS: Epinephrine reduced the peak plasma concentrations and delayed the time of peak concentration of ropivacaine in both the arterial and venous blood. The time course of drug input into the systemic circulation was best described by two inverse gaussian density functions. The median bioavailability of the rapid component was approximately 20% higher when epinephrine was not used. The mean absorption times were 7.8 min for the rapid absorption phase and 697 min for the slow absorption phase, with wide dispersion of the absorption function for the acute phase. The half-time of arterial-venous equilibration was 1.5 min. CONCLUSION: The absorption of ropivacaine after thoracic paravertebral block is described by rapid and slow absorption phases. The rapid phase approximates the speed of intravenous administration and accounts for nearly half of ropivacaine absorption. The addition of 5 mug/ml epinephrine to ropivacaine significantly delays its systemic absorption and reduces the peak plasma concentration.
Publication Types:
PMID: 16192762 [PubMed - indexed for MEDLINE]
Comment on:
[Beware of the residual curarization!]
[Article in French]
Baillard C.
Publication Types:
PMID: 16099133 [PubMed - indexed for MEDLINE]
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[Premixed 50% nitrous oxide and oxygen: theoretical recalls and practical modalities]
[Article in French]
Boulland P, Favier JC, Villevieille T, Allanic L, Plancade D, Nadaud J, Ruttimann M.
Departement d'anesthesie-reanimation-urgences, hopital d'instruction-des-armees-Legouest, 57998 Metz Armees, France. pascalboulland@wanadoo.fr
The concept of premixed 50% nitrous oxide and oxygen dated back to 1961 in England, where it is commercialised under the name Entonox. In France, after a so marginal use, premixed 50% nitrous oxide and oxygen now knows such a revival since we first consider the pain provoked by the cure. To use correctly premixed 50% nitrous oxide and oxygen, we need to know the main properties of the nitrous oxide. The four commercial versions, now on the market, are presented (Kalinox, Medimix, Antasol, Oxynox. Except a few contraindications, these indications are large, as well at hospital as outside. In less than 10% of the cases, side effects are possible. Conditions of administration are given in details. The limits of the technic and the particular precautions of use are precised.
Publication Types:
PMID: 16099128 [PubMed - indexed for MEDLINE]
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[Clinical evaluation of the single use Laryngeal Tube in adults: the LTD]
[Article in French]
Richebe P, Verdonck O, Biais M, Breton Y, Cros AM, Maurette P.
Departement d'anesthesie et reanimation III, CHU de Bordeaux, hopital Saint-Andre, 33075 Bordeaux, France. philippe.richebe@u-bordeaux2.fr
OBJECTIVES: The Laryngeal Tube (LT) is a supra-laryngeal device indicated to manage upper airway during anaesthesia. Leak pressures were lately reported higher for the LT as compared to the LMA. A recent study found a small amount of proteinaceous material on LMA after classical sterilization suggesting a risk of contamination by unconventional transmissible agents (prions). The aim of this study was to evaluate the effectiveness of the single use Laryngeal Tube: the LTD. STUDY DESIGN: Prospective study realized after ethical committee agreement and patient consent for participation. PATIENTS ET METHODS: Adults, ASA score< or =3, 18 to 75-year-old, without upper airway abnormality or difficult intubation criteria, anaesthesia< or =2 h, free access to patient's head and LTD. The following criteria were evaluated: easiness of insertion, assisted (AV), controlled (CV) and spontaneous ventilation (SV); leak pressure (LP) 5 and 15 min after insertion; complications during anaesthesia conducted with propofol and remifentanil under bispectral index monitoring. RESULTS: 55 patients were included; only one failure was reported at insertion. AV and CV were easy, SV difficult in 4 patients with chin lift necessary for adequate ventilation. LP was 28.92+/-8.4 and 30.87+/-8.68 cmH2O 5 and 15 min after insertion respectively. No major incident was noticed throughout the study. CONCLUSION: the use of the LTD was easy and successful. Moreover the LTD totally excluded the risk of contamination by unconventional transmissible agents.
Publication Types:
PMID: 16006089 [PubMed - indexed for MEDLINE]
I can fly light aircraft, therefore I can anaesthetise?
Pledger G.
Publication Types:
PMID: 16357003 [PubMed - indexed for MEDLINE]
Comment on:
Re: Iohom G, Fitzgerald D, Cunningham AJ. Principles of pharmacogenetics--implications for the anaesthetist. Br J Anaesth 2004; 93: 440-50.
Iohom G, Fitzgerald D, Cunningham AJ.
Publication Types:
PMID: 16342366 [PubMed - indexed for MEDLINE]
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Intra-articular injection of warmed lidocaine improves intraoperative anaesthetic and postoperative analgesic conditions.
Arai YC, Ikeuchi M, Fukunaga K, Ueda W, Kimura T, Komatsu T.
Department of Anaesthesiology, Kochi Medical School, Department of Orthopaedics, Kochi Medical School and Department of Anaesthesiology, Clinical Physiology and Pharmacology, School of Nursing, Kochi Medical School, Oko-Cho, Nankoku City, Kochi, Japan.
BACKGROUND: Although local anaesthesia for knee arthroscopy is a well-documented procedure, arthroscopy under local anaesthesia is often interrupted because of intolerable discomfort and pain. Warming local anaesthetic solutions may increase its anaesthetic effect. We tested whether intra-articular injection of warmed lidocaine solution could improve intraoperative anaesthetic and postoperative analgesic conditions. METHODS: Patients in the warmed group received 20 ml warmed (40 degrees C) lidocaine 1% intra-articularly 20 min before surgery. The patients in the control group received 20 ml room-temperature (25 degrees C) lidocaine 1% intra-articularly 20 min before surgery. During surgery, the patients reported pain on a visual analogue scale (VAS). RESULTS: The median VAS pain score was 1.5 (range, 0.0-3.0) in the warmed lidocaine group and 5.0 (4.0-8.0) in the control group (P<0.001). The median intra- and postoperative analgesic requirements in the control group were significantly greater than that in the warmed group. CONCLUSION: Warmed lidocaine injected intra-articularly provides improved intraoperative anaesthetic and postoperative analgesic conditions for patients undergoing knee arthroscopy.
PMID: 16339791 [PubMed - in process]
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Comment on:
Regional cerebral oximetry after oxygen administration.
Baraka AS, Nawfal M, El-Khatib M, Haroun-Bizri S.
Publication Types:
PMID: 16215266 [PubMed - indexed for MEDLINE]
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Tracheal intubating conditions and apnoea time after small-dose succinylcholine are not modified by the choice of induction agent.
El-Orbany MI, Joseph NJ, Salem MR.
Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA. mohammad.el-orbany-md@advocatehealth.com
BACKGROUND: In a randomized, double-blind clinical trial, we studied the effect of different i.v. induction drugs on tracheal intubation conditions and apnoea time after small-dose (0.6 mg kg(-1)) succinylcholine used to facilitate orotracheal intubation at an urban, university-affiliated community medical centre. METHODS: One hundred and seventy-five ASA I and II adult patients scheduled to undergo surgical procedures requiring general anaesthesia and tracheal intubation were allocated to one of five groups according to i.v. anaesthetic induction drug used. General anaesthesia was induced by i.v. administration of lidocaine 30 mg and propofol 2.5 mg kg(-1) (Group 1), thiopental 5 mg kg(-1) (Group 2), lidocaine 30 mg and thiopental 5 mg kg(-1) (Group 3), etomidate 0.3 mg kg(-1) (Group 4), or lidocaine 30 mg and etomidate 0.3 mg kg(-1) (Group 5). After loss of consciousness, succinylcholine 0.6 mg kg(-1) was given i.v. followed by direct laryngoscopy and tracheal intubation after 60 s. Measurements included intubation conditions recorded during laryngoscopy 60 s after succinylcholine administration, and apnoea time. RESULTS: Overall, clinically acceptable intubation conditions were met in 168 out of the 175 patients studied (96%). They were met in 35/35 patients in Group 1, 33/35 patients in Group 2, 34/35 patients in Group 3, 33/35 patients in Group 4, and 33/35 patients in Group 5. Mean (SD) apnoea time was 4.0 (0.4), 4.2 (0.3), 4.2 (0.6), 4.1 (0.2) and 4.1 (0.2) min respectively in Groups 1-5. There were no differences in the intubation conditions or apnoea times between the groups. CONCLUSIONS: The use of succinylcholine 0.6 mg kg(-1) produced the same favourable intubation conditions and a short apnoea time regardless of the induction drug used.
Publication Types:
PMID: 16169891 [PubMed - indexed for MEDLINE]
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Effects of stellate ganglion block on cerebral haemodynamics as assessed by transcranial Doppler ultrasonography.
Gupta MM, Bithal PK, Dash HH, Chaturvedi A, Mahajan RP.
Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India.
BACKGROUND: Stellate ganglion block (SGB) causes vasodilatation in the skin of the head and neck because of regional sympathetic block. Its effects on cerebral haemodynamics, in health or in disease, are not clear. We evaluated the effects of SGB on ipsilateral middle cerebral artery flow velocity (MCAFV), estimated cerebral perfusion pressure (eCPP), zero flow pressure (ZFP), carbon dioxide reactivity (CO2R) and cerebral autoregulation using transcranial Doppler ultrasonography (TCD). METHODS: Twenty male patients, with pre-existing brachial plexus injury, and undergoing SGB for the treatment of complex regional pain syndrome of the upper limb, were studied. For SGB, 10 ml of plain lidocaine 2% was used and the onset of block was confirmed by presence of ipsilateral Horner's syndrome. The MCAFV, eCPP, ZFP, CO2R, and cerebral autoregulation were assessed before and after SGB using established TCD methods. The changes in these variables were analysed using Wilcoxon's signed rank test. RESULTS: The block caused a significant decrease in MCAFV from median (inter-quartile range) value of 61 (53, 67) to 55 (46, 60) cm s(-1), a significant increase in eCPP from 59 (51, 67) to 70 (60, 78) mm Hg, and a significant decrease in ZFP from 32 (26, 39) to 25 (16, 30) mm Hg. There were no significant changes in CO2R or cerebral autoregulation. CONCLUSION: The increase in eCPP, decrease in ZFP, and no changes in CO2R or cerebral autoregulation suggest that the SGB decreases cerebral vascular tone without affecting the capacity of the vessels to autoregulate. These effects may be of therapeutic advantage in relieving cerebral vasospasm in certain clinical settings.
PMID: 16155036 [PubMed - indexed for MEDLINE]
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Landmarks of the sacral hiatus for caudal epidural block: an anatomical study.
Senoglu N, Senoglu M, Oksuz H, Gumusalan Y, Yuksel KZ, Zencirci B, Ezberci M, Kizilkanat E.
Department of Anesthesiology, KSU Medical School, 46050 Kahramanmaras, Turkey. nimetsenoglu@hotmail.com
BACKGROUND: This study determined the landmarks for caudal epidural block (CEB) after morphometric measurements of the sacral hiatus on dry sacral bones. Anatomical features of the sacral hiatus of clinical importance during CEB, along with distances and angles of use in detecting the apex, were measured. This provides detailed knowledge of the anatomy of the sacral hiatus and practical landmarks. METHODS: Ninety-six dry sacral bones were used. Anatomical measurements were made with a Vernier caliper accurate to 0.1 mm. RESULTS: Two sacral bones were excluded since they had total posterior closure defect. Agenesis of the sacral hiatus was detected in six sacral bones. As the posterior superior iliac spines impose on the superolateral sacral crests of the sacrum, the latter were accepted as forming the base of a triangle. The distance between the two superolateral sacral crests and the distances between the sacral apex and the right and left superolateral sacral crest were 66.5 (SD 53.5), 67.1 (10.0) and 67.5 (9.5) mm respectively, on average. CONCLUSION: The triangle formed between the apex of the sacral hiatus and the superolateral sacral crests was found to have the features of an equilateral triangle. The sacrum and sacral hiatus are variable anatomical structures. However, the equilateral triangle located between the apex of the sacral hiatus and superolateral sacral crests will certainly be of use in determining the location of the sacral hiatus during CEB.
PMID: 16155035 [PubMed - indexed for MEDLINE]
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Intubating laryngeal mask for airway management in lateral decubitus state: comparative study of right and left lateral positions.
Biswas BK, Agarwal B, Bhattacharyya P, Badhani UK, Bhattarai B.
Department of Anaesthesia and Critical Care, B.P. Koirala Institute of Health Sciences, Dharan-18, Nepal. binsaiims@sify.com
BACKGROUND: The intubating laryngeal mask has been used for the emergency management of the airway in patients placed in the lateral decubitus position. We have conducted this prospective study to compare the feasibility of placement of an intubating laryngeal mask and blind tracheal intubation guided by the intubating laryngeal mask in patients placed in the right and the left lateral positions. METHODS: A total of 82 adults of both sexes with normal airways, scheduled for cholecystectomy, were allocated randomly to be placed in either the right (n=41) or left (n=41) lateral position for the insertion of an intubating laryngeal mask and blind tracheal intubation guided by the intubating laryngeal mask under balanced general anaesthesia. A sequence of standard manoeuvres was performed after each failed attempt at intubating laryngeal mask placement and intubation. RESULTS: The intubating laryngeal mask was placed in all patients at the first attempt. Ventilation of the lungs through the intubating laryngeal mask was possible in 40 patients (97.5%) from each group after the first attempt at insertion (P=1). Following adjustments, adequate ventilation could be achieved in all patients. The first attempt success rates of blind tracheal intubation were 85.3% (35/41) and 87.8% (36/41) in the right and left lateral groups, respectively (P=1). The remaining patients from both groups (except for one patient in the left lateral group who had a failed intubation) were intubated at the second attempt. CONCLUSION: Insertion of the intubating laryngeal mask and blind tracheal intubation through it in the lateral position is feasible in patients with normal airways. These procedures have a high and comparable success rate when patients are placed in the right and left lateral positions.
Publication Types:
PMID: 16143578 [PubMed - indexed for MEDLINE]
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Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea.
Altermatt FR, Munoz HR, Delfino AE, Cortinez LI.
Departamento de Anestesiologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Chile. falterma@med.puc.cl
BACKGROUND: In obese patients, reduced functional residual capacity exacerbated by supine position might decrease the effectiveness of pre-oxygenation and the tolerance to apnoea. The aim of this study was to compare the effect of body posture during pre-oxygenation, sitting or supine, on its effectiveness in obese patients. METHODS: Forty obese patients (BMI > or =35 kg m(-2)) undergoing surgery with general anaesthesia were randomly assigned to one of two groups: Group 1 (sitting, n=20) or Group 2 (supine, n=20). In the predetermined body position, pre-oxygenation was achieved with eight deep breaths within 60 s and an oxygen flow of 10 litre min(-1). After rapid sequence induction of anaesthesia in decubitus position, the trachea was intubated and the patient was left apneic and disconnected from the anaesthesia circuit until Sp(o2) decreased to 90%. The time taken for desaturation to 90% from the end of induction of anaesthesia was recorded. Arterial blood oxygen tension was measured before (baseline) and after pre-oxygenation. Values were compared with two-way anova and unpaired Student's t-test. RESULTS: Oxygen and carbon dioxide tensions were similar between groups, both at baseline and after pre-oxygenation. However, the mean time to desaturation to 90% was significantly longer in the sitting group compared with the supine group [mean (SD): 214 (28) vs 162 (38) s, P<0.05]. CONCLUSIONS: Pre-oxygenation in sitting position significantly extends the tolerance to apnoea in obese patients when compared with the supine position.
Publication Types:
PMID: 16143575 [PubMed - indexed for MEDLINE]
Comment on:
Neuraxial blockade and patient risk.
Egan BJ, Brown AR.
Publication Types:
PMID: 16211784 [PubMed - indexed for MEDLINE]
Comment on:
Neuraxial blockade and patient risk.
Hunter D.
Publication Types:
PMID: 16211758 [PubMed - indexed for MEDLINE]
Which is responsible for the haemodynamic response due to laryngoscopy and endotracheal intubation? Catecholamines, vasopressin or angiotensin?
Kayhan Z, Aldemir D, Mutlu H, Ogus E.
Baskent University, Faculty of Medicine, Department of Anaesthesiology, Ankara, Turkey. zeynepk@baskent-ank.edu.tr
BACKGROUND AND OBJECTIVE: We have investigated the concentrations of epinephrine, norepinephrine, vasopressin and angiotensin converting enzyme activity to explore the role of these mediators in the neuroendocrine response to laryngoscopy and tracheal intubation. METHODS: One hundred (50 male, 50 female) ASA I patients aged 20-50 yr (mean+/-SEM; 35.59+/-0.99) were included in the study. They were undergoing elective surgery under standard anaesthesia induction and maintenance using tracheal intubation. Plasma concentrations of epinephrine, norepinephrine and vasopressin as well as plasma angiotensin converting enzyme activity were determined at four time points, before (T1) and after (T2) induction, and 2 (T3) and 5 min (T4) after intubation. Blood pressure and heart rate were recorded at corresponding times to reveal if any correlation existed between haemodynamic parameters and neuroendocrine response. RESULTS: Heart rate increased after induction and intubation (P<0.05) and decreased significantly at T4 (P<0.05). Systolic blood pressure decreased significantly (P<0.05) after induction and increased slightly after intubation decreasing to below baseline value (P<0.05) at T4. Diastolic blood pressure increased slightly after intubation and decreased significantly (P<0.05) at T4. Plasma epinephrine and norepinephrine concentrations decreased after induction and increased at T3 and T4 without reaching significance. Vasopressin concentrations increased slightly at T2 and T3 and decreased significantly at T4 (P<0.05). Angiotensin converting enzyme activity was unaffected when compared with baseline values. CONCLUSIONS: Blood pressure, heart rate, plasma epinephrine, norepinephrine and vasopressin concentrations increased slightly in response to laryngoscopy and intubation, all returning to or below baseline 5 min later with no change in angiotensin converting enzyme activity in normotensive patients.
PMID: 16211744 [PubMed - indexed for MEDLINE]
Comparision of etomidate and propofol for fibreoptic intubation as part of an airway management algorithm:a prospective, randomizes, double-blind study.
Schaeuble J, Heidegger T, Gerig HJ, Ulrich B, Schnider TW.
Cantonal Hospital, Department of Anaesthesiology, St. Gallen, Switzerland. thomas.heidegger@kssg.ch
BACKGROUND AND OBJECTIVE: In our algorithm for management of the anticipated difficult airway the induction agent (etomidate) is administered after the tip of the fibreoptic is placed in the trachea but before the tube is advanced over it. In a previous investigation we demonstrated the safety of this method. Due to its popularity as an induction agent, some would like to replace etomidate with propofol. However, because rapid recovery of spontaneous breathing is crucial with this technique, substitution might not be advisable. We compared the speed of recovery of spontaneous breathing after fibreoptic intubation between etomidate and propofol. METHODS: In this prospective, randomized, double-blind study we used either 0.2 mg kg[-1] etomidate or 2 mg kg[-1] propofol for induction. Our technique of nasotracheal fibreoptic intubation consists of using fentanyl, cocaine instillation into the lower nasal canals, cricothyroid injection of lidocaine, performing bronchoscopy, administration of etomidate and advancing the tube after loss of consciousness. We measured time to loss of consciousness, time to recovery of spontaneous breathing, lowest bi-spectral index value and time to lowest value. RESULTS: Time to loss of consciousness did not differ. The time to recovery of spontaneous breathing differed significantly: the median time (interquartile range [range]) for etomidate was 81 s (62--102 [0--166]), and for propofol 146 s (95--260 [65--315]); P=0.001. The lowest bi-spectral index values were not different. The time of the lowest bi-spectral index values differed significantly: for etomidate 58 s (51--68 [38--100]), and for propofol 90 s (52--125 [38--172]); P=0.015. CONCLUSION: For nasotracheal fibreoptic intubation, where the tube is advanced after induction of anaesthesia, we still recommend etomidate because spontaneous breathing recovers faster than with propofol.
Publication Types:
PMID: 16211735 [PubMed - indexed for MEDLINE]
Multiple-trauma management: standardized evaluation of the subjective experience of involved team members.
Gross T, Amsler F, Ummenhofer W, Zuercher M, Jacob AL, Messmer P, Huegli RW.
University Hospital, Department of Surgery, Trauma Unit, Basel, Switzerland. tgross@uhbs.ch
BACKGROUND AND OBJECTIVE: Staff attitude plays a pivotal role in quality management. The objective of the present study was to further define how interdisciplinary emergency hospital staff experience their daily work and the extent to which the professional speciality and training of an individual influences his/her assessment of multiple-trauma team performance. METHODS: The clinical staff involved in multiple-trauma emergency management of a university hospital was asked to answer a confidential questionnaire. Factorial analysis was used to identify 8 major dimensions from a total of 53 items. RESULTs: The questionnaire was returned by 128 team members. All professional groups were most dissatisfied with the dimensions 'education and training', 'work sequence between specialities' and 'communication between specialities'. Assessment of the quality of in-hospital emergency-trauma management differed significantly between professional specialities (ANOVA, F=5.2; P=0.028); surgeons gave the highest ratings for all but one dimension. Having taken an Advanced Trauma Life Support (ATLS) course influenced significantly the total rating of multiple-trauma treatments of anaesthetists and surgeons (F=5.5; P=0.024). CONCLUSIONS: The perceptions of interdisciplinary trauma team members without the completion of an ATLS training course were that they did not communicate enough with each other and that there were differences between their expectations and reality. The differences and the communication deficits were overcome in team members who had passed an ATLS course.
PMID: 16211733 [PubMed - indexed for MEDLINE]
Intubation conditions after rocuronium or succinylcholine for rapid sequence induction with alfentanil and propofol in the emergency patient.
Larsen PB, Hansen EG, Jacobsen LS, Wiis J, Holst P, Rottensten H, Siddiqui R, Wittrup H, Sorensen AM, Persson S, Engbaek J.
University of Copenhagen, Department of Anaesthesiology, Herlev Hospital, Glostrup, Denmark. pebola01@herlevhosp.kbhamt.dk
Background and objective: Previous studies mainly conducted on elective patients recommend doses of 0.9-1.2 mg kg[-1] rocuronium to obtain comparable intubation conditions with succinylcholine 1.0 mg kg[-1] after 60 s during a rapid-sequence induction. We decided to compare the overall intubating conditions of standard doses of rocuronium 0.6 mg kg[-1] and succinylcholine 1.0 mg kg[-1] during a strict rapid-sequence induction regimen including propofol and alfentanil. Methods: Male and female patients (ASA I-III) older than 17 yr scheduled for emergency abdominal or gynaecological surgery and with increased risk of pulmonary aspiration of gastric content were randomized to a rapid-sequence induction with succinylcholine 1.0 mg kg[-1] or rocuronium 0.6 mg kg[-1]. Patients with a predicted difficult airway were excluded. A senior anaesthesiologist 'blinded' for the randomization performed the intubation 60 s after injection of the neuromuscular blocker. Intubating conditions were evaluated according to an established guideline. Tracheal intubation not completed within 30 s was recorded as failed. Results: 222 patients were randomized. Three patients had their operation cancelled and 10 did not fulfil the inclusion criteria. Clinically acceptable intubation conditions were present in 93.5% and 96.1% of patients in the succinylcholine group (n=107) and the rocuronium group (n=102), respectively (P=0.59). Conclusions: During a rapid-sequence induction with alfentanil and propofol, both rocuronium 0.6 mg kg[-1] and succinylcholine 1.0 mg kg[-1] provide clinically acceptable intubation conditions in 60 s in patients scheduled for emergency surgery. Under the conditions of this rapid-sequence induction regimen rocuronium may be a substitute for succinylcholine.
Publication Types:
PMID: 16211732 [PubMed - indexed for MEDLINE]
Negotiating ethics in anaethesia.
Tannsjo T.
Publication Types:
PMID: 16211730 [PubMed - indexed for MEDLINE]
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An infrequent case of fire in the operating room during open surgery of a tracheobronchopleural fistula.
Errando CL, Garcia-Covisa N, Del-Rosario E, Peiro CM.
Publication Types:
PMID: 16085269 [PubMed - indexed for MEDLINE]
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Xenon and the inflammatory response to cardiopulmonary bypass in the rat.
Clark JA, Ma D, Homi HM, Maze M, Grocott HP.
Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
OBJECTIVE: The purpose of this study was to investigate the effect of xenon on the inflammatory response to cardiopulmonary bypass. DESIGN: Prospective, randomized experimental study. SETTING: University research laboratory. PARTICIPANTS: Sprague-Dawley rats. INTERVENTIONS: After surgical preparation, rats were randomly divided into 4 groups: (1) SHAM rats were cannulated but did not undergo cardiopulmonary bypass; (2) cardiopulmonary bypass rats were subjected to 60 minutes of cardiopulmonary bypass using an oxygenator receiving a 30% O(2), 65% N(2), and 5% CO(2) gas mixture; (3) MK801 rats received MK801 (0.15 mg/kg intravenous) 15 minutes before 60 minutes of cardiopulmonary bypass with the same gas mixture; and (4) xenon rats underwent 60 minutes of cardiopulmonary bypass receiving a 30% O(2), 60% xenon, 5% N(2), and 5% CO(2) gas mixture. MEASUREMENTS AND MAIN RESULTS: All bypass groups showed elevations in both cytokines compared with the SHAM-operated group. However, the inflammatory response to cardiopulmonary bypass in the group receiving xenon was no different from the other bypass groups. CONCLUSIONS: Xenon appears to have no effect on the inflammatory response to cardiopulmonary bypass, making its previously described neuroprotective effect during cardiopulmonary bypass likely independent of any inflammation modulation.
PMID: 16085255 [PubMed - indexed for MEDLINE]
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Monitoring oxygenator expiratory isoflurane concentrations and the bispectral index to guide isoflurane requirements during cardiopulmonary bypass.
Liu EH, Dhara SS.
Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, 119074 Singapore. analiue@nus.edu.sg
OBJECTIVE: The purpose of this study was to measure the changes in isoflurane requirements during the rewarming phase of cardiopulmonary bypass with moderate hypothermia. DESIGN: An observational study. SETTING: University hospital, single center. PARTICIPANTS: Forty patients undergoing elective coronary artery bypass surgery with cardiopulmonary bypass. INTERVENTIONS: Isoflurane requirements were quantified by measuring the concentrations in the oxygenator expiratory gas. Anesthesia was guided by bispectral index monitoring. MEASUREMENTS AND MAIN RESULTS: Isoflurane concentrations required to maintain the bispectral index between 40 and 50 during the rewarming phase of cardiopulmonary bypass were measured. There was a progressive increase in expiratory isoflurane requirements during rewarming from 30 degrees C to 37 degrees C, with a Pearson correlation coefficient of 0.78. There was a significant difference in the concentration required at 30 degrees C (0.41% +/- 0.14%) compared with 37 degrees C (1.00% +/- 0.12%). CONCLUSION: Isoflurane requirements are reduced during hypothermic cardiopulmonary bypass. Monitoring anesthetic concentrations in the oxygenator expiratory gas may be a useful adjunct to monitoring the depth of anesthesia.
PMID: 16085254 [PubMed - indexed for MEDLINE]
The effect of preemptive pudendal nerve blockade on pain after transvaginal pelvic reconstructive surgery.
Abramov Y, Sand PK, Gandhi S, Botros SM, Miller JJ, Koh EK, Goldberg RP.
Division of Urogynecology, Evanston Continence Center, and Division of Anesthesia, Northwestern University Feinberg School of Medicine, Evanston, Illinois 60201, USA. y-abramov@northwestern.edu
OBJECTIVE: To assess the effect of preemptive pudendal nerve blockade on pain and consumption of narcotic analgesia following transvaginal pelvic reconstructive surgery. METHODS: This was a randomized, double-blind, placebo-controlled trial. Patients undergoing transvaginal pelvic reconstructive surgery under general anesthesia were randomized to receive pudendal block with either bupivacaine 0.25% or placebo (normal saline 0.9%) immediately before surgery. All patients received postoperative intravenous hydromorphone patient-controlled analgesia. Patients were asked to report on their pain intensity 1, 3, 5, 7, 18, and 24 hours postoperatively, using a validated visual analog pain scale from 0-10. Main outcome measures included postoperative pain intensity and hydromorphone consumption. RESULTS: One hundred ten patients enrolled in the study, of whom 106 underwent randomization, and 102 received pudendal nerve blockade, 51 with bupivacaine and 51 with saline. Demographic and baseline clinical characteristics were not significantly different between the 2 patients groups. There were no significant differences in postoperative pain intensity (median scores: 1 hour, 4.0 versus 5.0; 3 hours, 3.0 versus 4.0; 7 hours, 2.0 versus 3.0; 18 hours, 3.0 versus 4.0), the consumption of hydromorphone (0-3 hours, 1.84 mg versus 1.77 mg; 4-7 hours, 1.19 mg versus 1.20 mg; 8-18 hours, 2.89 mg versus 2.35 mg), or mean hospital stay (39.6 versus 37.3 hours) between the bupivacaine and saline groups. CONCLUSION: Preemptive pudendal nerve blockade does not affect postoperative pain intensity or the consumption of narcotic analgesia after transvaginal pelvic reconstructive surgery.
Publication Types:
PMID: 16199636 [PubMed - indexed for MEDLINE]
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Evidence for the innervation of pelvic floor muscles by the pudendal nerve.
Guaderrama NM, Liu J, Nager CW, Pretorius DH, Sheean G, Kassab G, Mittal RK.
Departments of Reproductive Medicine, Internal Medicine, Radiology, and Neurology, The Pelvic Floor Function and Disorder Group, University of California, San Diego, San Diego, California 92161, USA.
OBJECTIVE: To evaluate whether the pudendal nerve innervates the levator ani muscles by assessing the effect of pudendal nerve blockade on pelvic floor muscle function. METHODS: Eleven nulliparous women without symptoms of anal or urinary incontinence were studied before and after pudendal nerve blockade with vaginal manometry, electromyography of the external anal sphincter and puborectalis muscle, and 3-dimensional transperineal ultrasound imaging of the urogenital hiatus during rest and squeeze. RESULTS: After pudendal nerve blockade, mean vaginal resting pressures decreased from 19 +/- 10 mm Hg to 15 +/- 10 mm Hg (P < .05), and mean vaginal squeeze pressures decreased from 61 +/- 29 mm Hg to 37 +/- 24 mm Hg (P < .05). After pudendal nerve blockade, the anterior-posterior length of the urogenital hiatus increased from 51 +/- 4 mm to 55 +/- 5 mm at rest (P < .05) and increased from 47 +/- 3 mm to 52 +/- 5 mm during squeeze (P < .05). Resting and squeeze electromyography amplitude of the external anal sphincter and puborectalis muscle was markedly reduced by pudendal nerve blockade. CONCLUSION: Pudendal nerve blockade decreases vaginal pressures, increases length of urogenital hiatus, and decreases electromyography activity of the puborectalis muscle, all of which suggest that the pudendal nerve does innervate the levator ani muscle.
PMID: 16199635 [PubMed - indexed for MEDLINE]
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Comment on:
MRI sedation.
Hussain S, Siddiqui MS.
Publication Types:
PMID: 16101719 [PubMed - indexed for MEDLINE]
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Comment on:
A rose by any other name.
Abouleish AE, Cohen MS, Elkon D.
Publication Types:
PMID: 16101715 [PubMed - indexed for MEDLINE]
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Jet ventilation for laryngotracheal surgery in an ex-premature infant.
Koomen E, Poortmans G, Anderson BJ, Janssens MM.
Academisch Ziekenhuis Maastricht, Maastricht, The Netherlands. koomen-bijsterbosch@planet.nl
A 4-month-old ex-premature infant with severe airway obstruction from subglottic cysts presented for surgical cyst removal. Laryngeal and tracheal surgical procedures in children may present difficulties for the anesthetist because the airway is shared with the surgeon. We report the use of high-frequency jet ventilation (HFJV) to maintain ventilation and provide adequate surgical access. Anesthesia was induced using sevoflurane in oxygen and was maintained with intravenous infusions of propofol 7.5 mg.kg(-1).h(-1) and remifentanil 0.4 microg.kg(-1).min(-1). The suction channel of the ENT laryngoscope was used to introduce an 8-FG ureteric drainage catheter into the larynx and this catheter was used to provide HFJV. Obstruction to expiratory flow was a major concern and was dependent on good positioning of the rigid laryngoscope. Complications such as barotrauma, pneumopericardium, CO2-retention, necrotizing tracheobronchitis, and gastric rupture dictate a fastidious technique.
Publication Types:
PMID: 16101712 [PubMed - indexed for MEDLINE]
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Perioperative management of a child with short-chain acyl-CoA dehydrogenase deficiency.
Turpin B, Tobias JD.
College of Osteopathic Medicine, University of Health Sciences, Kansas City, MO, USA.
Short-chain acyl-CoA dehydrogenase (SCAD) is a mitochondrial enzyme that catalyzes the dehydrogenation of short chain fatty acids (4 to 6 carbons in length) thereby initiating the cycle of beta-oxidation. This process generates acetyl-CoA, the key substrate for hepatic ketogenesis or ATP production by the Kreb's cycle. A deficiency of SCAD results in the build-up of potentially cytotoxic metabolites including ethylmalonic acid, methylsuccinyl CoA and butyryl-carnitine. The end-organ involvement is heterogeneous, but most commonly includes hypotonia with possible lipid myopathy and developmental delay. Other reported complications include dysmorphic craniofacial features, hypoglycemia, seizures, scoliosis, hypertonia and hyperreflexia, cyclic vomiting and myocardial dysfunction. We present a 23-month-old girl with SCAD deficiency, who required posterior fossa decompression for type 1 Chiari malformation. The potential perioperative implications of SCAD deficiency are reviewed.
Publication Types:
PMID: 16101709 [PubMed - indexed for MEDLINE]
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Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy.
Guler G, Akin A, Tosun Z, Ors S, Esmaoglu A, Boyaci A.
Department of Anesthesiology, Erciyes University, Medical Faculty, Kayseri, Turkey. gulen@erciyes.edu.tr
BACKGROUND: Dexmedetomidine has shown sedative, analgesic, and anxiolytic effects after intravenous (IV) administration. Sevoflurane is associated with a high incidence of emergence agitation in preschool children. In this placebo-controlled study, we examined the effect of single dose dexmedetomidine on emergence agitation in children undergoing adenotonsillectomy. METHODS: In a double-blinded trial, 60 children (age 3-7 years) were randomly assigned to receive dexmedetomidine 0.5 microg.kg(-1) IV or placebo, 5 min before the end of surgery. All patients received a standardized anesthetic regimen. For induction and maintenance of anesthesia we used sevoflurane. After surgery, the incidence and severity of agitation was measured 2 h postoperatively. The incidence of untoward airway events after extubation, such as breath holding, severe coughing, or straining were recorded. After surgery, the children's behavior and pain were assessed with a 5-point scale. RESULTS: The agitation and pain scores in the dexmedetomidine group were better than those in the placebo group (P < 0.05). The incidence of severe agitation (a score of 4 or more), and severe pain (a score of 3 or more) were significantly less in the dexmedetomidine group (P < 0.05). The number of severe coughs per patient in the dexmedetomidine group was significantly decreased compared with the control group (P < 0.05). Postoperative vomiting was similar in both groups. Times to emergence and extubation were significantly longer in the dexmedetomidine group (P < 0.05). CONCLUSIONS: We conclude that 0.5 microg.kg(-1) dexmedetomidine reduces agitation after sevoflurane anesthesia in children undergoing adenotonsillectomy.
Publication Types:
PMID: 16101707 [PubMed - indexed for MEDLINE]
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Pharmacokinetics and efficacy of ropivacaine for continuous epidural infusion in neonates and infants.
Bosenberg AT, Thomas J, Cronje L, Lopez T, Crean PM, Gustafsson U, Huledal G, Larsson LE.
Department Anaesthesia, Faculty Health Sciences, University Natal, Durban, South Africa. bosie@cormack.uct.ac.za
INTRODUCTION: The primary objective of this noncomparative study was to evaluate the pharmacokinetics of ropivacaine during a 48-72-h continuous epidural infusion of ropivacaine in children under 1 year. The secondary objectives were to assess efficacy and safety. METHODS: Neonates and infants (ASA I-III, gestational age > or =37 weeks, > or =2.5 kg, scheduled for major abdominal or thoracic surgery) were included and separated into age groups: 0-30 (neonate), 31-90, 91-180, and 181-365 days. Ethics committee approval and informed parental consent were obtained before inclusion. An epidural catheter was introduced under general anesthesia at the appropriate dermatomal level. An initial bolus dose (0.9-2.0 mg.kg(-1) of ropivacaine 0.2%) was followed by an epidural infusion (0.2 mg.kg(-1).h(-1) for infants <180 days or 0.4 mg.kg(-1).h(-1) for infants >180 days). Plasma samples were collected every 12 h from 24 h, and on termination of the epidural infusion. Postoperative pain was evaluated using both the Objective Pain Scale and a four-graded descriptive scale. RESULTS: Forty-five infants, median age 116 (0-362) days, were included. Forty-three and 19 patients received an infusion for at least 48 and 72 h, respectively. Satisfactory analgesia was provided in the majority, only 20 patients were given supplementary medication during the infusion. In all age groups, plasma concentrations of unbound ropivacaine leveled at 24 h, without any further increase at 48 and 72 h. Because of lower clearance of unbound ropivacaine in neonates (mean 33 ml.min(-1).kg(-1)) than in infants above the age of 30 days (80, 124, and 163 ml.min(-1).kg(-1), respectively, in the age groups 31-90, 91-180, and 180-365 days), unbound ropivacaine concentrations at the end of infusion were higher in neonates [median 0.10 mg.l(-1) (0.04-0.21 mg.l(-1))] than in infants >30 days [median 0.03 mg.l(-1) (0.003-0.10 mg.l(-1))]. CONCLUSION: Epidural infusions (0.2-0.4 mg.kg(-1).h(-1) ropivacaine) provided satisfactory pain relief in neonates and infants under 1 year. As plasma concentrations of unbound ropivacaine were not influenced by the duration of the infusion, ropivacaine can be safely used for postoperative epidural infusion for 48-72 h. Levels of unbound ropivacaine were higher in the neonates than in the infants, but were below threshold concentrations for CNS toxicity in adults (> or =0.35 mg.l(-1)). This should not preclude the use of ropivacaine infusions in neonates but suggests a need for caution during the first weeks of life.
PMID: 16101704 [PubMed - indexed for MEDLINE]
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The correlation of the Narcotrend Index with endtidal sevoflurane concentrations and hemodynamic parameters in children.
Weber F, Hollnberger H, Gruber M, Frank B, Taeger K.
Department of Anaesthesia, University of Regensburg, Regensburg, Germany. frank.weber@klinik.uni-regensburg.de
BACKGROUND: The Narcotrend Index (NI) of anesthetic depth is potentially a pharmacodynamic measure of the effects of sevoflurane on the brain. METHODS: In this prospective observational study of 30 pediatric surgical patients (1-11 years), we investigated the correlation between nonsteady-state endtidal sevoflurane (eT(Sevo)), NI, mean arterial pressure (MAP), and heart rate (HR). The performance of the Narcotrend for differentiation between consciousness and unconsciousness was evaluated using prediction probability (P(K)). RESULTS: Spearman correlation analysis showed significant correlations (P < 0.01) between eT(Sevo) and NI (r = -0.85) and MAP (r = -0.43). P(K)-values for differentiation between consciousness and unconsciousness were 1.0 for NI and <0.85 for MAP and HR. During the surgical procedure, NI-values showed a constant rise with each 0.5% step of lowering eT(Sevo) (P < 0.03), whereas MAP remained unaltered and HR showed a constant decline (P < 0.03), except between 1.5 and 1%. CONCLUSIONS: In children, nonsteady-state eT(Sevo) concentrations are more closely related with NI than with MAP or HR. In this study, only NI reliably differentiated consciousness from unconsciousness.
Publication Types:
PMID: 16101702 [PubMed - indexed for MEDLINE]
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Do results from studies of a simulated epidural test dose improve our ability to detect unintentional epidural vascular puncture in children?
Sethna NF, McGowan FX Jr.
Publication Types:
PMID: 16101700 [PubMed - indexed for MEDLINE]
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