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Tracheal intubation using a new CCD camera-equipped device: a report of two cases with a difficult intubation.
Sehata H, Kohase H, Takahashi M, Miyamoto T, Umino M.
Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan.
In two patients, one with Klippel-Feil syndrome and one with fibrous dysplasia of the maxilla, no part of the larynx could be visualized by direct laryngoscopy. In both cases, the use of an intubation device equipped with a charge-coupled device camera, the endotracheal intubation device (EID), allowed smooth tracheal intubation.
Publication Types:
PMID: 16095466 [PubMed - indexed for MEDLINE]
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Bradycardia and hypertension in anticipation of, and exacerbated by, peribulbar block: a prospective audit.
van den Berg AA.
King Khaled Eye Specialist Hospital, Department of Anesthesia, Riyadh, Saudi Arabia. antonvdb2000@yahoo.com
BACKGROUND: Changes in heart rate (HR), systolic arterial pressure (SAP) and diastolic arterial pressure (DAP) occur in anticipation of, and following, injection of a peribulbar local analgesic agent. We examined these changes in two groups of awake patients given a pre-medication of either hydroxyzine 1.0 mg/kg alone (control) or hydroxyzine 1.0 mg/kg with morphine 0.05 mg/kg. METHODS: HR, SAP and DAP of 100 patients per group were monitored the day before surgery (baseline), every 5 min in the anesthesia holding room before peribulbar injection, every minute for the first 5 min after peribulbar injection and then every 5 min until transfer to the operating room. Within and between pre-medication group values of HR, SAP and DAP before and after peribulbar injection were compared with baseline. RESULTS: The two groups of patients were similar. Before peribulbar injection, HR was unchanged in the hydroxyzine group, but 6% slower in those given morphine (P<0.01). After injection, HR slowed in both groups, by 5% and 7% (P<0.01, both comparisons), respectively. In anticipation of injection, SAP increased in both groups to 20% and 16% above baseline, respectively, and increased further after injection to 26% and 24% above baseline, respectively (P<0.001, all comparisons). In both groups, maximum SAP following injection exceeded maximum SAP before injection (P<0.02, both comparisons). DAP increased by 4% (P<0.05) in the hydroxyzine group before injection, and by 5% and 4%, respectively (P<0.005 and P<0.05, respectively) after peribulbar injection. CONCLUSION: The audit reveals pronounced increases in SAP accompanied by lesser increases in DAP and a tendency to slowing of HR in awake patients in anticipation of peribulbar injections. Peribulbar injections cause further increases in blood pressure and mild bradycardia. These changes occur similarly in patients pre-medicated with hydroxyzine or hydroxyzine plus morphine. A mix of neuro-humoral influences (anxiety/catecholamine/baroreceptor/trigemino-vagal) are postulated as etiological.
PMID: 16095464 [PubMed - indexed for MEDLINE]
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Postoperative extradural analgesia with morphine and ropivacaine. A double-blind comparison between placebo and ropivacaine 10 mg/h or 16 mg/h.
Axelsson K, Johanzon E, Essving P, Weckstrom J, Ekback G.
Department of Anesthesiology & Intensive Care, Orebro University Hospital, Orebro, Sweden. kjell.axelsson@orebroll.se
BACKGROUND: Some controversy exists in the literature on the benefit of epidurals compared to patient-controlled intravenous analgesia (PCA). Also, the dose of ropivacaine for epidural analgesia when combined with morphine remains uncertain. The aim of this study was to compare the epidural vs. PCA technique and high-dose vs. low-dose ropivacaine combined with morphine during knee replacement surgery. METHODS: In this prospective, randomized, double-blind study, postoperative pain relief with a combination of epidural ropivacaine (Group L: 10 mg h-1, Group H: 16 mg h-1) and morphine (0.16 mg h-1) was evaluated in 30 patients. A placebo group (Group PL) of 15 patients having PCA morphine served as the control. Visual analog pain (VAS), morphine consumption, sensory and motor block and side-effects were recorded during 48 h. RESULTS: VAS scores at rest were significantly lower in Groups L and H compared to Group PL. On movement, Group H had lower VAS scores than Group PL during 3-27 h (P<0.05) and Group L during 4-9 h (P<0.05), while Group L had lower a VAS than Group PL during 9-18 h (P<0.05). Morphine consumption after 48 h was greater in Group PL (64.6+/-36.3 mg) vs. Group L (23.3+/-33.9 mg) (P<0.001) and Group H (4.3+/-9.6 mg) (P<0.0001). Mild motor block was seen in Group H in 20% and 14% patients at 24 h and 48 h, respectively, but time to mobilization was similar between the groups. Pruritus was more common in the ropivacaine groups (P<0.05). CONCLUSION: Lumbar epidural analgesia using a combination of ropivacaine (16 mg h-1) and morphine (0.16 mg h-1) provides superior analgesia compared to the PCA technique or ropivacaine (10 mg h-1) and morphine (0.16 mg h-1). Although this resulted in a mild motor block during the first 12 h, patient mobilization was similar in all groups.
Publication Types:
PMID: 16095462 [PubMed - indexed for MEDLINE]
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Continuous peripheral nerve blockade in lower extremity surgery.
Navas AM, Gutierrez TV, Moreno ME.
Department of Anaesthesiology, Valme Hospital, Seville, Spain. amarnavas@saludalia.com
Peripheral nerve blocks afford numerous benefits for lower extremity surgery. There is growing interest in continuous peripheral nerve blocks, mainly for treatment of postoperative pain, a field that represents a challenge to the anaesthesiologist. This paper seeks to review the efficacy of continuous lower limb blocks for postoperative pain relief. Not only do continuous peripheral nerve blocks afford specificity of analgesic area but current research has shown that they enhance postoperative analgesia and patient satisfaction. New techniques and devices are increasingly appearing, and catheters are constantly being developed and improved; an example being the stimulating catheter, which represents one of the newest advances in this area. The above techniques show that continuous postoperative analgesia with catheters in the lower extremities is not only possible, but indeed provides sustained effective postoperative analgesia, reduces use of opioids, and improves rehabilitation and patient well-being with minimal side-effects. These techniques could prove an alternative to postoperative pain treatment following ambulatory surgery.
Publication Types:
PMID: 16095441 [PubMed - indexed for MEDLINE]
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Pre-operative fasting guidelines: an update.
Soreide E, Eriksson LI, Hirlekar G, Eriksson H, Henneberg SW, Sandin R, Raeder J; (Task Force on Scandinavian Pre-operative Fasting Guidelines, Clinical Practice Committee Scandinavian Society of Anaesthesiology and Intensive Care Medicine).
Department of Anaesthesia and Intensive Care, Stavanger University Hospital, Stavanger, Norway. soed@sir.no
Liberal pre-operative fasting routines have been implemented in most countries. In general, clear fluids are allowed up to 2 h before anaesthesia, and light meals up to 6 h. The same recommendations apply for children and pregnant women not in labour. In children <6 months, most recommendations now allow breast- or formula milk feeding up to 4 h before anaesthesia. Recently, the concept of pre-operative oral nutrition using a special carbohydrate-rich beverage has also gained support and been shown not to increase gastric fluid volume or acidity. Based on the available literature, our Task Force has produced new consensus-based Scandinavian guidelines for pre-operative fasting. What is still not clear is to what extent the new liberal fasting routines should apply to patients with functional dyspepsia or systematic diseases such as diabetes mellitus. Other still controversial areas include the need for and effect of fasting in emergency patients, women in labour and in association with procedures done under 'deep sedation'. We think more research on the effect of various fasting regimes in subpopulations of patients is needed before we can move one step further towards completely evidence-based pre-operative fasting guidelines.
Publication Types:
PMID: 16095440 [PubMed - indexed for MEDLINE]
Ex utero intrapartum procedure for delivery of a fetus with a large cervical mass.
Faria A, Fonseca C, Sampaio C, Abreu F, Tavares J.
Publication Types:
PMID: 16119606 [PubMed - indexed for MEDLINE]
Free plasma levels of bupivacaine and ropivacaine when used for caudal block in children.
Bozkurt P, Arslan I, Bakan M, Cansever MS.
Publication Types:
PMID: 16119605 [PubMed - indexed for MEDLINE]
Prediction of difficult mask ventilation.
Gautam P, Gaul TK, Luthra N.
Publication Types:
PMID: 16119604 [PubMed - indexed for MEDLINE]
The ProSeal laryngeal mask airway may prevent of hiccup-related aspiration.
Brimacombe J, Keller C.
Publication Types:
PMID: 16119603 [PubMed - indexed for MEDLINE]
Pressure support ventilation with the ProSeal laryngeal mask airway. A comparison of sevoflurane, isoflurane and propofol.
Keller C, Brimacombe J, Hoermann C, Loeckinger A, Kleinsasser A.
Leopold-Franzens University, Department of Anesthesia and Intensive Care Medicine, Innsbruck, Austria.
BACKGROUND AND OBJECTIVE: There are no data about the influence of anaesthetics on cardiovascular variables during pressure support ventilation of the lungs through the laryngeal mask airway. We compared propofol, sevoflurane and isoflurane for maintenance of anaesthesia with the ProSeal laryngeal mask airway during pressure support ventilation. METHODS: Sixty healthy adults undergoing peripheral musculo-skeletal surgery were randomized for maintenance with sevoflurane end-tidal 2%, isoflurane end-tidal 1.1% or propofol 6 mg kg(-1) h(-1) in oxygen 33% and air. Pressure support ventilation comprised positive end-expiratory pressure set at 5 cmH2O, and pressure support set 5 cmH2O above positive end-expiratory pressure. Pressure support was initiated when inspiration produced a 2 cmH2O reduction in airway pressure. A blinded observer recorded cardiorespiratory variables (heart rate, mean blood pressure, oxygen saturation, airway occlusion pressure, respiratory rate, expired tidal volume, expired minute volume and end-tidal CO2), adverse events and emergence times. RESULTS: Respiratory rate and minute volume were 10-21% lower, and end-tidal CO2 6-11% higher with the propofol group compared with the sevoflurane or isoflurane groups, but otherwise cardiorespiratory variables were similar among groups. No adverse events occurred in any group. Emergence times were longer with the propofol group compared with the sevoflurane or isoflurane groups (10 vs. 7 vs. 7 min). CONCLUSION: Lung ventilation is less effective and emergence times are longer with propofol than sevoflurane or isoflurane for maintenance of anaesthesia during pressure support ventilation with the ProSeal laryngeal mask airway. However, these differences are small and of doubtful clinical importance.
Publication Types:
PMID: 16119601 [PubMed - indexed for MEDLINE]
Fast track in liver transplantation: 5 years' experience.
Biancofiore G, Bindi ML, Romanelli AM, Boldrini A, Bisa M, Esposito M, Urbani L, Catalano G, Mosca F, Filipponi F.
Cisanello Hospital, Postsurgical and Transplantation ICU, Department of Anaesthesia and Critical Care, Italy. g.biancofiore@med.unipi.it
BACKGROUND AND OBJECTIVE: Reducing postoperative mechanical ventilation in patients undergoing liver transplantation may have clinical and organizational advantages. On the basis of our experience, we here evaluate the possibility of practising immediate tracheal extubation in the operating theatre. METHODS: In this prospective study, patients consecutively undergoing liver transplantation between 1 June 1999 and 31 May 2004 were extubated in the operating theatre at the end of surgery on the basis of standardized and universally accepted criteria, under conditions of haemodynamic and metabolic stability. RESULTS: Two hundred and seven of the 354 patients (58.5%) were extubated immediately after the completion of the surgical procedure (mean time between end of surgery and extubation: 0.4 +/- 1.4 min); two were re-intubated. In the last of the 5 yr of the study, the percentage of immediate extubations increased to 82.5%. During the study period, there was a progressive increase in the number of immediate extubations per individual member of the team of anaesthetists. The pre-transplant Child-Pugh severity of the underlying liver disease did not predict rapid extubation, but the Model for End-stage Liver Disease score of < 11 did (receiver operator characteristic area under the curve = 0.61; P < 0.05). CONCLUSIONS: Immediate extubation after liver transplantation is possible in a substantial percentage of cases; confidence, habit and a spirit of emulation are decisive factors in encouraging anaesthetists to extend this practice to the largest possible number of patients. A successful immediate extubation may be an important indicator of perioperative quality of care in liver transplantation.
Publication Types:
PMID: 16119594 [PubMed - indexed for MEDLINE]
A review of sub-Tenon's block: current practice and recent development.
Kumar CM, Williamson S, Manickam B.
The James Cook University Hospital, Department of Anaesthesia, Middlesbrough, UK. Chandra.kumar@stees.nhs.uk
The place of sub-Tenon's block in ophthalmic surgery is now established. This block was introduced into clinical practice in the early 1990s as a simple, safe and effective technique. Since then, techniques have evolved, newer cannulae have been introduced and many complications, both minor as well as major, have been reported. This review deals with the recent developments in sub-Tenon's block.
Publication Types:
PMID: 16119592 [PubMed - indexed for MEDLINE]
Prophylactic ephedrine and combined spinal epidural: maternal blood pressure and fetal heart rate patterns.
Cleary-Goldman J, Negron M, Scott J, Downing RA, Camann W, Simpson L, Flood P.
Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York 10032, USA. jec32@columbia.edu
OBJECTIVE: Labor analgesia with the combined spinal epidural approach has been associated with maternal hypotension and fetal heart rate (FHR) changes. The purpose of this study was to estimate whether prophylactic intramuscular ephedrine before combined spinal epidural prevents these complications. METHODS: In a prospective double blind trial, 100 healthy patients with term singletons received intramuscular ephedrine 25 mg or placebo by random allocation before combined spinal epidural. During the first hour after analgesia, maternal heart rate, blood pressure, and need for treatment of significant hypotension were recorded. Fetal heart rate tracings for 1 hour before and for 1 hour after administration of anesthetic were evaluated. Categorical variables were compared with Fisher exact test. Continuous variables were compared with one way analysis of variance for repeated measures. P < .05 was considered significant. RESULTS: Prophylactic ephedrine reduced the incidence of maternal hypotension after combined spinal epidural (P < .007). In controls, there was a significant increase in the incidence and frequency of late decelerations in the hour following combined spinal epidural compared with the previous hour (P < .005 and P < .01). Compared with controls, there was an increased incidence of fetal tachycardia in patients who received prophylactic ephedrine (P < .006), which was associated with increased FHR reactivity (P < .03). CONCLUSION: Although prophylactic ephedrine prevents maternal hypotension and fetal late decelerations, it is associated with fetal tachycardia. The value of prophylactic ephedrine at combined spinal epidural should be weighed against potential changes in fetal heart rate patterns. LEVEL OF EVIDENCE: I.
Publication Types:
PMID: 16135575 [PubMed - indexed for MEDLINE]
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Preoperative apnea in a preterm infant after caudal block with ropivacaine and clonidine.
Galante D.
Publication Types:
PMID: 16029411 [PubMed - indexed for MEDLINE]
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Neonatal T-wave elevation from a positive epidural test dose.
Sparks JW, Seefelder C.
Publication Types:
PMID: 16029409 [PubMed - indexed for MEDLINE]
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An evaluation of pain and postoperative nausea and vomiting following the introduction of guidelines for tonsillectomy.
White MC, Nolan JA.
Department of Anaesthesia, Bristol Royal Hospital for Children, Bristol, UK.
BACKGROUND: Tonsillectomy and adenotonsillectomy have a high incidence of postoperative pain, and postoperative nausea and vomiting (PONV). Pain is traditionally controlled with morphine but this increases the risk of PONV and may cause respiratory depression. Antiemetics reduce PONV but their routine use has been questioned on safety grounds. METHOD: After determining the current anesthetic management of elective tonsillectomy and adenotonsillectomy patients in our hospital, guidelines were developed to avoid the routine use of morphine and antiemetics. The effect on pain and PONV was then evaluated over a 3 month period. Postoperative pain was scored using the Oucher visual analog scale and nausea scored using a five point scale. RESULTS: We analysed 34 cases to determine our current practice and 37 cases to evaluate the effect of introducing guidelines. Postguidelines, the median Oucher pain score at 4 h was 10, and at 8, 12, 16 h was zero. Despite receiving no antiemetics, only two children vomited (5%) after introduction of guidelines. CONCLUSION: Guidelines which use a combination of paracetamol, nonsteroidal anti-inflammatory drugs and fentanyl, provide excellent analgesia with minimal PONV after elective tonsillectomy and adenotonsillectomy. As a result the routine use of morphine and antiemetics can be avoided.
PMID: 16029404 [PubMed - indexed for MEDLINE]
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Pilot study of neuraxial imaging by ultrasound in infants and children.
Marhofer P, Bosenberg A, Sitzwohl C, Willschke H, Wanzel O, Kapral S.
Department of Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria. peter.marhofer@meduniwien.ac.at
BACKGROUND: Ultrasonography is becoming an important adjunct in regional anesthesia. Epidural anesthesia may pose significant challenges in infants and children because of difficulties in identifying the epidural space. In addition, epidural catheters are sometimes difficult to advance. The present study was performed to evaluate an optimal ultrasound technique for direct visualization of neuraxial structures in children. METHODS: A total of 32 infants and children scheduled for minor surgery were prospectively included in a high-resolution ultrasound study. Scans were performed using either a sector or linear probe and views from a longitudinal paramedian, median and transversal angle at lumbar and thoracic levels of the spinal cord were analyzed. RESULTS: In all children investigated, the linear probe generated better images than the sector probe. Of the various scanning perspectives, the paramedian longitudinal approach offered the best views at both cord levels. Broken down by age groups, the best visibility was clearly obtained in neonates up to 3 months of age (P < 0.0001 Vs all other age groups). In older children, the quality of ultrasound decreased in an age-dependent manner. CONCLUSIONS: Paramedian longitudinal scans with linear probes are the most favorable method of imaging neuraxial anatomy at lumbar and thoracic cord levels in infants and children, with the best results in neonates up to 3 months of age. Based on these results, and using real time imaging, a practical technique for ultrasound-guided epidural anesthesia for neonates and infants at lumbar and thoracic levels of the spinal cord is planned.
PMID: 16029402 [PubMed - indexed for MEDLINE]
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Tolerance and analgesic efficacy of a new i.v. paracetamol solution in children after inguinal hernia repair.
Murat I, Baujard C, Foussat C, Guyot E, Petel H, Rod B, Ricard C.
Department of Anesthesia, Hopital d'Enfants Armand Trousseau, Paris, France.
BACKGROUND: A new intravenous (i.v.) formulation of paracetamol and propacetamol (prodrug of paracetamol) were compared to determine tolerance and relative analgesic efficacy during the first 6 h after inguinal hernia repair performed under general anesthesia combined with ilioinguinal block in children. METHODS: A total of 183 ASA I or II in-patients, aged 1-12 years, admitted for unilateral inguinal hernia repair were randomized to receive in a double-blind design either i.v. paracetamol 15 mg.kg(-1) (n = 95) or propacetamol 30 mg.kg(-1) (n = 88) for postoperative pain relief as soon as pain intensity was greater than 30 on a 100 mm visual analog scale. All patients were evaluated for efficacy and tolerance. Efficacy was evaluated between 15 min and 6 h after the start of the 15 min infusion. RESULTS: The most frequently reported adverse event was injection site pain, which was significantly reduced in the new formulation group (i.v. paracetamol 14.7% vs propacetamol 33.0% of children, P = 0.005). No significant difference was obtained between treatments on pain relief (PR), pain intensity difference (PAID) from baseline, and objective pain scale intensity difference (OPSD). Also, treatment effects did not differ significantly for maximum values and weighted sums of PR, PAID (investigator and child rated), OPSD, time to first request for rescue medication, proportion of children requesting rescue medication, and investigators' global treatment satisfaction. CONCLUSION: A single infusion of i.v. paracetamol 15 mg.kg(-1) produced analgesia similar to a single infusion of propacetamol 30 mg.kg(-1) following inguinal hernia repair in children. Paracetamol i.v. 15 mg.kg(-1) was better tolerated at the injection site than propacetamol.
Publication Types:
PMID: 16029401 [PubMed - indexed for MEDLINE]
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Evaluation of relatively low dose of oral transmucosal ketamine premedication in children: a comparison with oral midazolam.
Horiuchi T, Kawaguchi M, Kurehara K, Kawaraguchi Y, Sasaoka N, Furuya H.
Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan.
BACKGROUND: Oral Transmucosal ketamine (lollipop) has been shown to be an effective, harmless preoperative medication for children. However, its efficacy was not compared with commonly used premedication drugs. We, therefore, compared the efficacy of oral transmucosal ketamine with oral midazolam for premedication in children. METHODS: Fifty-five children (2-6 years of age) were randomized to receive orally either a lollipop containing 50 mg of ketamine (the group K; n = 27) or syrup containing 0.5 mg.kg(-1) of midazolam (the group M; n = 28) before minor surgery. A five points-sedation score (1 = asleep to 5 = agitated; scores 2 and 3 were defined as 'effective') on arrival in the operating room and a three points-acceptance score of separation from the parents and a three points-mask cooperation score at induction of anesthesia (1 = easy to 3 = markedly resistant; score 3 was defined as 'poor') were used. RESULTS: Sedation scores in group K were significantly higher than those in group M (P = 0.012), and the incidence of 'effective' in sedation was significantly lower in group K than in group M (P = 0.036). The incidence of 'poor' at separation from the parents and for mask cooperation was significantly higher in group K than in group M (P = 0.017, P = 0.019, respectively). CONCLUSION: These results indicate that a relatively low dose of oral transmucosal ketamine premedication provides no benefits over oral midazolam in children.
Publication Types:
PMID: 16029398 [PubMed - indexed for MEDLINE]
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