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Comment on:
Unanticipated difficult airway: what about emergency cases?
Heidegger T, Gerig HJ.
Publication Types:
PMID: 15564973 [PubMed - indexed for MEDLINE]
Comment on:
Cholinesterase inhibitors, neuromuscular blocking drugs and perioperative memory enhancement.
Fodale V, Tescione M, Pratico C.
Publication Types:
PMID: 15564972 [PubMed - indexed for MEDLINE]
Comment on:
Prolonged wear of antichemical protective gear: the hazards and difficulties of wearing chemical warfare gear.
Bloomfield EL.
Publication Types:
PMID: 15564963 [PubMed - indexed for MEDLINE]
Comment on:
Cardiac arrest, a preventable yet a possible risk of dexmedetomidine: fact or fiction?
Muntazar M, Kumar FC.
Publication Types:
PMID: 15564961 [PubMed - indexed for MEDLINE]
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Severe thrombocytopenia, type 2B von Willebrand disease and pregnancy.
Hepner DL, Tsen LC.
Harvard Medical School and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Publication Types:
PMID: 15564956 [PubMed - indexed for MEDLINE]
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Efficacy of a prophylactic epidural blood patch in preventing post dural puncture headache in parturients after inadvertent dural puncture.
Scavone BM, Wong CA, Sullivan JT, Yaghmour E, Sherwani SS, McCarthy RJ.
Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, USA. bscavone@nmff.org
BACKGROUND: Postdural puncture headache (PDPH) occurs in up to 80% of parturients who experience inadvertent dural puncture during epidural catheter placement. The authors performed a randomized double blind study to assess the effect of prophylactic epidural blood patch on the incidence of PDPH and the need for therapeutic epidural blood patch. METHODS: Sixty-four parturients who incurred inadvertent dural puncture were randomized to receive a prophylactic epidural blood patch with 20 ml autologous blood (prophylactic epidural blood patch group) or a sham patch (sham group). Subjects were evaluated daily for development of PDPH for a minimum of 5 days after dural puncture. Those who developed a PDPH were followed daily for a minimum of 3 days after resolution of the headache. Subjects with moderate headaches who reported difficulties performing childcare activities and all those with severe headaches were advised to receive a therapeutic epidural blood patch. RESULTS: Eighteen of 32 subjects in each group (56%) developed PDPH. Therapeutic blood patch was recommended in similar numbers of patients in each group. The groups had similar onset time of PDPH, median peak pain scores, and number of days spent unable to perform childcare activities as a result of postural headache. The median duration of PDPH, however, was shorter in the prophylactic epidural blood patch group. CONCLUSIONS: A decrease in the incidence of PDPH or the need for criteria-directed therapeutic epidural patch was not detected when a prophylactic epidural blood patch was administered to parturients after inadvertent dural puncture. However, prophylactic epidural blood patch did shorten the duration of PDPH symptoms.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15564951 [PubMed - indexed for MEDLINE]
Comment in:
Combinations of bupivacaine, fentanyl, and clonidine for lumbar epidural postoperative analgesia: a novel optimization procedure.
Sveticic G, Gentilini A, Eichenberger U, Zanderigo E, Sartori V, Luginbuhl M, Curatolo M.
Division of Pain Therapy, Department of Anesthesiology, Inselspital, Bern, Switzerland. gorazd.sveticic@insel.ch
BACKGROUND: The authors developed and applied a method to optimize the combination of bupivacaine, fentanyl, and clonidine for continuous postoperative lumbar epidural analgesia. METHODS: One hundred eighteen patients undergoing knee or hip surgery participated in the study. Postoperative epidural analgesia during 48 h after surgery was optimized under restrictions dictated by side effects. Initially, eight combinations of bupivacaine, fentanyl, and clonidine (expressed as drug concentration in the solution administered) were empirically chosen and investigated. To determine subsequent combinations, an optimization model was applied until three consecutive steps showed no decrease in pain score. For the first time in a clinical investigation, a regression model was applied when the optimization procedure led to combinations associated with unacceptable side effects. RESULTS: The authors analyzed 12 combinations with an allowed bupivacaine concentration range of 0-2.5 mg/ml, a fentanyl concentration range of 0-5 microg/ml, and a clonidine concentration range of 0-5 microg/ml. The best combinations of bupivacaine, fentanyl, and clonidine concentrations were 1.0 mg/ml-1.4 microg/ml-0.5 microg/ml, 0.9 mg/ml-3.0 microg/ml-0.3 microg/ml, 0.6 mg/ml-2.5 microg/ml-0.8 microg/ml, and 1.0 mg/ml-2.4 microg/ml-1.0 microg/ml, respectively, all producing a similarly low pain score. The incidence of side effects was low. The application of the regression model to combinations associated with high incidence of motor block successfully directed the optimization procedure to combinations within the therapeutic range. CONCLUSIONS: The results support further study of the combinations of bupivacaine, fentanyl, and clonidine mentioned above for postoperative analgesia after knee and hip surgery. This novel optimization method may be useful in clinical research.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15564946 [PubMed - indexed for MEDLINE]
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Spectral entropy and bispectral index as measures of the electroencephalographic effects of sevoflurane.
Ellerkmann RK, Liermann VM, Alves TM, Wenningmann I, Kreuer S, Wilhelm W, Roepcke H, Hoeft A, Bruhn J.
Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany. richard.ellerkmann@ukb.uni-bonn.de
BACKGROUND: Recently, entropy algorithms have been proposed as electroencephalographic measures of anesthetic drug effects. Datex-Ohmeda (Helsinki, Finland) introduced the Entropy Module, a new electroencephalographic monitor designed for measuring depth of anesthesia. The monitor calculates a state entropy (SE) computed over the frequency range of 0.8-32 Hz and a response entropy (RE) computed over the frequency range of 0.8-47 Hz. The authors investigated the dose-response relation of SE and RE during sevoflurane anesthesia in comparison with the Bispectral Index (BIS). METHODS: Sixteen patients were studied without surgical stimulus. Anesthesia was induced by sevoflurane inhalation with a tight-fitting facemask. Sevoflurane concentrations were increased and subsequently decreased and increased two to four times until the measurement was stopped and patients were intubated for surgery. The performances of SE, RE, and BIS to predict the estimated sevoflurane effect site concentration, obtained by simultaneous pharmacokinetic and pharmacodynamic modeling, were compared by calculating the correlation coefficients and the prediction probability. RESULTS: State entropy, RE, and BIS values decreased continuously over the observed concentration range of sevoflurane. Correlation coefficients were slightly but not significantly better for entropy parameters (0.87 +/- 0.09 and 0.86 +/- 0.10 for SE and RE, respectively) than for BIS (0.85 +/- 0.12). Calculating the prediction probability confirmed these results with a prediction probability of 0.84 +/- 0.05 and 0.82 +/- 0.06 for SE and RE, respectively, and 0.80 +/- 0.06 for BIS. CONCLUSION: State entropy and RE seem to be useful electroencephalographic measures of sevoflurane drug effect.
Publication Types:
PMID: 15564933 [PubMed - indexed for MEDLINE]
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Estimation of the plasma effect site equilibration rate constant (ke0) of propofol in children using the time to peak effect: comparison with adults.
Munoz HR, Cortinez LI, Ibacache ME, Altermatt FR.
Departamento de Anestesiologia, Hospital Clinico U.C., Marcoleta, Santiago, Chile. hmunoz@med.puc.cl
BACKGROUND: Targeting the effect site concentration may offer advantages over the traditional forms of administrating intravenous anesthetics. Because the lack of the plasma effect site equilibration rate constant (ke0) for propofol in children precludes the use of this technique in this population, the authors estimated the value of ke0 for propofol in children using the time to peak effect (tpeak) method and two pharmacokinetic models of propofol for children. METHODS:: The tpeak after a submaximal bolus dose of propofol was measured by means of the Alaris A-Line auditory evoked potential monitor (Danmeter A/S, Odense, Denmark) in 25 children (aged 3-11 yr) and 25 adults (aged 35-48 yr). Using tpeak and two previously validated sets of pharmacokinetic parameters for propofol in children, Kataria's and that used in the Paedfusor (Graseby Medical Ltd., Hertfordshire, United Kingdom), the ke0 was estimated according to a method recently published. RESULTS: The mean tpeak was 80 +/- 20 s in adults and 132 +/- 49 s in children (P < 0.001). The median ke0 in children was 0.41 min(-1) with the model of Kataria and 0.91 min(-1) with the Paedfusor model (P < 0.01). The corresponding t1/2 ke0 values, in minutes, were 1.7 and 0.8, respectively (P < 0.01). CONCLUSIONS:: Children have a significantly longer tpeak of propofol than adults. The values of ke0 of propofol calculated for children depend on the pharmacokinetic model used and also can only be used with the appropriate set of pharmacokinetic parameters to target effect site in this population.
PMID: 15564932 [PubMed - indexed for MEDLINE]
Anesthesiologists, injectionists?
Aldrete JA.
Publication Types:
PMID: 15635528 [PubMed - in process]
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Panic attacks and hyperventilation may mimic local anesthesia toxicity.
Schulz-Stubner S.
Publication Types:
PMID: 15635524 [PubMed - in process]
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Anesthetic and analgesic management of mitral stenosis during pregnancy.
Pan PH, D'Angelo R.
Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
PMID: 15635522 [PubMed - in process]
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Maximum recommended doses of local anesthetics: a multifactorial concept.
Rosenberg PH, Veering BT, Urmey WF.
Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, PB 340, Helsinki, FIN-00029 HUS, Finland. per.rosenberg@hus.fi
The current recommendations regarding maximum doses of local anesthetics presented in textbooks, or by the responsible pharmaceutical companies, are not evidence based (ie, determined by randomized and controlled studies). Rather, decisions on recommending certain maximum local anesthetic doses have been made in part by extrapolations from animal experiments, clinical experiences from the use of various doses and measurement of blood concentrations, case reports of local anesthetic toxicity, and pharmacokinetic results. The common occurrence of central nervous system toxicity symptoms when large lidocaine doses were used in infiltration anesthesia led to the recommendation of just 200 mg as the maximum dose, which has remained unchanged for more than 50 years. In most cases, there is no scientific justification for presenting exact milligram doses or mg/kg doses as maximum dose recommendations. Instead, only clinically adequate and safe doses (ranges) that are block specific are justified, taking into consideration the site of local anesthetic injection and patient-related factors such as age, organ dysfunctions, and pregnancy, which may influence the effect and the pharmacokinetics of the local anesthetic. Epinephrine in concentrations of 2.5 to 5 microg/mL should be added to the local anesthetic solution when large doses are administered, providing there are no contraindications for the use of epinephrine. As a rule, conditions (eg, end-stage pregnancy, high age in epidural, or spinal block) or diseases (uremia) that may increase the rate of the initial uptake of the local anesthetic are indications to reduce the dose in comparison to one normally used for young, healthy, and nonpregnant adults. On the other hand, the reduced clearance of local anesthetics associated with renal, hepatic, and cardiac diseases is the most important reason to reduce the dose for repeated or continuous administration. The magnitude of the reduction should be related to the expected influence of the pharmacodynamic or pharmacokinetic change.
PMID: 15635516 [PubMed - in process]
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Interscalene brachial plexus anesthesia with ropivacaine 5 mg/mL and bupivacaine 5 mg/mL: effects on electrocardiogram.
Borgeat A, Ekatodramis G, Blumenthal S.
Department of Anesthesiology and Intensive Care, Orthopedic University Clinic Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland. aborgeat@balgrist.unizh.ch
BACKGROUND: Cardiotoxicity is the most severe complication of long-acting local anesthetics. The aim of this trial is to compare early signs of depression of cardiac conduction linked with the administration of either ropivacaine or bupivacaine for interscalene block. METHODS: Thirty-two patients (American Society of Anesthesiologists I/II) scheduled for elective shoulder arthroscopy were prospectively enrolled to receive, in a randomized and double-blind fashion, either 40 mL of ropivacaine 5 mg/mL or 40 mL of bupivacaine 5 mg/mL for interscalene block. Holter monitoring was started the night before surgery and continued until the end of the study. Peripheral blood sampling was performed before administration of local anesthetics (= baseline) and 15, 20, 25, 30, 35, 40, 45, 60, and 360 minutes after completion of the interscalene block for measurement of total and unbound concentration of the 2 local anesthetics. Alpha-1-acid-glycoprotein was measured at baseline, t(30), and t(360). RESULTS: All anesthetic blocks in both groups were successful and comparable. Electrocardiographic recordings for QRS, QT, and QTC intervals did not change and were similar in both groups. In the bupivacaine group, significant prolongation of the PQ interval was noted 15 minutes after drug application and remained significantly prolonged until t(60). Total and unbound plasma local-anesthetic concentrations were comparable between both groups at all times. In both groups, local-anesthetic plasma mean levels reached a peak between 30 and 45 minutes after the bolus application. The highest mean plasma levels were 0.103 (+/-0.05) mg/L for unbound ropivacaine and 0.084 (+/-0.03) mg/L for unbound bupivacaine, which occurred in both groups at t(30). CONCLUSIONS: Electrocardiographic recordings were similar in both groups, except for a significant prolongation of the PQ interval in the bupivacaine group at plasma levels below threshold for cardiotoxicity.
PMID: 15635515 [PubMed - in process]
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The learning curve associated with a simulated ultrasound-guided interventional task by inexperienced anesthesia residents.
Sites BD, Gallagher JD, Cravero J, Lundberg J, Blike G.
Department of Anesthesiology, Dartmouth Medical School, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA. brain.sites@hitchcock.org
BACKGROUND AND OBJECTIVE: Ultrasound has become an increasingly popular modality in facilitating the performance of peripheral nerve blocks. There exists no literature that examines the learning curve of the ultrasound novice. In this prospective series, we evaluated the learning curve of inexperienced anesthesia residents in performing a simulated ultrasound-guided interventional procedure. In doing so, we hoped to identify reproducible patterns of human errors, which could potentially aid in the prevention of real-life iatrogenic injuries. METHODS: Ten subjects were prospectively enrolled. After a brief introduction to the ultrasound system, the subjects were asked to perform 6 sequential trials of a simulated breast cyst aspiration. For the first 3 trials, each subject attempted to place a 22-gauge b-bevel needle into any aspect of an olive buried inside the turkey breast. After completion of these 3 trials, the subjects were asked to place the needle into the exact midpoint of the olive wall closest to the transducer. Trials were videotaped and analyzed for task performance in terms of speed and accuracy. RESULTS: All subjects successfully completed the 6 interventional trials. The mean time to perform the task was reduced by 38% and 48%, respectively, for the second and third trials. A composite score of accuracy showed an improvement of 36% and 59%, respectively, for the second and third trials. The most common committed error, which occurred in 7 of 10 subjects, was the failure to accurately image the needle while advancing. This resulted in excessive depth of penetration and inadvertent transfixation of the olive in 5 of these subjects. CONCLUSIONS: Anesthesiology residents, with little or no ultrasound experience, can rapidly learn and improve their speed and accuracy in performing a simulated interventional ultrasound procedure. A concerning novice pattern was identified where the subjects advanced the needle even though it was not appropriately visualized in the ultrasound beam. This resulted in needle placement error, which could cause iatrogenic injury in the clinical setting.
PMID: 15635513 [PubMed - in process]
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A clinical comparison of equal concentration and volume of ropivacaine and bupivacaine for interscalene brachial plexus anesthesia and analgesia in shoulder surgery.
Eroglu A, Uzunlar H, Sener M, Akinturk Y, Erciyes N.
Department of Anesthesiology, Karadeniz Technical University, 61080 Trabzon, Turkey. aheroglu@hotmail.com
BACKGROUND AND OBJECTIVES: The aim of this study was to compare the same volume and concentration of bupivacaine and ropivacaine for interscalene brachial plexus block anesthesia and postoperative analgesia in shoulder surgery. METHODS: Forty-four patients scheduled for elective shoulder surgery were prospectively randomized to receive in a double-blind fashion 30 mL of either 0.5% bupivacaine or ropivacaine for interscalene block. The block was prolonged after surgery by using a patient-controlled interscalene analgesia with 0.15% of either bupivacaine or ropivacaine. The mean onset times of surgical blocks were determined after interscalene block. Pain relief was regularly assessed by using a visual analog scale, side effects were noted, and the patients were asked to rate their satisfaction at the end of the study. RESULTS: Two patients with bupivacaine and 1 with ropivacaine failed to achieve surgical block and were excluded. The mean onset times of surgical blocks were 18 +/- 12 minutes with ropivacaine and 21 +/- 13 minutes with bupivacaine. The pain scores, total volume infused of local anesthetics, incremental dose requested and received, total rescue analgesic, and side effects were similar between the groups. Postoperative pain control was similarly effective and patient satisfaction was high in both groups. CONCLUSIONS: This study shows that the same volume and concentration of bupivacaine and ropivacaine (30 mL of 0.5%) for interscalene brachial plexus block anesthesia produce similar surgical block. When prolonging the block with a patient-controlled interscalene analgesia infusion, 0.15% bupivacaine or ropivacaine provide adequate pain relief, similar side effects, and high patient satisfaction after shoulder surgery.
PMID: 15635512 [PubMed - in process]
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Effect of postoperative epidural analgesia on morbidity and mortality following surgery in medicare patients.
Wu CL, Hurley RW, Anderson GF, Herbert R, Rowlingson AJ, Fleisher LA.
Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD 21287, USA. chwu@jhmi.edu
BACKGROUND: Because of the uncertainty and limitations in available randomized controlled trials, we performed an analysis of the Medicare claims database to determine whether an association exists between postoperative epidural analgesia and mortality. METHODS: A 5% nationally random sample of Medicare beneficiaries from 1997 to 2001 was analyzed to identify patients undergoing segmental excision of the lung (International Statistical Classification of Diseases, Ninth Revision, Clinical Modification codes 32.3 and 32.4), complete pneumonectomy (code 32.5), partial excision of large intestine (codes 45.73 and 45.76), anastomosis of the esophagus (codes 42.5 and 42.6), total knee replacement/revision (codes 81.54 and 81.55), total/radical abdominal hysterectomy (codes 68.4 and 68.6), partial/radical pancreaticoduodenectomy (codes 52.5 and 52.7), partial/complete nephrectomy (codes 55.4 and 55.5), partial/complete cystectomy (codes 57.6 and 57.7), hepatotomy/lobectomy of the liver (codes 50.0 and 50.3), partial/total gastrectomy (codes 43.5 to 43.9), and radical retropubic prostatectomy (codes 60.4 and 60.5). Patients were divided into 2 groups, depending on the presence or absence of postoperative epidural analgesia. The rate of major morbidity and death at 7 and 30 days after surgery were compared. Multivariate regression analyses incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status were performed. RESULTS: The presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.38 to 0.73; P = .0001) and 30 days (OR, 0.74; 95% CI, 0.63 to 0.89; P = .0005) after surgery; however, no difference was seen between the groups with regard to overall major morbidity, with the exception of an increase in pneumonia at 30 days for the epidural group (OR, 1.91;[95% CI, 1.09 to 3.34; P = .02). CONCLUSIONS: Postoperative epidural analgesia may contribute to lower odds of death after surgery.
PMID: 15635510 [PubMed - in process]
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Let's abandon blanket maximum recommended doses of local anesthetics.
Heavner JE.
Publication Types:
PMID: 15635509 [PubMed - in process]
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Anesthesia and surgical outcomes: an orphean ambition.
Yeager MP, Carli F.
Publication Types:
PMID: 15635507 [PubMed - in process]
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