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Anaesthesiological airway management in Denmark: Assessment, equipment and documentation.
Xavier A, Kulemekha G.
PMID: 15676006 [PubMed - in process]
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'To be? or not to be (an academic anesthesiologist)?'.
Kuczkowski KM.
PMID: 15676004 [PubMed - in process]
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A routine anesthetic (?) for a 'non-routine' patient.
Kuczkowski KM.
PMID: 15676003 [PubMed - in process]
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Two consecutive ruptures of the upper cuff of disposable laryngeal tubes during anaesthesia of a single patient.
Niemi-Murola L, Rautoma VP, Castren M, Pere P.
PMID: 15676002 [PubMed - in process]
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Anaesthetic considerations in a patient with right heart thrombi-in-transit.
Rastogi S, Abraham M, Geelani MA, Trehan V, Nagesh A.
Department of Anaesthesiology, G.B. Pant Hospital, Jawaharlal Nehru Marg, New Delhi, India.
This is a case report of a patient with underlying pulmonary thromboembolism who was diagnosed as having a large, mobile right heart thrombi while undergoing treatment with low-molecular weight heparin. She underwent emergency embolectomy with exploration of the right heart under a cardiopulmonary bypass (CPB). Soon after induction of anaesthesia, the patient had an episode of severe hypotension, which responded to inotropes. Large, serpiginous thrombi were found in the right atrium extending into the right ventricle and pulmonary arteries, which were evacuated. She was weaned off CPB on inotropic support and was extubated uneventfully on the 4th POD. Postoperatively, she was started on anticoagulant therapy and also underwent placement of a Greenfield inferior vena caval (IVC) filter to prevent further thromboembolic episodes.
PMID: 15675997 [PubMed - in process]
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Concealed mothball abuse prior to anesthesia: mothballs, inhalants, and their management.
Kong JT, Schmiesing C.
Department of Anesthesia, Stanford University Medical Center, CA.
Mothballs are one of a number of volatile compounds including model airplane glue, spray paint, nail polish remover, room fresheners, and gasoline that are intentionally inhaled for the purpose of recreational self-intoxication (1). Their inhalation produces a rapid 'high' characterized by euphoria and generalized intoxication. Chronic abuse can be associated with significant organ impairment, and, in rare cases, cardiac dysrhythmias and deranged end-tidal gas monitoring (2-5). Mothballs contain the aromatic compound naphthalene and/or paradichlorobenzene (6). Prolonged exposure can cause hepatic failure and severe hemolytic anemia (6-8). We present a case of a young adult who initially concealed her chronic mothball inhalation. The literature regarding mothball abuse as well as inhalant abuse relevant to anesthesia is reviewed, and suggestions for the diagnosis and peri-operative management are offered.
PMID: 15675996 [PubMed - in process]
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Spinal anesthesia for emergency abdominal surgery in uncontrolled hyperthyroidism.
Varela A, Yuste A, Villazala R, Garrido J, Lorenzo A, Lopez E.
Department of Anesthesia and Intensive Care, Gregorio Maranon General Hospital, Madrid, Spain.
Patients with uncontrolled hyperthyroidism presenting as an emergency are at considerable risk. The anesthetic management of a thyrotoxic patient undergoing incidental emergency surgery is discussed. We focus on the intraoperative problems and, above all, postoperative pain management with regional anesthesia.
PMID: 15675992 [PubMed - in process]
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Isolated bilateral paralysis of the hypoglossal and recurrent laryngeal nerves (Bilateral Tapia's syndrome) after transoral intubation for general anesthesia.
Cinar SO, Seven H, Cinar U, Turgut S.
Department of Anesthesiology, Sisli Etfal Teaching and Research Hospital, Istanbul, Turkey.
Tapia's syndrome is due to extracranial involvement of the hypoglossal nerve and the recurrent laryngeal branch of the vagal nerve. The injury of these nerves is a rare complication of anesthetic airway management. We present a patient with a postoperative bilateral hypoglossal and recurrent laryngeal nerves palsy after uncomplicated orotracheal intubation. Corticosteroid therapy was started after diagnosis. Forty-eight hours later, the movements of the vocal cords started to recover and full recovery was achieved by the fourth day. Within 3 days, tongue mobility was gradually improved and the patient's symptoms resolved completely by 4 weeks.
PMID: 15675991 [PubMed - in process]
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Influence of the injection site (L2/3 or L3/4) and the posture of the vertebral column on selective spinal anesthesia for ambulatory knee arthroscopy.
Korhonen AM, Valanne JV, Jokela RM, Ravaska P, Volmanen P, Korttila K.
Department of Anesthesia, Lapland Central Hospital, Rovaniemi, Finland.
Background: We tested the hypothesis that selective spinal anesthesia for ambulatory knee arthroscopy can be accomplished with a small dose of bupivacaine at the L3/4 interspace with or without a head-down tilt of 5 degrees when the patients were in the lateral decubitus position. Methods: In this double-blind study, 123 patients were randomly allocated to receive spinal anesthesia with 4 mg of hyperbaric bupivacaine inserted at either the L2/3 interspace, while the vertebral column was kept horizontal (L2/3 group), or the L3/4 level, with the vertebral column horizontal (L3/4H) or tilted 5 degrees head-down (L3/4T). At 7 min, an additional head down tilt was used in all groups if the sensory block was inadequate. Results: In the L3/4T group the sensory block (Th8) reached a significantly higher level 30 min after spinal injection, compared with both the L2/3 (Th10) and L3/4H (Th11) groups. In the L3/4H group, 39% of the patients needed an additional tilt for 3 min at 7 min, compared with 10% (P=0.004) in the L3/4T group. Sacral block developed later and recovered faster (P<0.05) in the L3/4T group compared to the L3/4H group. Home-readiness was achieved equally fast in all groups. Conclusion: When producing selective spinal anesthesia, the posture of the vertebral column is a major determinant of both sensory and motor segments to be blocked. A 4-mg dose of hyperbaric bupivacaine at the L3/4 interspace with a 5 degrees head-down tilt of the vertebral column for 6 min is recommended for knee arthroscopy.
PMID: 15675986 [PubMed - in process]
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Spinal cord damage following thoracic epidural anaesthesia.
Gibson P.
Publication Types:
PMID: 15675229 [PubMed - in process]
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Anaesthesia and isolated systolic hypertension.
Campbell DI.
Publication Types:
PMID: 15675224 [PubMed - in process]
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Anaesthesia for correction of scoliosis in children.
Gibson PR.
Department of Anaesthesia, Children's Hospital at Westmead, Sydney, New South Wales.
Surgical correction of spinal deformities in children presents a challenge to the anaesthetist because of the extensive nature of the surgery, the co-morbidities of the patients and the constraints on anaesthetic techniques of intraoperative neurophysiological monitoring of the spinal cord. Adolescent idiopathic scoliosis is the most common deformity. Patients with scoliosis secondary to neuromuscular conditions are at greatest risk of perioperative problems, particularly excessive blood loss and respiratory failure. The risk of spinal cord damage can be decreased by the use of intraoperative spinal cord monitoring, particularly monitoring of the lower limb compound muscle action potential evoked by transcranial electrical stimulation. Specific anaesthetic techniques are required for this monitoring to be reliable. Because of concerns about spinal cord perfusion there is now less reliance on induced hypotension and haemodilution to reduce blood loss, with emphasis on proper patient positioning, controlled haemodynamics and antifibrinolytic therapy. Effective postoperative pain management requires a multimodal approach.
PMID: 15675216 [PubMed - in process]
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Anaesthetic management of planned or emergency endovascular stent graft surgery for thoracic aneurysms and dissections.
See JJ, Lee CW, Lew TW.
Department of Anaesthesiology, Tan Tock Seng Hospital, Singapore.
We reviewed the intraoperative anaesthetic management and outcome of seven consecutive cases of endovascular stent graft surgery for thoracic aortic aneurysms or dissections over a period of 20 months in our institution. Seven males (median age 63) underwent endovascular stent graft surgery of the thoracic aorta under general anaesthesia. Four were emergency procedures for acute dissection or leaks of thoracic aneurysms. The duration of the procedures ranged from 120 to 300 minutes. Intraoperative stent migration occurred in one patient. Induced hypotension and immobilization were critical during stent deployment. Six out of the seven patients were discharged home between three to 20 days postoperatively. There was no 30-day mortality. One patient died sixty days postoperatively. Anaemia and respiratory complications were the most common postoperative problems encountered. None of the patients sustained spinal cord ischaemia, acute myocardial infarction or renal impairment. Endovascular stent graft surgery of the thoracic aorta is a relatively new alternative to conventional open surgery. Our experience suggests satisfactory short-term outcome even for patients with acute dissection. However, long-term survival and results require further evaluation.
PMID: 15675211 [PubMed - in process]
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Challenges that opioid-dependent women present to the obstetric anaesthetist.
Cassidy B, Cyna AM.
Women's and Children's Hospital, Adelaide, South Australia.
A retrospective casenote review was performed to identify anaesthetic challenges relevant to the opioid-dependent obstetric population. Medical records showed that of the 7,449 deliveries during a 24 month period, 85 women (1.1%) were taking regular opioids such as methadone and/or heroin. Of these 67 (79%) received anaesthetic services, ten of whom (11.7%) were referred antenatally. Forty opioid-dependent women (47%) received epidural analgesia in labour compared with the overall hospital rate of 38%. Twenty-three women (27%) delivered by caesarean section: five received general anaesthesia, five combined spinal anaesthesia, five spinal anaesthesia and eight epidural anaesthesia. Twenty opioid-dependent women (23.5%) had documented problems related to labour analgesia and 17 (74%) had problems with analgesia after caesarean section. A variety of postoperative analgesia methods were administered in addition to maintenance methadone. Fourteen patients (16.5%) had difficult intravenous access and seven "arrest" calls were documented. One anaesthetist was exposed to hepatitis C. This review demonstrates the demands placed on obstetric anaesthetic services by opioid-dependent women. Early antenatal referral for anaesthetic review is recommended.
PMID: 15675209 [PubMed - in process]
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Entropy and bispectral index during anaesthesia in children.
Davidson AJ, Kim MJ, Sangolt GK.
Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melboume.
Entropy is a new EEG based technology developed as a measure of depth of anaesthesia. The Entropy algorithm quantifies the degree of disorder in the EEG. During anaesthesia the disorder of the EEG, or entropy, falls. Entropy is independent of absolute frequency or amplitude of the EEG. This may make it suitable for paediatric anaesthesia. In this prospective observational blinded study we recorded the Entropy and Bispectral Index in 23 children undergoing general anaesthesia with isoflurane and nitrous oxide, supplemented with peripheral nerve blockade. We recorded Entropy at several times during anaesthesia, pre-awakening and 1-minute post-awakening. Entropy pre-awakening and 1 minute after awakening was compared to a value during anaesthesia in three age groups; less than one-year-old (infants), one to five years (toddlers) and five to twelve years (children). The correlation between BIS and Entropy was also calculated. Entropy post-awakening was higher than during anaesthesia for all age groups. Entropy pre-awakening was higher than during anaesthesia for the children and toddlers. This was not as apparent in infants. There was a strong correlation between BIS and Entropy for children and toddlers. The correlation was less for infants. This study demonstrates that, in children, Entropy is lower during anaesthesia when compared to awake values. Further evaluation in the paediatric population is worthwhile.
PMID: 15675208 [PubMed - in process]
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Nitrous oxide in neonates and infants.
Ragg P.
Publication Types:
PMID: 15535508 [PubMed - indexed for MEDLINE]
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Refractory hypotension in a patient chronically treated with a long acting angiotensin-converting enzyme inhibitor.
Akinci SB, Ayhan B, Kanbak M, Aypar U.
Publication Types:
PMID: 15535507 [PubMed - indexed for MEDLINE]
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An audit of the Single Use Portex Laryngeal Mask.
Orlikowski CE.
Department of Anaesthesia, Royal Hobart Hospital, Hobart, Tasmania.
We performed an audit of the insertion of the Single Use Portex Laryngeal Mask in 400 patients. Insertion was successful at first attempt in 335 out of 400 patients (83.8%). However in 15 patients (3.8%), the Portex laryngeal mask could not be placed despite repeated attempts. In 12 of these 15 patients (80%), a standard Laryngeal Mask Airway (LMA) was successfully placed. After the completion of the audit, 22 out of 29 anaesthetists (75.9%), who had inserted > or = 5 Portex laryngeal masks, considered it inferior to the standard LMA. It would appear to us that the Portex laryngeal mask might need some design modifications to be a real alternative to the standard LMA.
Publication Types:
PMID: 15535497 [PubMed - indexed for MEDLINE]
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The single-connector technique for initial placement of double-lumen tubes.
Pfitzner J, Alexander HI, Hung PK.
Department of Anaesthesia, The Queen Elizabeth Hospital, Woodville, South Australia.
Due to the presence of major lung or extra-pulmonary pathology, which may be unilateral or bilateral, the initial placement of a double-lumen tube is not always straightforward. Although fibreoptic bronchoscopy is often used to confirm "correct" placement, a "blind" technique is frequently used for the initial insertion. The currently widely taught blind technique involves tracheal cuff inflation and ventilation of both lungs as a first manoeuvre, with a subsequent assessment of single-lung ventilation by clamping off in turn, the two limbs of the double-lumen tube double-connector: An alternative approach involves the bronchial cuff being inflated first, and then using a single-connector to transfer ventilation from one lung to the other. In this paper this technique is described and compared to the more traditional method. On a purely "number of steps" basis, the single-connector approach has several advantages. Furthermore, use of a technique that involves bronchial cuff inflation and single-lung ventilation as a first manoeuvre may reduce the risk of a temporarily malplaced double-lumen tube creating a potentially harmful ball-valve effect in a partially obstructed lobe or lung.
Publication Types:
PMID: 15535496 [PubMed - indexed for MEDLINE]
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Gum elastic bougie-guided insertion of the ProSeal Laryngeal Mask Airway.
Brimacombe J, Keller C.
Department of Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns, Queensland.
We tested the hypothesis that gum elastic-bougie-guided insertion of the ProSeal Laryngeal Mask Airway is more frequently successful than introducer tool guided insertion after failed digital insertion. One hundred anaesthetized patients (ASA 1-2, aged 18 to 80 years) were randomized for the second insertion attempt using either the gum elastic bougie-guided or introducer tool techniques. The bougie-guided technique involved priming the drain tube with the bougie, placing the bougie in the oesophagus using laryngoscope guidance, digital insertion along the palato-pharyngeal curve, and bougie removal. The introducer tool technique involved attaching the introducer tool, single-handed rotation along the palatopharyngeal curve, and introducer tool removal. Failed insertion was classified as (i) failed passage into the pharynx, (ii) malposition, or (iii) ineffective ventilation. Any blood staining was documented. Insertion was more frequently successful (50/50 vs 15/50, P=0.0002) and faster (35+/-17 s vs 54+/-45 s, mean+/-SD, P=0.006) with the bougie-guided technique. All failed insertions with the introducer tool technique were successful with the bougie-guided technique. The aetiology of failed insertion was similar for the digital and introducer tool techniques in 94% (33/35) of patients. There was no blood staining on the bougie, laryngoscope or introducer tool at removal, but blood staining was more common on the ProSeal Laryngeal Mask Airway with the introducer tool technique (9/50 vs 2/50, P=0.03). We conclude that the gum elastic bougie-guided insertion has a higher success rate and causes less trauma than the insertion tool insertion technique after failed digital insertion of the ProSeal Laryngeal Mask Airway.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15535495 [PubMed - indexed for MEDLINE]
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Pain during injection of propofol: the effect of prior administration of ephedrine.
Agarwal A, Dhiraaj S, Raza M, Singhal V, Gupta D, Ranjan R, Singh PK, Singh U.
Department of Anesthesia, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
Propofol causes pain on intravenous injection in 28 to 90% of patients. A number of techniques have been tried to minimize propofol-induced pain, with variable results. In a randomized, double-blind, placebo-controlled trial, we compared the efficacy of ephedrine 30 microg/kg pretreatment to lignocaine 40 mg for prevention of propofol-induced pain. Ninety-three adult patients, ASA 1 and 2, undergoing elective laparoscopic cholecystectomy were randomly assigned to three groups of 31 each. Group 1 received normal saline, group 2 received lignocaine 2% (40 mg) and group 3 received 30 microg/kg ephedrine. All pretreatment drugs were made up to 2 ml. Pain at the time of propofol injection was assessed on a four-point scale: 0=no pain, 1 =mild pain, 2=moderate pain, and 3=severe pain. Twenty-seven patients (87%) of ephedrine pretreatment patients had pain during intravenous injection of propofol as compared to 24 (77%) in the normal saline group. In the lignocaine group, propofol-induced pain was observed in only 13 (42%) when compared with other study groups (P<0.05). Pretreatment with ephedrine 30 microg/kg did not attenuate pain associated with intravenous injection of propofol, nor did it improve haemodynamic stability during induction. However, pretreatment with 2% lignocaine (40 mg) was effective in attenuating propofol-associated pain.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15535489 [PubMed - indexed for MEDLINE]
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Effect of metoclopramide on pain on injection of propofol.
Fujii Y, Uemura A.
Department of Anaesthesiology, University of Tsukuba Institue of Clinical Medicine, Tsukuba City, Ibaraki, Japan.
We undertook a randomized, double-blind, placebo-controlled study to examine the efficacy of metoclopramide at three different doses (2.5 mg, 5 mg, 10 mg) for reducing pain on injection of propofol in 100 patients scheduled for elective surgery. Patients received intravenously the study drug, with venous occlusion for one minute, followed by propofol 2 mg/kg into a dorsal hand vein. The incidence of pain was significantly less in patients receiving metoclopramide 5 mg (32%) or 10 mg (28%) than in patients receiving placebo (80%) (P<0.01). No difference between metoclopramide 2.5 mg and the placebo groups was found. We conclude that pretreatment of a dorsal hand vein with metoclopramide in a dose of 5 or 10 mg, with venous occlusion for one minute, effectively decreases the incidence of pain caused by propofol injection.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15535488 [PubMed - indexed for MEDLINE]
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Laryngeal mask airway to prevent a gas leak around a tracheal tube.
Asai T, Murao K, Shingu K.
Publication Types:
PMID: 15601294 [PubMed - indexed for MEDLINE]
Comment on:
Effect of injected epinephrine on the end-tidal carbon dioxide concentration.
Tabboush Z, Diab M.
Publication Types:
PMID: 15601288 [PubMed - indexed for MEDLINE]
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Continuous paravertebral block for thoraco-abdominal oesophageal surgery.
Kelly FE, Murdoch JA, Sanders DJ, Berrisford RG.
Publication Types:
PMID: 15601286 [PubMed - indexed for MEDLINE]
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Management of a parturient with respiratory failure secondary to cystic fibrosis.
Cameron AJ, Skinner TA.
Auckland City Hospital, Private Bag 92-024, Auckland, New Zealand. acameron@adhb.govt.nz
A 21-year-old with end-stage respiratory failure and cor pulmonale due to cystic fibrosis became pregnant. Her forced expiratory volume in 1 s (FEV1) was 17% of that predicted antenatally, and termination was strongly advised on the grounds that continuing pregnancy was likely to be fatal. She elected to continue with the pregnancy and gave birth by lower segment caesarean section at 29 weeks and 5 days' gestation. Despite a problematic postnatal course, she was successfully discharged home and, 7 months postnatally, continues to live at home with her partner and their baby. There are no previous reports of cystic fibrosis patients with this level of respiratory impairment surviving pregnancy.
Publication Types:
PMID: 15601277 [PubMed - indexed for MEDLINE]
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Drug related critical incidents.
Khan FA, Hoda MQ.
Department of Anaesthesia, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan. fanzia.khan@aku.edu
Drug related incidents are a common form of reported medical errors. This paper reviews the critical incidents related to drug errors reported from the main operating theatre suite in a teaching hospital in a developing country from January 1997 to December 2002. Each report was evaluated individually by two reviewers using a structured process. During this period, 44 874 anaesthetics were administered; 768 critical incidents were reported, 165 (21%) of which were related to drug errors. Underdosage, side-effect/drug reaction and syringe swap were the most common. A total of 76% were classified as preventable; 56% due to human error and 19% due to system error. High risk incidents accounted for 10% of all drug errors and most of these were related to the use of neuromuscular blocking drugs. This analysis has been found useful in addressing some issues about priorities.
PMID: 15601272 [PubMed - indexed for MEDLINE]
Epidural analgesia in advanced cancer patients.
Linklater GT, Macaulay L.
Publication Types:
PMID: 15673911 [PubMed - in process]
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Epidural analgesia in advanced cancer patients.
Eikermann M, Peters J.
PMID: 15673910 [PubMed - in process]
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A tooth broken after laryngoscopy: unlikely to be caused by the force applied by the anesthesiologist.
Quinn JB, Schultheis LW, Schumacher GE.
ADAF Paffenbarger Research Center, Mailstop 8546, National Institute of Standards and Technology, Gaithersburg, MD 20899, USA. janet.quinn@nist.gov
PMID: 15673900 [PubMed - in process]
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Positive end-expiratory pressure during induction of general anesthesia increases duration of nonhypoxic apnea in morbidly obese patients.
Gander S, Frascarolo P, Suter M, Spahn DR, Magnusson L.
Department of Anesthesiology, University Hospital, CHUV BH-10, CH-1011 Lausanne, Switzerland.
Positive end-expiratory pressure (PEEP) applied during induction of anesthesia prevents atelectasis formation and increases the duration of nonhypoxic apnea in nonobese patients. PEEP also prevents atelectasis formation in morbidly obese patients. Because morbidly obese patients have difficult airway management more often and because arterial desaturation develops rapidly, we studied the clinical benefit of PEEP applied during anesthesia induction. Thirty morbidly obese patients were randomly allocated to one of two groups. In the PEEP group, patients breathed 100% O(2) through a continuous positive airway pressure device (10 cm H(2)O) for 5 min. After induction of anesthesia, they were mechanically ventilated with PEEP (10 cm H(2)O) for another 5 min until tracheal intubation. In the control group, the sequence was the same but without any continuous positive airway pressure or PEEP. We measured apnea duration until Spo(2) reached 90% and we performed arterial blood gases analyses just before apnea and at 92% Spo(2). Nonhypoxic apnea duration was longer in the PEEP group compared with the control group (188 +/- 46 versus 127 +/- 43 s; P = 0.002). Pao(2) was higher before apnea in the PEEP group (P = 0.038). Application of positive airway pressure during induction of general anesthesia in morbidly obese patients increases nonhypoxic apnea duration by 50%.
PMID: 15673897 [PubMed - in process]
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Chloroprocaine spinal anesthesia: back to the future?
Drasner K.
Publication Types:
PMID: 15673892 [PubMed - in process]
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The prevalence and characteristics of incentive plans for clinical productivity among academic anesthesiology programs.
Abouleish AE, Apfelbaum JL, Prough DS, Williams JP, Roskoph JA, Johnston WE, Whitten CW.
Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX 77555-0591, USA. aaboulei@utmb.edu
Performance-based compensation is encouraged in medical schools to improve faculty productivity. Medical specialties other than anesthesiology have used financial incentives for clinical work. The goal of this study was to determine the prevalence and the types of clinical incentive plans among academic anesthesiology departments. We performed an electronic survey of the members of the Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors in the spring of 2003. The survey included questions about departmental size, presence of a clinical incentive plan, characteristics of existing incentive plans, primary quantifiers of productivity, and factors used to modify productivity measurements. An incentive plan was considered to be present if the department measured clinical productivity and varied compensation according to the measurements. The plans were grouped by the primary measure used into the following categories: None, Charges, Time, Shift, Late/Call (only late rooms and call), and Other. Eighty-eight (64%) of 138 programs responded to the survey, and 5 were excluded for incomplete data. Of the responding programs, 29% had no system, 30% used a Late/Call system, 20% used a Shift system, 11% used a Charges system, 6% used a Time system, and 3% fit in the Other category. Larger groups (>40 faculty members) had a significantly more frequent prevalence of incentive plans compared with smaller groups (<20 faculty members). Incentives were paid monthly or quarterly in 85% of the groups. In 90% of groups, incentive payments accounted for <25% of total compensation. Adjustments for operating room schedule supervisors, personally performed cases, day surgery preoperative clinics, pain-management services, and critical care services were included in less than half of the programs that reported incentive plans. Call and late room compensation was based on varied formulas. Sixty-nine percent of academic anesthesiology departments did not vary compensation according to clinical activity during regular hours. Most did vary payments on the basis of call and/or late rooms worked. Larger departments were more likely to use clinical incentive plans.
PMID: 15673882 [PubMed - in process]
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Academic anesthesia faculty salaries: incentives, availability, and productivity.
Miller RD.
Publication Types:
PMID: 15673880 [PubMed - in process]
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Sorptive loss of volatile and gaseous anesthetics from in vitro drug application systems.
Suzuki T, Uchida I, Mashimo T.
Department of Anesthesiology, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, Japan 565-0871. tsuzuki@anes.med.osaka-u.ac.jp
In in vitro pharmacological experiments, determination of effective concentration values for various anesthetics depends on understanding the exact concentration of the drugs dissolved in physiological solutions. Actual anesthetic concentration may differ from expectations because of drug adsorption, absorption or other loss, especially in tubing. We tested the hypothesis that delivered concentrations of anesthetics decrease when solutions pass through laboratory tubing and investigated such loss by measuring the entering and exiting dissolved concentrations of two volatile (sevoflurane and isoflurane) and two gaseous (nitrous oxide and xenon) anesthetics. We tested solutions passed through tubes (1 m x 2 mm ID x 4 mm OD) made of five different materials (glass, Teflon, polyethylene (PE), polyvinyl chloride (PVC), and silicon rubber). Exiting concentrations of anesthetics were significantly reduced when they were passed through PVC (>33%) and silicon (>43%) tubes. There were no decreases in anesthetic concentrations with glass, Teflon, or PE tubes. When sevoflurane solution flowed through PVC and silicon tubes, it took 20 and 30 min, respectively, after start of flow until the anesthetic loss became negligible. These results indicate that frequently used PVC and silicon tubes, whereas flexible and easy to handle, have serious drawbacks when used in inhaled anesthetic pharmacology experiments.
PMID: 15673870 [PubMed - in process]
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Hyperresponsiveness on washout of volatile anesthetics from isolated spinal cord compared to withdrawal from ethanol.
Wong SM, Sweitzer SM, Peters MC, Kendig JJ.
Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305-5117, USA.
We performed experiments in spinal cords isolated from neonatal rats to probe the mechanisms responsible for hyperresponsiveness of the population excitatory evoked potential (pEPSP) observed on washout of the volatile anesthetics halothane and isoflurane (1 minimal alveolar anesthetic concentration equivalent, MAC) compared with that observed after an anesthetic concentration of ethanol. After 30 min exposure to each anesthetic and washout, pEPSP area increased to levels significantly more than control (P < 0.01-0.001). Exposure to a very small (0.025 MAC) concentration of isoflurane over the same period itself produced a similarly exaggerated pEPSP (P < 0.05) in the continued presence of the drug, suggesting that the phenomenon is a direct excitatory effect of the small concentrations of anesthetic on washout, unlike the true withdrawal observed with ethanol. Isoflurane, but not halothane, significantly increased the amount of potassium-stimulated release of the excitatory neurotransmitters glutamate, aspartate, and substance P, suggesting the hyperresponsiveness for that drug is the result of a presynaptically mediated increase in transmitter release. A broad spectrum specific protein kinase C inhibitor, GF109203X, blocked ethanol withdrawal hyperresponsiveness but not hyperresponsiveness after halothane. If the behavioral symptoms of emergence from anesthesia are based on excitatory actions similar to those observed in the spinal cord, the results show that they represent direct excitatory actions rather than withdrawal and are attributable to direct actions on ion channels or receptors, rather than indirect effects mediated by protein kinase C.
PMID: 15673868 [PubMed - in process]
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Carbon dioxide depresses the F wave by a central, not peripheral, mechanism during isoflurane anesthesia.
Dominguez C, Carstens E, Antognini JF.
Department of Anesthesiology and Pain Medicine, University of California-Davis, Shields Avenue, Davis, CA 95616, USA.
Carbon dioxide (CO(2)) has anesthetic properties and has been reported to depress the F wave of the evoked electromyogram; the F wave is thought to reflect motoneuron excitability. Anesthetics such as isoflurane also depress the F wave. Because CO(2) can depress muscle contractile function, as well as spinal cord neurons, it is unclear whether CO(2) depresses the F wave via a central or peripheral mechanism. We anesthetized rabbits with isoflurane (1.4%) and prepared for hindlimb bypass (with a membrane oxygenator) whereby the partial pressures of CO(2) in the hindlimb muscle and torso could be independently adjusted. The F wave was recorded from the hindlimb plantar muscles when the CO(2) was normal to the hindlimb and torso, and when it was increased (to approximately 90 mm Hg) in the hindlimb, the torso, or both. Increasing the CO(2) to just the hindlimb had no significant effect on the F-wave amplitude, but increasing the CO(2) to the torso depressed the F wave to 52% +/- 32% of control; adding CO(2) to the hindlimb during torso hypercarbia did not result in any additional depression of the F wave. CO(2) depressed the F wave via a central, not peripheral, mechanism, although the precise mechanism is unknown.
PMID: 15673865 [PubMed - in process]
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The timing of acupuncture stimulation does not influence anesthetic requirement.
Chernyak G, Sengupta P, Lenhardt R, Liem E, Doufas AG, Sessler DI, Akca O.
Outcomes Research Institute, 501 East Broadway, Louisville, KY 40202, USA.
Studies suggest that acupuncture is more effective when induced before the induction of general anesthesia than afterwards. We tested the hypothesis that electro-acupuncture initiated 30 min before the induction reduces anesthetic requirement more than acupuncture initiated after the induction. Seven volunteers were each anesthetized with desflurane on 3 study days. Needles were inserted percutaneously at four acupuncture points thought to produce analgesia in the upper abdominal area and provide generalized sedative and analgesic effects: Zusanli (St36), Sanyinjiao (Sp6), Liangqiu (Sp34), and Hegu (LI4). Needles were stimulated at 2 Hz and 10 Hz, with frequencies alternating at 2-s intervals. On Preinduction day, electro-acupuncture was started 30 min before the induction of anesthesia and maintained throughout the study. On At-induction day, needles were positioned before the induction of anesthesia, but electro-acupuncture stimulation was not initiated until after the induction. On Control day, electrodes were positioned near the acupoints, but needles were not inserted. Noxious electrical stimulation was administered via 25-gauge needles on the upper abdomen (70 mA; 100 Hz; 10 s). The desflurane concentration was increased 0.5% when movement occurred and decreased 0.5% when it did not. These up-and-down sequences continued until volunteers crossed from movement to no movement four times. The P(50) of logistic regression identified desflurane requirement. Desflurane requirement was similar on the Control (mean +/- sd; 5.2% +/- 0.6%), Preinduction (5.0% +/- 0.8%), and At-induction (4.7% +/- 0.3%; P = 0.125) days. This type of acupuncture is thus unlikely to facilitate general anesthesia or decrease the requirement for anesthetic drugs.
PMID: 15673863 [PubMed - in process]
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Anesthetic management for thoracopagus twins with complex cyanotic heart disease in the magnetic resonance imaging suite.
Shank E, Manohar N, Schmidt U.
Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, MA 02114, USA. eshank@etherdome.mgh.harvard.edu
We report a case of thoracopagus twins undergoing magnetic resonance imaging (MRI) studies under general anesthesia. The twins had a complex shared cardiac anatomy that posed additional challenges to an already-difficult anesthesia care area. This report emphasizes the approach to anesthetic management of conjoined twins in the MRI environment.
PMID: 15673857 [PubMed - in process]
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Pressure support ventilation versus continuous positive airway pressure ventilation with the ProSeal laryngeal mask airway: a randomized crossover study of anesthetized pediatric patients.
von Goedecke A, Brimacombe J, Hormann C, Jeske HC, Kleinsasser A, Keller C.
Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria.
Continuous positive airway pressure (CPAP) and pressure support ventilation (PSV) improve gas exchange in adults, but there are little published data regarding children. We compared the efficacy of PSV with CPAP in anesthetized children managed with the ProSeal laryngeal mask airway. Patients were randomized into two equal-sized crossover groups and data were collected before surgery. In Group 1, patients underwent CPAP, PSV, and CPAP in sequence. In Group 2, patients underwent PSV, CPAP, and PSV in sequence. PSV comprised positive end-expiratory pressure set at 3 cm H(2)O and inspiratory pressure support set at 10 cm H(2)O above positive end-expiratory pressure. CPAP was set at 3 cm H(2)O. Each ventilatory mode was maintained for 5 min. The following data were recorded at each ventilatory mode: ETco(2), Spo(2), expired tidal volume, peak airway pressure, work of breathing patient (WOB), delta esophageal pressure, pressure time product, respiratory drive, inspiratory time fraction, respiratory rate, noninvasive mean arterial blood pressure, and heart rate. In Group 1, measurements for CPAP were similar before and after PSV. In Group 2, measurements for PSV were similar before and after CPAP. When compared with CPAP, PSV had lower ETco(2) (46 +/- 6 versus 52 +/- 7 mm Hg; P < 0.001), slower respiratory rate (24 +/- 6 versus 30 +/- 6 min(-1); P < 0.001), lower WOB (0.54 +/- 0.54 versus 0.95 +/- 0.72 JL(-1); P < 0.05), lower pressure time product (94 +/- 88 versus 150 +/- 90 cm H(2)O s(-1)min(-1); P < 0.001), lower delta esophageal pressure (10.6 +/- 7.4 versus 14.1 +/- 8.9 cm H(2)O; P < 0.05), lower inspiratory time fraction (29% +/- 3% versus 34% +/- 5%; P < 0.001), and higher expired tidal volume (179 +/- 50 versus 129 +/- 44 mL; P < 0.001). There were no differences in Spo(2), respiratory drive, mean arterial blood pressure, and heart rate. We conclude that PSV improves gas exchange and reduces WOB during ProSeal laryngeal mask airway anesthesia compared with CPAP in ASA physical status I children aged 1-7 yr.
PMID: 15673856 [PubMed - in process]
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The effect of volatile anesthetics on respiratory system resistance in patients with chronic obstructive pulmonary disease.
Volta CA, Alvisi V, Petrini S, Zardi S, Marangoni E, Ragazzi R, Capuzzo M, Alvisi R.
Department of Surgical, Anesthesiological and Radiological Science, Section of Anesthesia and Intensive Care, S. Anna Hospital, University of Ferrara, Corso Giovecca 203, 44100 Ferrara, Italy. vlc@dns.unife.it
We examined the effect of isoflurane and sevoflurane on respiratory system resistance (Rmin,rs) in patients with chronic obstructive pulmonary disease (COPD). The diagnosis of COPD rests on the presence of airway obstruction, which is only partially reversible after bronchodilator treatment. Ninety-six consecutive patients undergoing thoracic surgery for peripheral lung cancer were enrolled. They were divided into two groups: preoperative forced expiratory volume in 1 s/forced vital capacity ratio <70% or >70%. Rmin,rs was measured after 5 and 10 min of maintenance anesthesia by using the constant flow/rapid occlusion method. Maintenance of anesthesia was randomized to thiopental 0.30 mg . kg(-1) . min(-1) or 1.1 minimum alveolar anesthetic concentration end-tidal isoflurane or sevoflurane. Eleven patients were excluded: two because anesthesia was erroneously induced with propofol and nine because of an incorrect tube position. Maintenance with thiopental failed to decrease Rmin,rs, whereas both volatile anesthetics were able to decrease Rmin,rs in patients with COPD. The percentage of patients who did not respond to volatile anesthetics was larger in those with COPD as well. In conclusion, we have demonstrated that isoflurane and sevoflurane produce bronchodilation in patients with COPD.
PMID: 15673854 [PubMed - in process]
Comment on:
Failed obstetric tracheal intubation and postoperative respiratory support with the proseal laryngeal mask airway.
Cook TM, Nolan JP.
Publication Types:
PMID: 15616094 [PubMed - indexed for MEDLINE]
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Conventional tracheal tubes for intubation through the intubating laryngeal mask airway.
Kundra P, Sujata N, Ravishankar M.
Department of Anaesthesiology and Critical Care, JIPMER Campus, Pondicherry 605006, India. pankajkundra@vsnl.net
The laryngeal mask airway (LMA)-Fastrach silicone wire-reinforced tracheal tube (FTST) was specially designed for tracheal intubation through the intubating LMA (ILMA). However, conventional tracheal tubes have been successfully used to accomplish tracheal intubation. We designed this study to evaluate the success rate of blind tracheal intubation through the ILMA by using the FTST, the Rusch polyvinyl chloride tube (PVCT), and the Rusch latex armored tube (LAT). One-hundred-fifty healthy adults of ASA physical status I and II who were undergoing elective surgery under general anesthesia were randomly allocated into three groups. FTST (n=50), prewarmed PVCT (n=50), and LAT (n=50) were used for tracheal intubation. Ease of tracheal intubation was assessed by the time taken, the number of attempts, and the number of maneuvers required for success. In addition, numbers of failed intubation attempts and times taken for ILMA removal were also recorded. After surgery, the incidence of trauma, sore throat, and hoarseness was noted. Significantly more frequent success in tracheal intubation was achieved with the PVCT and FTST (96%) compared with the LAT (82%) (P <0.05). Tracheal intubation on the first attempt was similar with the PVCT and FTST (86%) and was significantly more frequent than with the LAT (52%) (P <0.05). Esophageal placement was significantly more frequent with the LAT (29.7%) when compared with the PVCT and FTST (1.8% and 7.4%, respectively) (P <0.05). The authors conclude that a prewarmed PVCT can be used as successfully as the FTST for blind tracheal intubation through the ILMA, whereas the LAT is associated with more frequent failure and esophageal intubation.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15616092 [PubMed - indexed for MEDLINE]
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A modified coracoid approach to infraclavicular brachial plexus blocks using a double-stimulation technique in 300 patients.
Minville V, N'Guyen L, Chassery C, Zetlaoui P, Pourrut JC, Gris C, Eychennes B, Benhamou D, Samii K.
Department of Anesthesiology and Intensive Care, Toulouse University Hospital, France. vincentminville@yahoo.fr
Infraclavicular brachial plexus block is used less than other techniques of regional anesthesia for upper-limb surgery. We describe a modified coracoid approach to the infraclavicular brachial plexus using a double-stimulation technique and assess its efficacy. Patients undergoing orthopedic surgery of the upper limb were included in this prospective study. The landmarks used were the coracoid process and the clavicle. The needle was inserted in the direction of the top of the axillary fossa (in relation to the axillary artery), with an angle of 45 degrees. Using nerve stimulation, the musculocutaneous nerve was identified first and blocked with 10 mL of 1.5% lidocaine with 1:400,000 epinephrine. The needle was then withdrawn and redirected posteriorly and medially. The radial, ulnar, or median nerve was then blocked. The block was tested every 5 min for 30 min. The overall success rate, i.e., adequate sensory block in the 4 major nerve distributions at 30 min, was 92%, and 6% of the patients required supplementation. Five patients required general anesthesia. No major complications were observed. This modified infraclavicular brachial plexus block using a double-stimulation technique was easy to perform, had frequent success, and was safe in this cohort.
Publication Types:
PMID: 15616088 [PubMed - indexed for MEDLINE]
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Plantar flexion seems more reliable than dorsiflexion with Labat's sciatic nerve block: a prospective, randomized comparison.
Taboada M, Atanassoff PG, Rodriguez J, Cortes J, Del Rio S, Lagunilla J, Gude F, Alvarez J.
Department of Anesthesiology, Hospital Clinico Universitario de Santiago, Travesia da Choupana s/n, 15706 Santiago de Compostela, Spain. manutabo@mixmail.co
Labat's classic approach to the sciatic nerve has not been able to show which motor response of the foot provides a more frequent rate of complete sensory and motor block. In this prospective, randomized, double-blind study, we compared plantar flexion with dorsiflexion with regard to onset time and efficacy of sciatic nerve block using the classic posterior approach. A total of 80 patients undergoing hallux valgus repair were randomly allocated to receive sciatic nerve block after evoked plantar flexion (n=40) or dorsiflexion (n=40). Twenty milliliters of 0.75% ropivacaine was injected after the motor response was elicited at <0.5 mA. Success rate was defined as complete sensory and motor block in all sciatic nerve distributions associated with a pain-free surgery. Time required for onset of sensory and motor block of the foot was recorded. Success was more frequent after elicited plantar flexion (87.5%) than dorsiflexion (55%; P <0.05). Onset of complete sensory and motor block of the foot was faster after elicited plantar flexion (10 +/- 10 min and 13 +/- 10 min, respectively) compared with dorsiflexion (20 +/- 11 min and 24 +/- 12 min; P <0.05). We conclude that plantar flexion of the foot predicts a shorter onset time and a more frequent success rate than dorsiflexion with Labat's classic posterior sciatic nerve block.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15616086 [PubMed - indexed for MEDLINE]
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Intrathecal morphine for analgesia after postpartum bilateral tubal ligation.
Habib AS, Muir HA, White WD, Spahn TE, Olufolabi AJ, Breen TW.
Department of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710, USA. habib001@mc.duke.edu
Postpartum bilateral tubal ligation (PPBTL) causes postoperative pain. We designed this study to determine the efficacy of 50 microg intrathecal morphine for analgesia after PPBTL. Sixty-five women received spinal anesthesia with 12.75 mg hyperbaric bupivacaine, 20 microg of fentanyl, and either 50 microg of morphine (morphine group) or 0.05 mL of saline (control group). Postoperative analgesia was provided with regular naproxen 500 mg and oxycodone 5 mg/acetaminophen 325 mg mixture as needed. Overall, satisfaction was higher (P=0.003) and pain was less intense at rest (P=0.008) and on movement (P <0.0001) in the morphine group. There was no significant overall difference in nausea, pruritus, or sedation scores, but vomiting occurred more frequently in the morphine group (21.4% versus 3.5%; P=0.052). In post hoc comparisons, pain at rest within the morphine group was significantly less at 4 h (P=0.006), pain on movement was significantly less at 4 h (P=0.002) and 12 h (P=0.0004), and pruritus was significantly more frequent at 12 h (P=0.002) compared with the control group. Oxycodone 5 mg/acetaminophen 325 mg mixture consumption was significantly smaller (P=0.006) and the time to first request of analgesia was significantly longer (P=0.006) in the morphine group. We conclude that the addition of 50 microg of morphine to intrathecal hyperbaric bupivacaine and fentanyl provides improved postoperative analgesia in women undergoing PPBTL.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15616084 [PubMed - indexed for MEDLINE]
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Postoperative gastrointestinal tract dysfunction.
Mythen MG.
The Portex Unit, Institute of Child Health, Sixth Floor Cardiac Wing, 30 Guilford St., London WC1N 1EH, UK. m.mythen@ich.ucl.ac.uk
Postoperative gastrointestinal (GI) tract dysfunction (PGID) is common and is associated with increased patient suffering and cost of care. The pathogenesis of PGID is complex and multifactorial. Traditional measures intended to reduce the incidence of PGID, such as the use of prokinetic drugs, nasogastric tube drainage, and the avoidance of early fluid and/or food intake, are apparently not beneficial. The administration of larger volumes of IV fluids to achieve predetermined increases in cardiac output has been shown in randomized trials to improve gut perfusion and reduce the incidence of PGID. A multimodal approach that includes limited surgical incision, regional local anesthesia, early mobilization, and enteral feeding has been associated with a dramatic reduction in postoperative complications, PGID, and length of hospital stay. However, none of these approaches has been validated in adequately powered multicenter prospective randomized controlled trials.
Publication Types:
PMID: 15616078 [PubMed - indexed for MEDLINE]
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Patient state index during a cardiac arrest in the operating room.
Nguyen NK, Lenkovsky F, Joshi GP.
Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9068, USA.
A 53-yr-old man undergoing laparoscopic cholecystectomy experienced cardiac arrest intraoperatively. Patient state index values decreased to single digits during the cardiac arrest and returned to baseline after successful cardiopulmonary resuscitation.
Publication Types:
PMID: 15616070 [PubMed - indexed for MEDLINE]
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Train-of-four stimulation for adductor pollicis neuromuscular monitoring can be applied at the wrist or over the hand.
Nepveu ME, Donati F, Fortier LP.
FRCPC, Hopital Maisonneuve-Rosemont, 5415 boulevard de l'Assomption, Montreal, QC, H1T 2M4, Canada.
Adductor pollicis stimulation over the ulnar nerve at the wrist is the standard method of monitoring neuromuscular function. Stimulation over a muscle is believed to cause direct muscle contraction, but evidence for this is lacking. In this study we sought to determine whether direct muscle stimulation occurred during stimulation of the adductor pollicis in the hand and whether the responses were comparable to those observed with stimulation at the wrist. In 20 patients anesthetized with sevoflurane, 1 pair of stimulating electrodes was positioned over the ulnar nerve at the wrist. A second pair was placed between the first and second metacarpals on the palmar and dorsal aspects of the hand. The acceleromyographic response was monitored. Rocuronium 0.6 mg/kg was administered. Train-of-four (TOF) stimulations were applied at the wrist site until maximal blockade. Then, stimulation was applied to the hand site. During recovery, both sites were monitored alternately. After injection of rocuronium, 17 of 20 patients showed no twitch response at either site. One patient had a response at both stimulation sites, and two patients had responses only at the wrist site. With a Bland and Altman analysis, TOF ratios during recovery at the hand showed a bias of 0.5% and limits of agreement of +/-11.8% as compared with the wrist. Stimulation in the hand causes no direct muscle stimulation because the response is no more than that produced by stimulation at the wrist. Both sites yield comparable TOF ratios.
Publication Types:
PMID: 15616069 [PubMed - indexed for MEDLINE]
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The association between propofol-induced loss of consciousness and the SNAP index.
Wong CA, Fragen RJ, Fitzgerald PC, McCarthy RJ.
Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E. Huron St., F 5-704, Chicago, IL 60611, USA. c-wong2@northwestern.edu
The SNAP is a processed electroencephalogram monitor that uses an algorithm based on low- and high-frequency spectral components to derive a SNAP index. In this study we sought to determine the relationship of the SNAP index with loss of consciousness in subjects receiving a bolus of propofol. Unpremedicated subjects were randomized to receive 1 of 11 doses of IV propofol (0, 0.6, 0.8, 1.0, 1.2, 1.4, 1.6, 1.8, 2.0, 2.2, or 2.4 mg/kg; n=20 per group). The SNAP index was recorded when the subject became unconscious (end-point) or at 160 s after the injection. Sixty-five percent of subjects achieved the end-point (defined as the time at which the subject dropped a weighted syringe). The 50% effective dose for propofol was 0.97 mg/kg (95% confidence interval [CI], 0.86-1.07 mg/kg). The median awake SNAP index was 92 (range 78-99) and did not differ between subjects who reached the end-point and those who did not. The end-point SNAP index decreased from baseline in the subjects who dropped the syringe to a median of 76 (range, 57-94) at doses > or =1.0 mg/kg but was not different among doses. The index was not different from baseline at 160 s in subjects who did not reach the end-point. Binary logistic regression models predicted a SNAP index 95% effective dose for loss of consciousness of 71 (95% CI, 63-74) and 19 (95% CI, 16-22) for changes in SNAP index from baseline. The areas under the receiver operator characteristic curves for these models were 0.837 and 0.864. The SNAP index correlated with propofol-induced loss of consciousness. It appears to be a useful indicator of loss of consciousness and should be further investigated as a monitor of anesthesia depth.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
- Validation Studies
PMID: 15616068 [PubMed - indexed for MEDLINE]
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Fascia iliaca block for an infant with arthrogryposis multiplex congenita undergoing muscle biopsy.
Ion T, Cook-Sather SD, Finkel RS, Cucchiaro G.
Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA 19104-4399, USA.
Children with arthrogryposis multiplex congenita often require multiple surgical procedures. We present a case of a neonate with arthrogryposis multiplex congenita in which intubation was judged to be technically difficult and in which peripheral regional anesthesia allowed us to obtain a satisfactory muscle biopsy without risking the complications of general anesthesia.
Publication Types:
PMID: 15616056 [PubMed - indexed for MEDLINE]
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The effects of propofol and sevoflurane on the QT interval and transmural dispersion of repolarization in children.
Whyte SD, Booker PD, Buckley DG.
Children's Hospital, Department of Anesthesia, Room 1L7, 4480 Oak Street, Vancouver, BC, V6H 3V4. sdwhyte@bigfoot.com
Prolongation of the QT interval is associated with torsades de pointes (TdP), especially in children or young adults with long QT syndromes. Susceptibility to TdP arises from increased transmural dispersion of repolarization (TDR) across the myocardial wall. Several anesthetic drugs prolong the QT interval, but their effect on TDR is unknown. TDR can be measured on the electrocardiograph (ECG) as the time interval between the peak and end of the T wave (Tp-e). We investigated the effects of propofol and sevoflurane on the corrected QT (QTc) and Tp-e intervals in 50 unpremedicated ASA physical status I-II children, aged 1-16 yr, who were randomized to receive propofol (group P) or sevoflurane (group S). Twelve-lead ECGs were recorded preoperatively and intraoperatively. Sevoflurane significantly prolonged the preoperative QTc; propofol did not. Neither anesthetic had any significant effect on the preoperative Tp-e. Sevoflurane increases the duration of myocardial repolarization in children to a larger extent than does propofol, but as the dispersion of repolarization appears unaffected, the risk of TdP is likely to be minimal with either anesthetic.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15616054 [PubMed - indexed for MEDLINE]
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Direction of the J-tip of the guidewire, in seldinger technique, is a significant factor in misplacement of subclavian vein catheter: a randomized, controlled study.
Tripathi M, Dubey PK, Ambesh SP.
Department of Anesthesiology, SGPGIMS, Lucknow-226 014, India. mukesh_tripathi@yahoo.com
Misplacement of central venous catheters, predisposing to poor functioning including inability to aspirate blood, is common with the subclavian approach. In this prospective study we sought to determine whether the direction of the guidewire J-tip influenced the catheter tip placement during right subclavian catheterization. In this randomized, double-blind clinical study, we observed the placement of catheters via the right subclavian vein while keeping the J-tip directed either caudad in Group 1 (n=147) or cephalad in Group 2 (n=148) patients. The majority of catheters (97% and 57%) in Groups 1 and 2 respectively entered the superior vena cava/right atrium (P <0.05). The incidence of catheter misplacement into the ipsilateral internal jugular vein was 2% and 40% in Groups 1 and 2, respectively (P = <0.01). Subsequent experimental study confirmed that the direction of the J-tip was retained inside a model of vascular tubes and its tip led the guidewire into the tubing on the same side even at the acute angulation formed between tubings representing the subclavian, internal jugular, and superior vena cava junction complex. The authors conclude that the simple measure of keeping the guidewire J-tip directed caudad increased correct placement of central venous catheters towards the right atrium during right subclavian catheterization.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15616046 [PubMed - indexed for MEDLINE]
Comment in:
The effects of acute isovolemic hemodilution on oxygenation during one-lung ventilation.
Szegedi LL, Van der Linden P, Ducart A, Cosaert P, Poelaert J, Vermassen F, Mortier EP, d'Hollander AA.
Department of Anesthesiology 2K12, Gent University Hospital, De Pintelaan, 185, 9000 Gent, Belgium. laszlo.szegedi@ugent.be
Data on the effects of isovolemic hemodilution (IH) on oxygenation during one-lung ventilation (OLV) are lacking. We studied 47 patients with hemoglobin >14 g/dL who were scheduled for lung surgery (17 with normal lung function [group NL], 17 with chronic obstructive pulmonary disease [COPD] [group COPD], and 13 with COPD as control for time/anesthesia effects [group CTRL]). Anesthesia was standardized. The tracheas were intubated with a double-lumen tube. Ventilatory settings and fraction of inspired oxygen remained constant. The study was performed with patients in the supine position before surgery. OLV was initiated for 15 min. Two-lung ventilation was reinstituted, and IH was performed (500 mL); an identical volume of hydroxyethyl starch was administered. Subsequently, OLV was again performed for 15 min. In group CTRL, the same sequences of OLV were performed without IH. At the end of each period of OLV, pulmonary mechanics and blood gases were recorded. Data were analyzed by analysis of variance (mean +/- sd). In group NL and group CTRL, the arterial oxygen partial pressure remained constant, whereas it decreased in group COPD from 119 +/- 21 mm Hg before IH to 86 +/- 16 mm Hg after IH (P <0.01). Mild IH impairs gas exchange during OLV in COPD patients, but not in patients with normal lung function.
Publication Types:
PMID: 15616045 [PubMed - indexed for MEDLINE]
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Local anesthesia in dentistry.
Bahl R.
School of Dental Medicine, University of Connecticut Health Center, Farmington, Connecticut 06030, USA. bahl@student.uchc.edu
PMID: 15675263 [PubMed - in process]
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Comparison of injection pain, heart rate increase, and postinjection pain of articaine and lidocaine in a primary intraligamentary injection administered with a computer-controlled local anesthetic delivery system.
Nusstein J, Berlin J, Reader A, Beck M, Weaver JM.
Department of Graduate Endodontics, College of Dentistry, The Ohio State University, Columbus, Ohio 43218, USA.
The purpose of this prospective, randomized, double-blind study was to compare the pain of injection, heart rate increase, and postinjection pain of the intraligamentary injection of 4% articaine with 1:100,000 epinephrine and 2% lidocaine with 1:100,000 epinephrine administered with a computer-controlled local anesthetic delivery system. Using a crossover design, intraligamentary injections of 1.4 mL of 4% articaine with 1:100,000 epinephrine and 1.4 mL of 2% lidocaine with 1:100,000 epinephrine were randomly administered on the mesial and distal aspects of the mandibular first molar with a computer-controlled local anesthetic delivery system in a double-blind manner at 2 separate appointments to 51 subjects. The results demonstrated the incidence of moderate pain was 14%-27% with needle insertion, with 0%-4% reporting severe pain. For solution deposition, moderate pain was reported 8%-18% of the time, with no reports of severe pain. There were no significant differences between the articaine and lidocaine solutions. Regarding heart rate changes, neither anesthetic solution resulted in a significant increase in heart rate over baseline readings. On day 1 postinjection, there was a 31% incidence of moderate/severe pain with the articaine solution and 20% incidence of moderate/severe pain with the lidocaine solution. The moderate/severe pain ratings decreased over the next 2 days. There were no significant differences between the articaine and lidocaine solutions. We concluded that the intraligamentary injection of 4% articaine with 1:100,000 epinephrine was similar to 2% lidocaine with 1:100,000 epinephrine for injection pain and postinjection pain in the mandibular first molar when administered with a computer-controlled local anesthetic delivery system. For both anesthetic solutions, heart rate did not significantly increase with the intraligamentary injection using the computer-controlled local anesthetic system.
PMID: 15675261 [PubMed - in process]
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Survey of oral and maxillofacial surgeons' offices in Virginia: anesthesia team characteristics.
Campbell RL, Fritz G, Campbell JR.
Virginia Commonwealth University, Medical College of Virginia School of Dentistry, Richmond, Virginia, USA.
This survey assesses whether oral and maxillofacial surgeons in the state of Virginia are prepared for inspection of their offices. A survey asking pertinent questions on the availability of specific equipment and the educational qualifications of the anesthesia care team was developed and sent to 155 offices. Seven questions were asked regarding the availability of nurses, types of life support training, (formal or informal), the surgeons and anesthesia care personnel, and the presence of a defibrillator. Questionnaires were short and simple to encourage compliance with the study guidelines. A total of 128 (82.6%) questionnaires were returned. Only 42 of 128 (32.8%) offices employed nurses, and 6 of the 42 nurses were not considered as part of the anesthesia care team. Only 36 of 128 (28.1%) of the offices had assistants with formal anesthesia assistant course training from the American Association of Oral and Maxillofacial Surgeons (AAOMS) or the American Dental Society of Anesthesiology (ADSA). However, 93% of the assistants who participated in the anesthesia had current basic life support training (BLS) training, and 74% of the surgeons had current advanced cardiac life support (ACLS) training. The AAOMS Office Emergency Manual was present in 118 of 128 offices (92.2%), and 124 of 128 offices (96.9%) had defibrillators. The survey suggests that the surgeons are well prepared from the standpoint of having a defibrillator present and the AAOMS Office Emergency Manual available as a template for the team to use in order to answer questions that the inspection team may ask of the primary anesthesia care provider and surgeon. The majority of the surgeons had current ACLS certification, and the office anesthesia assistants had current BLS training. Most of the assistants did not have formal course training, which indicates that on-the-job training is probably the norm. Less than one third of the offices had nurses.
PMID: 15675260 [PubMed - in process]
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Intranasal sufentanil/midazolam versus ketamine/midazolam for analgesia/sedation in the pediatric population prior to undergoing multiple dental extractions under general anesthesia: a prospective, double-blind, randomized comparison.
Roelofse JA, Shipton EA, de la Harpe CJ, Blignaut RJ.
Department of Anesthesiology, Faculty of Dentistry, University of Stellenbosch.
This article details a double-blind, randomized study evaluating the efficacy and safety of intranasal sufentanil and intranasal midazolam (S/M) when compared with intranasal ketamine and intranasal midazolam (K/M) for sedation and analgesia in pediatric patients undergoing dental surgery. Fifty healthy ASA status 1 children aged 5-7 years, weighing 15-20 kg, and having 6 or more teeth extracted, were randomly allocated to 2 groups of 25 patients each (n = 50). In the S/M group, 25 children received intranasal sufentanil 20 microg, and intranasal midazolam 0.3 mg/kg 20 minutes before the induction of anesthesia. In the K/M group, 25 children received intranasal ketamine 5 mg/kg and intranasal midazolam 0.3 mg/kg 20 minutes before the induction of anesthesia. Sevoflurane in nitrous oxide and oxygen was used for induction and maintenance of anesthesia. This study demonstrated the safety and efficacy of both methods with ease of administration, combined with a rapid onset of action. Both groups were equally sedated. A smooth mask induction of anesthesia was experienced in the majority of children. Effective postoperative analgesia for multiple dental extractions was provided. The intranasal administration of drugs for sedation and analgesia has some promising features in preschool children undergoing multiple dental extractions.
PMID: 15675259 [PubMed - in process]
[Do we have to monitor foetal heart rate during general anesthesia?]
[Article in French]
Martin F, Viviand X, Desbriere R, Boubli L, Martin C.
Departement d'anesthesie et de reanimation, CHU Nord, boulevard Pierre-Dramard, 13915, Marseille 20, France. frmart01@wanadoo.fr
We present a case of an emergency Caesarean section due to misinterpretation of the cardiotocography (CTG) trace during general anaesthesia for treatment of dental abscess. Following failure of the dental abscess treatment under local anaesthesia, a 29-year-old female in the 36th week of a twin pregnancy was to undergo general anaesthesia. Foetal well-being was monitored with ultrasonographic evaluations of foetal heart rate. During surgery, senior obstetrician recorded a lack of beat-to-beat variability of the cardiotocography trace. The CTG pattern was interpreted as foetal distress and an emergency Caesarean section was performed under general anaesthesia. That was probably due to general anaesthesia. Then, two infants were extracted without neonatal distress necessitating intubation. This case report underlines the risk to misread an intraoperative CTG monitoring and if the CTG monitoring is normal before anaesthesia, reduced foetal beat-to-beat variability with a normal baseline heart rate during general anaesthesia is probably normal.
Publication Types:
PMID: 15589358 [PubMed - indexed for MEDLINE]
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[Ischaemia of the lower limbs: anaesthesia and intensive care]
[Article in French]
Piriou V, Feugier P, Granger S, Gueugniaud PY.
Service d'anesthesie-reanimation, centre hospitalier Lyon-Sud, 69495 Pierre-Benite, France. vincent.piriou@chu-lyon.fr
OBJECTIVES: To appreciate the severity of a patient with acute limb ischaemia, to know how to manage these patients during the perioperative period. DATA SOURCES: References were obtained from PubMed data bank (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) using the following keywords: acute limb, ischaemia, prognosis, complications, rhabdomyolysis, hyperkalaemia, compartment syndrome, fasciotomy. DATA SYNTHESIS: Ischaemia of the lower limbs is a medico-surgical emergency. The ischaemia implies a decrease of cellular energetic stocks and an increase in intracellular calcium. During reperfusion, the calcium paradox is exacerbated and ROS formation produces membrane damage. Tissue oedema and a local and general inflammatory syndrome occur. Clinical symptoms of acute ischaemia include pallor, pulselessness, decrease of temperature and pain. Occurrence of neurological symptoms is a sign of severity. Prognosis of patients relates directly to preexisting collateral circulation, aetiology of the occlusion (thrombosis vs embolus), duration of ischaemia, topography of the occlusion (severity of proximal occlusions as the acute aortic occlusion), and co-morbidity (renal failure, heart failure). The temperature of the ischaemic limb, quality of the downstream circulation, extension of the thrombus, arterial pressure and association to a venous thrombosis are other prognostic factors of lower limb ischaemia. The first treatment to be initiated is high doses of heparin. Once the diagnosis is made, the number of preoperative tests will be as small as possible because of the urgency of revascularization. Arteriography will be performed only when really needed and when its realization will not delay revascularization and will not alter the patient's prognosis. Where general anesthesia is required, the choice of anaesthetic agents will be based on their haemodynamic stability. During severe acute limb ischaemia, monitoring of invasive pressure is recommended, as well as regular dosages of potassium, arterial gases and CPK. Preoperatively in case of severe ischaemia, (proximal occlusion lasting more than 6 hours), preventive treatment, including controlled reperfusion with heparinized serum is indicated. Surveillance and prevention of a rhabdomyolysis and renal failure are imperative. Immediately after reperfusion, a dosage of potassium must be performed; moreover that hyperkalaemia is favoured by acidosis or renal failure. Postoperative haemodialysis is performed in case of hyperkalaemia or renal failure. Occurrence of compartment syndrome has to be checked and fasciotomy must be performed in case of a doubt on the microcirculation integrity.
Publication Types:
PMID: 15589356 [PubMed - indexed for MEDLINE]
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[Comparison of eight deep breaths and tidal volume breathing preoxygenation techniques in morbid obese patients]
[Article in French]
Rapaport S, Joannes-Boyau O, Bazin R, Janvier G.
Departement d'anesthesie et de reanimation-II, CHU de Bordeaux, maison du Haut-Leveque, avenue de Magellan, 33600 Pessac, France. stephane.rapaport@chu-bordeaux.fr
OBJECTIVE: To compare two techniques of preoxygenation, eight deep breaths (8DB) and tidal volume breathing in obese patients by measuring end-tidal fractional oxygen concentration (FETO2) and apnea time from 100% of hemoglobin saturation to 95% (T95%). STUDY DESIGN: Prospective randomized study. METHODS: Twenty obese patients (BMI >40 kg/m2) without cardiorespiratory disease nor difficult intubation criteria were randomized into two groups of ten. One group received preoxygenation with eight deep breaths in one minute (8DB) and the other with three minutes tidal volume preoxygenation (3TV) both under FIO2 100%. FETO2 every minute of preoxygenation and T95% were measured. Data were analyzed with Mann and Whitney test. A p <0.05 was considered significant. RESULT: There was no significant difference between the groups regarding FETO2 values [84 +/- 4% (8DB) and 88 +/- 5% (3TV)] and T95% [176 +/- 23 s (8DB) and 181 +/- 35 s (3TV)]. The PETCO2 was significantly inferior in the 8DB group at the end of preoxygenation [PETCO2 =29 +/- 1 mmHg (8DB) and PETCO2 =36 +/- 5 mmHg (3TV)]. CONCLUSION: 8DB and 3TV preoxygenation techniques in morbid obese patients induce similar FETO2 and T95%. However hyperventilation effects in the 8DB group are unknown.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15589355 [PubMed - indexed for MEDLINE]
Comment in:
[Anaphylactic and anaphylactoid reactions occurring during anaesthesia in France. Seventh epidemiologic survey (January 2001-December 2002)]
[Article in French]
Mertes PM, Laxenaire MC; GERAP.
Service d'anesthesie-reanimation Chirurgicale, hopital Central, Nancy, France. pm.mertes@chu-nancy.fr
OBJECTIVES: Hypersensitivity reactions IgE-mediated (anaphylaxis) or non-IgE-mediated (anaphylactoid) reactions occurring during anaesthesia remain a major cause of concern for anaesthesiologists, since these reactions remain usually unpredictable, may be potentially life-threatening even when appropriately treated. The authors report the results of the last 2-year survey (2001, 2002) of such reactions conducted in France by the GERAP (groupe d'etude des reactions anaphylactoides peranesthesiques), and compare these results with their previous published surveys. METHODS: Between January 1, 2001 to December 31, 2002, 712 patients who experienced immune-mediated (anaphylaxis) or non-immune-mediated (anaphylactoid) reactions were referred to one of the 40 allergo-anaesthesia centres members of the GERAP. Anaphylaxis was diagnosed on the basis of clinical history, tryptase measurements during the adverse reaction, and skin tests and/or specific IgE assay. RESULTS: Anaphylactic and anaphylactoid reactions were diagnosed in 491 cases (69%) and 221 cases (31%), respectively. The most common causes of anaphylaxis were neuromuscular blocking agents (NMBA) (n=271, 55%), latex (n=112, 22.3%), and antibiotics (n=74, 14.7%). Succinylcholine (n=102, 37.6%) and rocuronium (n=71, 26.2%) were the most frequently incriminated NMBAs. Cross-reactivity between NMBAs was observed in 63.4 % of cases of anaphylaxis to a NMBA. No difference was observed between anaphylactoid and anaphylactic reactions when the incidences of atopy, food, or drug intolerance were compared. However atopy, asthma and food allergy were significantly more frequent in case of latex allergy, when compared with NMBA allergy. Clinical manifestations were more severe in anaphylaxis. The positive predictive value of tryptase measurement for the diagnosis of anaphylaxis was 95.3%, the negative predictive value 49%. The diagnostic value of specific neuromuscular blocking agent IgE assays was confirmed. CONCLUSION: Our results further corroborate the need for systematic screening in case of immediate hypersensitivity reaction during anaesthesia and for the constitution of allergo-anaesthesia centres to provide expert advice to anaesthesiologists and allergologists.
PMID: 15589352 [PubMed - indexed for MEDLINE]
Comment on:
[The anaphylactic shock exists: we have met it]
[Article in French]
Lienhart A, Auroy Y.
Publication Types:
PMID: 15589349 [PubMed - indexed for MEDLINE]
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Anesthesia in caudal regression syndrome.
Yegin A, Sanli S, Hadimioglu N, Sahin N.
PMID: 15675942 [PubMed - in process]
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Anesthetic management of a child with Aicardi syndrome.
Gooden CK, Pate VA, Kavee R.
PMID: 15675939 [PubMed - in process]
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Anesthetic management of a child with Klippel-Feil syndrome in the radiology suite.
Manivel S.
PMID: 15675938 [PubMed - in process]
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Automatic atrial tachycardia in an infant following general anesthesia.
Tripi PA, Dorostkar P.
Department of Anesthesiology, University Hospitals of Cleveland, Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
Summary Automatic atrial tachycardia (AAT) is a rare supraventricular tachyarrhythmia (<10% of all supraventricular tachycardias), which can present in infants or young children. There are no published reports of AAT occurring in an infant or child following noncardiac surgery and general anesthesia. This report describes the management of a previously healthy 5-month-old infant, who developed AAT in the postanesthesia care unit following an uneventful circumcision under general anesthesia.
PMID: 15675935 [PubMed - in process]
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The Portex 'Soft Seal' single use laryngeal mask - a preliminary study in pediatric anesthesia.
Glaisyer HR, Yule C.
Anaesthetic Department, Great Ormond Street Hospital, London, UK.
Summary Background: Portex have developed a single use pediatric laryngeal mask (LM), which is available in all sizes. Methods: We prospectively evaluated its use in 40 infants and children undergoing a variety of surgical procedures. Results: The LM provided a satisfactory airway in all patients. Insertion was quick and easy and achieved at the first attempt in 38 patients. Repositioning was required during anesthesia in four cases. Conclusions: The Portex 'Soft Seal' LM performs satisfactorily in elective pediatric anesthesia.
PMID: 15675926 [PubMed - in process]
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Distorted perception of smell by volatile agents facilitated inhalational induction of anesthesia.
Fukumoto M, Arima H, Ito S, Takeuchi N, Nakano H.
Department of Anaesthesia and Intensive Care, Okazaki City Hospital, Okazaki, Japan.
Summary Background: Unpleasant smell of halogenated volatile agents is one of the frustrating factors for inhalational induction. We developed a new modification that might enable children to enjoy the smell itself while incrementally elevating sevoflurane concentration. Troposmia is usually a pathological quality change of smell perception and an olfactory stimulus is distortedly perceived in this state, which we applied to inhalational induction. Methods: At the preoperative visit an anesthetist told the children that the smell of a facemask could be magically changed from strawberry into anything and promised to change the smell as they requested. In the operating room, a strawberry scented facemask was fitted to the face and the anesthetist announced to them that the magical change of the smell would begin when sevoflurane was added. Whether children perceived the change of the smell as they requested was investigated in the troposmia group, and resistance to fit a facemask was compared between the troposmia group and a control group. Results: Significantly fewer children resisted the facemask in the troposmia group (1 of 32 Vs 9 of 32; P = 0.0059). In the troposmia group 18, 22 and 25 of the 32 children said the smell of the facemask changed as they requested before they fell asleep, at the postoperative visit or both, respectively. Conclusions: Troposmia can be intentionally induced to perceive the smell of sevoflurane on request. Troposmia might contribute to promote children's participation in anesthesia induction and facilitate inhalational induction.
PMID: 15675924 [PubMed - in process]
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Anesthesia during intralesional bare fiber laser treatment of a giant hemangioma of head and neck region of an infant using the laryngeal mask airway.
Kurt E, Kulahci Y, Zor F, Celikoz B.
Publication Types:
PMID: 15662735 [PubMed - in process]
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Perioperative care of the patient with nephropathic cystinosis.
Ray TL, Tobias JD.
Department of Child Health, The Division of Pediatric Critical Care/Pediatric Anesthesiology, The University of Missouri, Columbia, MO, USA.
Cystinosis is an autosomal recessive disease that results in a defective integral membrane protein responsible for the transport of cystine out of lysosomes. This results in the accumulation of cystine in the lysosomes of almost every tissue, with subsequent formation of damaging crystals. The cystinotic process may affect every system of the body, but is particularly damaging to the kidneys and eyes. We discuss the perioperative care of a cystinotic patient with renal insufficiency, Fanconi's syndrome, and photophobia. Other organ systems affected by the cystinotic process are also discussed, with suggestions for the perioperative management of each. Issues of primary concern during perioperative care include preservation of renal function and maintenance of fluid and electrolyte homeostasis. Copyright 2004 Blackwell Publishing Ltd.
Publication Types:
PMID: 15385020 [PubMed - indexed for MEDLINE]
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Caudal analgesia in children: S(+)-ketamine vs S(+)-ketamine plus clonidine.
Passariello M, Almenrader N, Canneti A, Rubeo L, Haiberger R, Pietropaoli P.
Department of Anaesthesia and Intensive Care Medicine, Univerity of Rome La Sapienza, Rome, Italy. maurizio.passariello@libero.it
BACKGROUND: The aim of this study was to evaluate postoperative analgesia provided by caudal S(+)-ketamine and S(+)-ketamine plus clonidine without local anesthetic. METHODS: Forty-four children aged 1-5 years consecutively scheduled for inguinal hernia repair, hydrocele repair or orchidopexy were randomly assigned to receive a caudal injection of either S(+)-ketamine 1 mg x kg(-1) (group K) or S(+)-ketamine 0.5 mg x kg(-1) plus clonidine 1 microg x kg(-1) (group KC). Postoperative analgesia and sedation were evaluated by CHEOPS and Ramsay scale from emergence from general anesthesia for 24 h. RESULTS: No statistical difference was observed between study groups with respect to pain and sedation assessment. A slight trend toward a reduced requirement for rescue analgesia in group KC was observed, although not statistically significant. CONCLUSIONS: Caudal S(+)-ketamine 1 mg x kg(-1) and S(+)-ketamine 0.5 mg x kg(-1) plus clonidine 1 microg x kg(-1) are safe and provide effective postoperative analgesia in children without adverse effects. Copyright 2004 Blackwell Publishing Ltd.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15385014 [PubMed - indexed for MEDLINE]
Comment on:
Early intravenous cannulation in children during sevoflurane induction.
Schwartz D, Connelly NR, Gutta S, Freeman K, Gibson C.
Department of Anesthesiology, Baystate Medical Center, Springfield, MA 01199, USA.
BACKGROUND: It has been shown that early placement of an intravenous line in children anesthetized with halothane is equally safe compared with later placement. Whether this is true of sevoflurane is not known. METHODS: Pediatric patients, age 1-18 years, undergoing elective general anesthesia via an inhalation induction were randomized to intravenous placement either 30 or 120 s following loss of lid reflex. Movement on intravenous placement and incidence of laryngospasm were determined. Difficulty with intravenous placement was recorded. RESULTS: Movement on intravenous placement was more prevalent in the early group than in the late group (P < 0.0001). There was no laryngospasm in the late group and eight cases in the early group (P < 0.004). Children who had laryngospasm were older (P < 0.02) and weighed more (P < 0.04). Older children in the early group were more likely to have significant movement. CONCLUSION: Following an inhalation induction with sevoflurane in children, movement with intravenous placement was greater, and the incidence of laryngospasm was higher, when the intravenous access was attempted 30 s rather than 120 s following loss of lid reflex. We recommend waiting two min following the loss of lid reflex before attempting intravenous placement in children receiving an inhalation induction with sevoflurane. Copyright 2004 Blackwell Publishing Ltd.
Publication Types:
- Clinical Trial
- Comment
- Randomized Controlled Trial
PMID: 15385009 [PubMed - indexed for MEDLINE]
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Is tissue coring a real problem after caudal injection in children.
Baris S, Guldogus F, Baris YS, Karakaya D, Kelsaka E.
Department of Anaesthesiology, Ondokuz Mayis University, Samsun, Turkey. sbaris@omu.edu.tr
BACKGROUND: The aim of this study was to determine whether tissue coring occurs with 22-G hollow needle and 22-G caudal block needle during caudal injection in children, as well as evaluating the nature of the coring material if it did occur. METHODS: Seventy children were randomly allocated to two groups and caudal block was performed with either 22-G hollow (group I) or 22-G caudal block (group II) needle under general anesthesia. The needles and guides were washed with 0.5 ml of 70% ethanol in a sterile tube and were evaluated by a pathologist blinded to the type of needle used, for the type and number of cells. RESULTS: Nucleated cells, which have no mitotic activity, were present in 8.5% in each study group and bloody material was present in 8.5 and 2.8%, in group I and II, respectively. Non-nucleated epidermal cells were detected in 94.2 and 97.1% of the patients in group I and II, respectively. However, cells with mitotic activity from the stratum basale were not detected in any slides. CONCLUSIONS: The incidence of transporting nucleated epidermal cells with no mitotic activity from stratum spinosum during puncture for caudal block is low and no differences exist between different types of needle used. However, it may also suggest that transporting nucleated cells with mitotic activity from the stratum basale may be possible during caudal puncture.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15330958 [PubMed - indexed for MEDLINE]
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Audio-Doppler guidance using a small-caliber Doppler probe for internal jugular venous puncture for central venous catheterization in infants and children.
Arai T, Yamashita M.
Department of Anesthesiology, Ibaraki Children's Hospital, Mito, Ibaraki, Japan. tsmaria@nifty.com
BACKGROUND: We evaluated an audio-Doppler with a small-caliber probe as a guide for central venous cannulation (CVC) via the internal jugular vein (IJV) in infants and children. METHODS: The right IJV was located with a small-caliber (2.0 mm in diameter) audio-Doppler probe using 10 MHz ultrasound. The probe was placed on the neck about the level of sixth cervical vertebra and was moved until the crisp pulsatile sound of the carotid artery was identified. Then the probe was moved laterally to identify the low-pitched venous hum of the right IJV. After marking the puncture site on the skin, a sterile cannulation procedure was performed. Ultimate success rate, cannulation time < 10 min, successful cannulation within three punctures, and complications were recorded. RESULTS: Ultimate success rate was 65.6% (42/64) in infants (< 12 m), and 94.7% (72/76) in children (12 m or older). Cannulation time < 10 min was 48.4% in infants, and 85.5% in children. Successful cannulation within three punctures was 45.3% in infants and 82.8% in children. Three carotid arterial punctures occurred. CONCLUSIONS: We were not able to demonstrate absolute superiority of the results utilizing this device over the reported results of traditional landmark techniques for CVC via the right IJV. However, this device may contribute to reducing complications and be of value in teaching residents where to insert a needle for an internal jugular puncture.
Publication Types:
PMID: 15330956 [PubMed - indexed for MEDLINE]
Comment in:
Ropivacaine in neonates and infants: a population pharmacokinetic evaluation following single caudal block.
Rapp HJ, Molnar V, Austin S, Krohn S, Gadeke V, Motsch J, Boos K, Williams DG, Gustafsson U, Huledal G, Larsson LE.
Department of Anaesthesiology, Universitatsklinikum Mannheim, Mannheim, Germany. h-j.rapp@urz.uni-heidelberg.de
BACKGROUND: The aims of this study were to evaluate pharmacokinetics, efficacy and safety of ropivacaine in infants aged 0-12 months following a single caudal injection. METHODS: Term ASA I-III patients, scheduled for surgery, with a body weight of > or = 2500 g received a caudal block with ropivacaine 2 mg x ml(-1), 1.0 ml x kg(-1). Plasma samples were collected at different time intervals up to 30 h, for analysis of total and unbound ropivacaine and alpha-1-acid glycoprotein (AAG). Pharmacokinetic data were characterized by population analysis. Unbound and total concentrations from 35 patients, median (min-max) postnatal age of 66 (4-351) days, were included in the nonlinear mixed effects modeling to provide estimates of pharmacokinetic parameters and the exploration of covariate relationships. Simulations were made to test the predictive performance of the final model and to describe the effect of significant covariates on systemic exposure. RESULTS: The mean (min-max) peak plasma concentration of total ropivacaine was 0.83 (0.05-1.57) mg x l(-1) at 0.5-5.7 h (median: 1.0 h) and the plasma concentration of unbound ropivacaine was 0.042 (0.012-0.081) mg x l(-1) within 0.5-1 h. The observed unbound fraction in plasma was 6% (1%-14%). A one-compartment open model with first-order absorption and elimination, incorporating a linear-binding model of ropivacaine to AAG best described the data. The only significant covariate relationship was that of age on Clu/F according to the following relationship Clu/F = 3.01 x e0.00474 x Age. This predicts a Clu/F of 3.5 l x h(-1) x kg(-1) at 30 days and 10.8 l x h(-1) x kg(-1) at 270 days with corresponding terminal half-lives of 6.7 and 2.2 h. The interindividual variability (coefficient of variation, CV) in Clu/F was 39%. The population estimate (CV) of ka was 1.65 h(-1) (30%), Vu/F was 33.6 (l x kg(-1)) (45%) and Ka was 1.78 l x mg(-1) (14%). Thirty-five infants received supplementary analgesics (mostly paracetamol). The median time to first supplementary analgesic (based on all 37 patients) was 3.9 h. No safety concerns or signs of systemic toxicity were observed. CONCLUSIONS: Following a caudal block with ropivacaine 2 mg x kg(-1) plasma concentrations of unbound ropivacaine were well below threshold levels for toxicity in adults. Apparent volume of distribution is unchanged, apparent unbound clearance increases and the terminal half-life decreases with age in 0-12-month-old neonates and infants. The postoperative pain management provided adequate analgesia and was well tolerated.
Publication Types:
- Clinical Trial
- Multicenter Study
PMID: 15330953 [PubMed - indexed for MEDLINE]
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Clinical guideline on use of anesthesia-trained personnel in the provision of general anesthesia/ deep sedation to the pediatric dental patient.
American Academy of Pediatric Dentistry.
Publication Types:
- Guideline
- Practice Guideline
PMID: 15656445 [PubMed - in process]
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Clinical guideline on the elective use of minimal, moderate, and deep sedation and general anesthesia for pediatric dental patients.
American Academy of Pediatric Dentistry.
Publication Types:
- Guideline
- Practice Guideline
PMID: 15656444 [PubMed - in process]
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