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A randomized non-crossover study comparing the ProSealTM and ClassicTM laryngeal mask airway in anaesthetized children.
Lopez-Gil M, Brimacombe J, Garcia G.
Department of Anaesthesia and Reanimation, Maranon University Hospital, Madrid, Spain.
BACKGROUND: We tested the hypothesis that ease of insertion, oropharyngeal leak pressure, fibreoptic position, gastric insufflation, and the frequency of mucosal trauma differ between the ProSeal laryngeal mask airway (PLMA) and the classic laryngeal mask airway (cLMA) in anaesthetized children. For the PLMA, we also assessed the ease of gastric tube placement via the PLMA drain tube and measure residual gastric volume. METHODS: 240 consecutive ASA I-III children aged 1-16 yr were randomized for airway management with the ProSeal or cLMA. RESULTS: The time taken to provide an effective airway, the number of insertion attempts, fibreoptic position of the airway tube and frequency of mucosal trauma were similar, but oropharyngeal leak pressure was higher (33 vs 26 cm H2O, P<0.0001) and gastric insufflation less common (0 vs 6%, P<0.01) for the PLMA. Gastric tube insertion was successful at the first attempt in 106 of 120, and at the second attempt in 14 of 120. The mean (SD; range) value for residual gastric volume was 2.2 (5.9; 0-30) ml. There were no differences in performance among sizes for the PLMA and the cLMA. CONCLUSIONS: We conclude that ease of insertion, fibreoptic position, and frequency of mucosal trauma are similar for the PLMA and cLMA in children, but oropharyngeal leak pressure is higher and gastric insufflation less common for the PLMA. Gastric tube insertion has a high success rate, provided the PLMA is correctly positioned.
PMID: 16210311 [PubMed - as supplied by publisher]
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Conjunctival inclusion cyst following sub-Tenon's local anaesthetic injection.
Vishwanath MR, Jain A.
Department of Ophthalmology, Kent and Canterbury Hospital, Ethelbert Road, Canterbury, Kent CT1 3NG, UK.
Sub-Tenon's local anaesthesia has become a popular technique of infiltrative anaesthesia for small incision cataract surgery. We report the development of an inclusion cyst of the conjunctiva following this technique. The aetiology of this complication and how it can be avoided are discussed.
PMID: 16199416 [PubMed - as supplied by publisher]
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Glycopyrrolate during sevoflurane-remifentanil-based anaesthesia for cardiac catheterization of children with congenital heart disease.
Reyntjens K, Foubert L, Wolf DD, Vanlerberghe G, Mortier E.
Department of Anaesthesiology, University Hospital Ghent, Ghent, Belgium.
BACKGROUND: Remifentanil is recommended for use in procedures with painful intraoperative stimuli but minimal postoperative pain. However, bradycardia and hypotension are known side-effects. We evaluated haemodynamic effects of i.v. glycopyrrolate during remifentanil-sevoflurane anaesthesia for cardiac catheterization of children with congenital heart disease. METHODS: Forty-five children undergoing general anaesthesia with remifentanil and sevoflurane were randomly allocated to receive either saline, glycopyrrolate 6 microg kg(-1) or glycopyrrolate 12 microg kg(-1). After induction of anaesthesia with sevoflurane, i.v. placebo or glycopyrrolate was administered. An infusion of remifentanil at the rate of 0.15 microg kg(-1)min(-1) was started, sevoflurane continued at 0.6 MAC and cisatracurium 0.2 mg kg(-1) was given. Heart rate (HR) and non-invasive arterial pressures were monitored and noted every minute for the first 10 min and then every 2.5 min for subsequent maximum of 45 min. RESULTS: Baseline HR [mean (sd)] of 117 (20) beats min(-1) decreased significantly from 12.5 min onwards after starting the remifentanil infusion in the control group [106 (18) at 12.5 min and 99 (16) beats min(-1) at 45 min]. In the groups receiving glycopyrrolate, no significant decrease in HR was noticed. Glycopyrrolate at 12 microg kg(-1) induced tachycardia between 5 and 9 min after administration. Systolic and diastolic arterial pressures decreased gradually, but there were no significant differences in the pressures between groups. CONCLUSION: I.V. glycopyrrolate 6 microg kg(-1) prevents bradycardia during general anaesthesia with remifentanil and sevoflurane for cardiac catheterization in children with congenital heart disease. Administering 12 microg kg(-1) of glycopyrrolate temporarily induces tachycardia and offers no additional advantage.
PMID: 16199414 [PubMed - in process]
Peripheral blocks of trigeminal nerve for facial soft-tissue surgery: learning from failures.
Pascal J, Charier D, Perret D, Navez M, Auboyer C, Molliex S.
Publication Types:
PMID: 15991518 [PubMed - indexed for MEDLINE]
Minimum inspired oxygen concentration alarm: do we go too low?
Dale MT, Jadhav D.
Publication Types:
PMID: 15991517 [PubMed - indexed for MEDLINE]
Interference of patent blue V dye with pulse oximetry and co-oximetry.
Hueter L, Schwarzkopf K, Karzai W.
Publication Types:
PMID: 15991515 [PubMed - indexed for MEDLINE]
Brachial plexus block with ropivacaine and bupivacaine for the formation of arteriovenous fistula in patients with end-stage renal failure.
Misiolek HD, Kucia HJ, Knapik P, Werszner MM, Karpe JW, Gumprecht J.
Publication Types:
PMID: 15991514 [PubMed - indexed for MEDLINE]
Use of epidural blockade in a patient with hip fracture and aortic stenosis.
Bundgaard-Nielsen M, Foss NB, Kristensen BB.
Publication Types:
PMID: 15991513 [PubMed - indexed for MEDLINE]
Effects of hyperbaric spinal ropivacaine for caesarean section: with or without fentanyl.
Sanli S, Yegin A, Kayacan N, Yilmaz M, Coskunfirat N, Karsli B.
Akdeniz University, Faculty of Medicine, Department of Anaesthesiology, Antalya, Turkey. suatsanli@superonline.com
BACKGROUND AND OBJECTIVE: Adding various opioids to the local anaesthetic solution administrated intrathecally improves the analgesic potency of spinal analgesia. The purpose of this study was to evaluate the efficacy and safety of intrathecal fentanyl 10 microg added to 15 mg hyperbaric ropivacaine in patients undergoing caesarean section under spinal anaesthesia. METHODS: Thirty-seven healthy, full-term parturients were randomly assigned into two groups: Group S (saline group, n=17) received 15 mg hyperbaric ropivacaine in 2.5 mL + 0.5 mL saline; Group F (fentanyl group, n=20) received 15 mg hyperbaric ropivacaine in 2.5 mL + 10 microg fentanyl in 0.5 mL, intrathecally. Characteristics of spinal block, intraoperative quality of spinal anaesthesia, time to first feeling of pain (complete analgesia), time to first request of analgesics postoperatively (effective analgesia), side-effects and fetal outcomes were evaluated. RESULTS: Regression of sensory block to L5 was significantly prolonged in the fentanyl group compared with the saline group (P = 0.001). Time to the first feeling of pain (130.6 +/- 15.8 min vs. 154.3 +/- 31.1 min; P = 0.008) and the first analgesic requirement (161.2 +/- 32.6 min vs. 213.0 +/- 29.3 min; P < 0.001) were significantly shorter in the saline group compared with the fentanyl group. Side-effects, umbilical arterial and venous blood gases did not differ between the groups. Apgar scores were similar in both groups and no infants had an Apgar score < or =7 at 5 min. CONCLUSIONS: The addition of fentanyl 10 microg, to hyperbaric ropivacaine 15 mg, for spinal anaesthesia increased the duration of analgesia in the early postoperative period in patients undergoing caesarean delivery.
Publication Types:
PMID: 15991510 [PubMed - indexed for MEDLINE]
Sciatic nerve block with 0.5% levobupivacaine, 0.75% levobupivacaine or 0.75% ropivacaine: a double-blind, randomized comparison.
Casati A, Vinciguerra F, Santorsola R, Aldegheri G, Putzu M, Fanelli G.
University of Parma, Department of Anaesthesia, Analgesia, and Pain Therapy, Hospital of Parma, Parma, Italy. acasati@ao.pr.it
BACKGROUND AND OBJECTIVE: This prospective, randomized, double-blind study was conducted to evaluate the onset time and duration of sciatic nerve block produced with 0.5% levobupivacaine, 0.75% levobupivacaine and 0.75% ropivacaine. METHODS: Forty-five healthy patients undergoing hallux valgus repair were randomly allocated to receive sciatic nerve block with levobupivacaine 0.5% (n=15), levobupivacaine 0.75% (n=15) or ropivacaine 0.75% 20 mL (n=15). A femoral nerve block was also performed with mepivacaine 2% 15 mL to cover pain related to the thigh tourniquet. A blinded observer recorded the onset time and duration of sciatic nerve block. RESULTS: The median (range) onset time was 5 (5-40) min with 0.75% levobupivacaine, 30 (5-60) min with 0.5% levobupivacaine and 20 (5-50) min with 0.75% ropivacaine (P = 0.02 and P = 0.12, respectively). Mean (25-75 percentiles) first request for pain medication occurred after 13 (11-14) h with 0.75% ropivacaine, 18 (15-19) h with 0.75% levobupivacaine and 16 (13-20) h with 0.5% levobupivacaine (P = 0.002 and P = 0.002, respectively). Rescue tramadol after surgery was required by three patients in the 0.75% levobupivacaine group, eight patients in the 0.5% levobupivacaine group and nine patients in the 0.75% ropivacaine group (P = 0.05). CONCLUSIONS: We conclude that 0.75% levobupivacaine provides a shorter onset time than 0.5% levobupivacaine and a longer duration of postoperative analgesia than both 0.5% levobupivacaine and 0.75% ropivacaine with reduced need for rescue analgesia after surgery.
Publication Types:
PMID: 15991509 [PubMed - indexed for MEDLINE]
Postoperative condition after the use of remifentanil with a small dose of piritramide compared with a fentanyl-based protocol in patients undergoing craniotomy.
van der Zwan T, Baerts WD, Perez RS, de Lange JJ.
VU University Medical Centre, Department of Anesthesiology, Amsterdam, The Netherlands. tvdzwan@kabelfoon.nl
BACKGROUND AND OBJECTIVE: The use of remifentanil requires other analgesics for postoperative pain relief compared to fentanyl in patients undergoing craniotomy. This could possibly reduce the postoperative advantages of this short-acting opioid. METHODS: We compared remifentanil and fentanyl-based anaesthesia in a randomized observer and patient blinded trial on patients, undergoing an elective craniotomy. Twenty patients received anaesthesia using remifentanil with a small dose of piritramide (0.1 mg kg(-1)) after closure of the dura mater. Twenty patients underwent a fentanyl-based protocol. In both groups, anaesthesia was induced with thiopental and rocuronium, and maintained with 0.6-1 minimum alveolar concentration (MAC) isoflurane in a nitrous oxide/oxygen mixture 2:1 and rocuronium. Patients received 1 g of paracetamol rectally postoperatively. A visual analogue scale (VAS) for pain, the Glasgow Coma Score, a modified Aldrete Score, arterial carbon dioxide tension (PaCO2) and piritramide consumption were evaluated every half an hour postoperatively. RESULTS: No significant differences were found for pain, Aldrete or Glasgow Coma scores or for PaCO2 between the groups when controlled for age, although the pain and Glasgow Coma Scores were consistently higher and PaCO2 lower in the remifentanil group. Furthermore, 11 out of 20 patients in the remifentanil group requested extra piritramide as opposed to 7 out of 20 in the fentanyl group (P = 0.11). CONCLUSIONS: Despite the intraoperative use of piritramide in the remifentanil group, patients experienced more pain postoperatively. A significant influence of age on pain intensity was found. The use of remifentanil with a small dose of piritramide of 0.1 mg kg(-1) has no evident advantage over the use of fentanyl considering the postoperative conditions after craniotomy.
Publication Types:
PMID: 15991506 [PubMed - indexed for MEDLINE]
The effect of adding nitrous oxide on MAC of sevoflurane combined with two target-controlled concentrations of remifentanil in women.
Albertin A, Casati A, Bergonzi PC, Moizo E, Lombardo F, Torri G.
Vita-Salute University of Milano, Department of Anesthesiology, IRCCS H, San Raffaele, Milan, Italy. albertin.andrea@hsr.it
BACKGROUND AND OBJECTIVE: The aim of this prospective, randomized, double-blind study was to determine the effects of adding nitrous oxide on sevoflurane requirement for blunting sympathetic responses after surgical incision combined with two different target-controlled concentrations of remifentanil (1 and 3 ng mL(-1)) in female. METHODS: 102 female patients, aged 20-50 yr, ASA I, undergoing general anaesthesia for elective abdominal surgery were enrolled and randomly allocated to receive sevoflurane anaesthesia alone (Group A, n=53), or with the addition of 60% nitrous oxide (Group N, n=49). Patients of both groups were further assigned to receive a target-controlled remifentanil infusion with an effect-site concentration of either 1 ng mL(-1) (Group N1, n=27; Group A1, n=30), or 3 ng mL(-1) (Group N3, n=22; Group A3, n=23). Sympathetic responses to surgical incision were determined after a 20-min period of stable end-tidal sevoflurane and target-controlled remifentanil concentrations. Predetermined end-tidal sevoflurane concentrations and minimum alveolar concentration (MAC) for each group were determined using an up-and-down sequential allocation technique. RESULTS: The MAC of sevoflurane was 3.96% (95% confidence interval, CI95: 3.69-4.23%) in Group A1 and 1.2% (CI95: 0.9-1.3%) in Group N1 (P < 0.01), while in Groups A3 and N3 the MAC of sevoflurane was 0.36% (CI95: 0.24-0.47%) and 0.18% (CI95: 0.1-0.3%), respectively (P < 0.05). CONCLUSION: Adding 60% nitrous oxide reduces the MAC of sevoflurane by 70% when using a remifentanil concentration of 1 ng mL(-1) and 50% when using a remifentanil concentration of 3 ng mL(-1).
Publication Types:
PMID: 15991505 [PubMed - indexed for MEDLINE]
Case 5--2005: anesthetic management of major hemorrhage during mediastinoscopy. [clin conf]
Lohser J, Donington JS, Mitchell JD, Brodsky JB, Raman J, Slinger P.
Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305-5640, USA. jlohser@yahoo.ca
PMID: 16202909 [PubMed - in process]
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A prospective, double-blind, randomized, placebo-controlled study of dexmedetomidine as an adjunct to epidural analgesia after thoracic surgery.
Wahlander S, Frumento RJ, Wagener G, Saldana-Ferretti B, Joshi RR, Playford HR, Sladen RN.
Department of Anesthesiology, Division of Critical Care Medicine, College of Physicians and Surgeons of Columbia University, New York, NY 10032-3784, USA.
OBJECTIVE: The purpose of this study was to test the hypothesis that after thoracic surgery, the supplementation of a low-dose thoracic epidural (ED) bupivacaine (0.125%) infusion by intravenous (IV) dexmedetomidine decreases analgesic requirement without causing respiratory depression. The primary endpoint was the need for additional ED bupivacaine administered through patient-controlled epidural analgesia (PCEA). Secondary endpoints included the requirement for supplemental opioids and the impact of dexmedetomidine on CO2 retention. DESIGN: A prospective, randomized, double-blinded study. SETTING: A major US tertiary care university hospital. PATIENTS: Twenty-eight patients scheduled to undergo elective thoracotomy for wedge resection, lobectomy, or pneumonectomy. INTERVENTIONS: On intensive care unit arrival, the thoracic ED catheter was loaded with 0.125% bupivacaine to a T4 sensory level and a continuous infusion of 0.125% bupivacaine without opioid was commenced at 4 mL/h. Patients were then randomized into 1 of 2 groups. The dexmedetomidine group received an IV loading dose of dexmedetomidine of 0.5 microg/kg over 20 minutes, followed by continuous IV infusion at 0.4 microg/kg/h. The placebo group received IV saline at the same calculated loading and infusion rates by volume. If necessary, supplemental analgesia (increased ED rate, ED fentanyl, ketorolac [IV]) was provided to ensure a visual analog scale (VAS) score of < or =3. MEASUREMENTS: The analgesic effect was monitored by the VAS, and the requirement for PCEA dosing and additional analgesics was recorded. Heart rate, blood pressure, and blood gases were also monitored. MAIN RESULTS: There was no significant difference in PCEA use and VAS score between the 2 groups, but requirement for supplemental ED fentanyl analgesia was significantly greater in the placebo group (66.1 +/- 95.6 v 5.3 +/- 17.1 microg, p = 0.039). Mean PaCO2 was also significantly greater in the placebo group (40.3 +/- 4.1 v 43.9 +/- 4.3 mmHg, p = 0.04). Patients in the dexmedetomidine group exhibited significantly decreased heart rate (1 patient required and responded to atropine) and blood pressure (4 patients required and readily responded to IV fluid) compared with the placebo group. CONCLUSION: The authors conclude that in postthoracotomy patients, IV dexmedetomidine is a potentially effective analgesic adjunct to thoracic ED bupivacaine infusion and may decrease the requirement for opioids and potential for respiratory depression.
PMID: 16202898 [PubMed - in process]
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Anesthesia for port-access cardiac surgery in a pediatric population.
Preisman S, Keidan I, Perel A, Mishaly D.
Department of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. preisman@netvision.et.il
OBJECTIVE: A less invasive approach to cardiac surgical procedures has become widely accepted. The Port-Access (Heartport Inc, Redwood City, CA) technique for correction of acquired and congenital heart defects in adults produces superior cosmetic results without increasing perioperative morbidity. This study evaluated the feasibility of the Port-Access approach for repairs of various congenital heart defects in children and describes the anesthetic management for this procedure. DESIGN: Prospective observational study. SETTING: University hospital. PARTICIPANTS: Ten 3- to 15-year-old patients. INTERVENTIONS: Patients underwent repairs of congenital heart defects via minimal right thoracotomy. The induction and maintenance of anesthesia were tailored to achieve early extubation. Endotracheal intubation with a double-lumen tube was performed in 3 patients with body weight more than 25 kg. In other patients, lung separation was achieved with the use of a bronchial blocker. Arterial and venous cannulation were done under transesophageal echocardiography (TEE) guidance. A small surgical incision was performed in the fifth right intercostal space. In most patients, operations were performed on a fibrillating heart in normothermic condition. RESULTS: TEE-guided cannulation posed no technical difficulties. Flow rates, calculated for patients' body surface area, were easily achieved. No inotropic support was necessary for the separation from cardiopulmonary bypass. All patients but 1 were extubated in the operating room. Despite longer times of operation and cardiopulmonary bypass, intensive care unit stay and postoperative hospital length of stay were not different from the historic matched control group and were 2.7 +/- 1.1 days and 5.0 +/- 1.6 days, respectively. CONCLUSIONS: The Port-Access method for the correction of selected congenital cardiac defects is feasible in children.
PMID: 16202897 [PubMed - in process]
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Anesthetic care during modified fontan procedure without cardiopulmonary bypass.
Tobias JD, Russo P.
Department of Pediatrics, University of Missouri, Health Sciences Center, Columbia, MO 65212, USA. Tobiasj@health.missouri.edu
OBJECTIVE: The purpose of this study was to report the anesthetic care of patients during performance of a Fontan procedure without cardiopulmonary bypass (CPB). DESIGN: Retrospective chart review. SETTING: Operating room of a university hospital. PARTICIPANTS: Seven pediatric-patients undergoing inferior vena cava (IVC)-to-pulmonary artery (PA) anastomosis for completion of the Fontan procedure. INTERVENTIONS: Charts were reviewed for anesthetic technique, hemodynamic and ventilatory changes occurring during the procedure, and anesthetic interventions that were provided. MEASUREMENTS AND MAIN RESULTS: The off-bypass Fontan procedure was attempted in 7 patients (age: 26 months-7 years, weight: 13 to 28 kg). Exposure of the PA was not feasible in 1 patient because of a markedly enlarged right atrium. In the remaining 6 patients, before cross-clamping of the PA to allow for the proximal anastomosis between the PA and the conduit, alkalosis (pH > or =7.5) was maintained by the administration of sodium bicarbonate. After PA cross-clamping, fluid administration was necessary in 5 patients and dopamine (3-7 microg/kg/min) was necessary in 4 patients. The minute ventilation was increased by 18 +/- 7% to maintain baseline PaCO2 values. Before the placement of the PA cross-clamp, the end-tidal PaCO2 difference was 7 +/- 4 mmHg and the transcutaneous (TC)-PaCO2 difference was 3 +/- 2 mmHg. The end-tidal PaCO2 difference increased to 14 +/- 6 mmHg during cross-clamping of the PA, whereas no change was noted in the TC-PaCO2 difference. Once the proximal anastomosis was completed, a bridge was placed to redirect blood from the IVC to the right atrium while the IVC was clamped and attached to the distal end of the conduit. After placement of the distal end of the bridge into the IVC, fluid administration to maintain the blood pressure was necessary in 3 patients. In 1 patient, 20 minutes after placement of the bridge, the authors noted a progressive increase in the central venous pressure reading measured from the left femoral vein and the need for the administration of volume to maintain the mean arterial pressure. Examination of the bridge revealed occlusion with thrombus despite an activated coagulation time value of 250 to 300 seconds. The tracheas of 3 of the 6 patients were extubated in the operating room, whereas the other 3 were extubated in the pediatric intensive care unit within 4 hours of completion of the procedure. The 1 patient who required the use of CPB required reintubation and had a protracted intensive care unit course. The other 6 patients were discharged home on postoperative days 7 to 12. CONCLUSIONS: With alteration of the anesthetic technique, the Fontan procedure can be performed in selected patients without the need for CPB.
PMID: 16202895 [PubMed - in process]
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Hemodynamic, hepatorenal, and postoperative effects of desflurane-fentanyl and midazolam-fentanyl anesthesia in coronary artery bypass surgery.
But AK, Durmus M, Toprak HI, Ozturk E, Demirbilek S, Ersoy MO.
Department of Anesthesiology, Inonu University School of Medicine, Malatya, Turkey. kbut@inonu.edu.tr
OBJECTIVE: The purpose of this study was to compare the hemodynamic, hepatorenal, and postoperative effects of desflurane-fentanyl and midazolam-fentanyl anesthesia during coronary artery bypass surgery. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Sixty patients undergoing elective coronary artery bypass grafting surgery with ejection fraction more than 45%. INTERVENTIONS: Anesthesia was induced with etomidate, 0.2 mg/kg, and fentanyl, 5 microg/kg, in group D (n = 30) and with midazolam, 0.1 to 0.3 mg/kg, and fentanyl, 5 microg/kg, in group M (n = 30). Anesthesia was maintained with desflurane, 2% to 6%, and fentanyl, 15 to 25 microg/kg, in group D and midazolam infusion, 0.1 to 0.5 mg/kg/h, and fentanyl, 15 to 25 microg/kg, in group M. MEASUREMENTS AND MAIN RESULTS: Hemodynamic monitoring included a 5-lead electrocardiogram, a radial artery catheter, and a pulmonary artery catheter. Data were obtained before induction of anesthesia (t0), after induction of anesthesia (t1), after intubation (t2), after surgical incision (t3), after sternotomy (t4), before cardiopulmonary bypass (t5), after protamine infusion (t6), and at the end of the surgery (t7). Blood samples were obtained to measure total bilirubin, aspartate aminotransferase, gamma glutamyl transferase, lactate dehydrogenase, alkaline phosphatase, creatinine, and blood urea nitrogen just before induction of anesthesia and at the first, fourth, and 14th days postoperatively. CONCLUSIONS: Intraoperative hemodynamic responses were similar in both groups, and transient hepatic and renal dysfunctions were observed in the postoperative period in both groups. The extubation and intensive care unit discharge times were found to be shorter in the desflurane-fentanyl group.
PMID: 16202892 [PubMed - in process]
George W. Crile, Ohio's first neurosurgeon, and his relationship with Harvey Cushing.
Nathoo N, Lautzenheiser FK, Barnett GH.
Brain Tumor Institute, The Taussig Cancer Center, Cleveland, Ohio, USA.
Much has been written about Harvey Cushing, his contributions to neurosurgery, and his relationship with many of his contemporaries. Nevertheless, there is no independent report documenting his relationship with Ohio's first neurosurgeon, George W. Crile. Crile's role as a neurosurgeon is limited to the late nineteenth and early twentieth centuries, and he is best remembered for other accomplishments. Father of physiological surgery, pioneering surgeon, innovator, inventor, soldier, and the principal founder of the Cleveland Clinic Foundation, Crile lived during the golden era of surgery, when the discipline was evolving from a crude and chancy art to an applied science. Crile achieved distinction by performing and describing the first successful radical neck dissection for head and neck cancers and the first successful direct human-to-human blood transfusion. He helped introduce the measurement of blood pressure during surgery, first used cocaine for regional anesthesia in the US, proposed "anoci-anesthesia" to prevent shock during surgery, helped establish one of the first nurse anesthetist schools, and invented the Crile forceps and the pneumatic suit, which was the forerunner to the aviator's antigravity suit. He was a founding member of the American College of Surgeons, its second president (1916-1917), and chairman of the Board of Regents (1913-1939). Crile was a teacher, lecturer, and author who published more than 400 papers and 24 books. In this report the authors trace the relationship between Crile and Cushing from their initial competition for a staff surgeon's position to their common interest in blood pressure, and their roles in the American Ambulance in France and later in World War I.
Publication Types:
Personal Name as Subject:
PMID: 16175872 [PubMed - indexed for MEDLINE]
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Minor oral surgery without stopping daily low-dose aspirin therapy: a study of 51 patients.
Madan GA, Madan SG, Madan G, Madan AD.
Madan Dental Hospital, Ahmedabad, India. gautammadan@yahoo.com
PURPOSE: The risk of excessive bleeding prompts physicians to stop low-dose long-term aspirin regimens before surgery, which puts the patient at risk from adverse thrombotic events. We hypothesize that most minor oral surgical procedures can be carried out safely without stopping low-dose aspirin. PATIENTS AND METHODS: All minor oral surgery patients at our hospital (Madan Dental Hospital, Ahmedabad, India) from May 2002 to May 2003, who were also on long-term low-dose aspirin therapy regimens (acetylsalicylic acid 75 mg to 100 mg/day), were included. Investigation of bleeding time and platelet count was performed. If within normal limits, aspirin was not stopped before surgery. Patients were operated under local anesthesia on an outpatient basis. All wounds were sutured and followed up at 24, 48, and 72 hours, 1 week, and 2 weeks after the procedure. RESULTS: The study included 51 patients (32 males, 19 females), ranging in age from 45 to 70 years. Preoperative values were within normal limits for all patients. Aspirin was not stopped for a single patient. There was no excessive intraoperative bleeding in all cases except 1; there was no postoperative bleeding in all cases. CONCLUSION: We conclude that most minor oral surgery procedures can be carried out safely without stopping long-term low-dose aspirin regimen.
PMID: 16122588 [PubMed - indexed for MEDLINE]
Comment on:
Very low dose of caudal morphine.
Mayhew J, Siddiqui S.
Publication Types:
PMID: 15960653 [PubMed - indexed for MEDLINE]
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Prolonged infusion of dexmedetomidine for sedation following tracheal resection.
Hammer GB, Philip BM, Schroeder AR, Rosen FS, Koltai PJ.
Department of Anesthesia, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA 94305-5640, USA. ham@stanford.edu
Dexmedetomidine is a centrally acting alpha-2 adrenergic agonist that is currently approved by the US Food and Drug Administration for short-term use (< or = 24 h) to provide sedation in adults in the ICU. This drug has been shown to be efficacious in adult medical and surgical patients in providing sedation, anxiolysis, and analgesia. Dexmedetomidine has been associated with rapid onset and offset, hemodynamic stability, and a natural, sleep-like state in mechanically ventilated adults. To date, there are few publications of the use of this drug in children, and prolonged infusion has not been described. We report our use of dexmedetomidine in a child during a 4-day period of mechanical ventilation following tracheal reconstruction for subglottic stenosis.
Publication Types:
PMID: 15960649 [PubMed - indexed for MEDLINE]
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Perioperative management of a child with severe hypertension from a catecholamine secreting neuroblastoma.
Seefelder C, Sparks JW, Chirnomas D, Diller L, Shamberger RC.
Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital, Boston, MA 02115, USA. christian.seefelder@childrens.harvard.edu
Increased catecholamine secretion from neuroblastomas can occasionally be demonstrated, but severe hypertension is uncommon. We report the perioperative management of a 5 year old child with stage III adrenal neuroblastoma who presented with malignant hypertension and high norepinephrine and dopamine levels. Hypertensive crises occurred during anesthesia for surgical biopsy and during chemotherapy. After blood pressure control using phenoxybenzamine and enalapril, doxazosin was used successfully as the preoperative alpha-adrenergic receptor antagonist for surgical tumor resection.
Publication Types:
PMID: 15960647 [PubMed - indexed for MEDLINE]
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Clonidine administered as adjuvant for bupivacaine in ilioinguinal-iliohypogastric nerve block does not prolong postoperative analgesia.
Kaabachi O, Zerelli Z, Methamem M, Abdelaziz AB, Moncer K, Toumi M.
Department of Anesthesiology and Intensive Care Medicine, Hopital Sahloul, Sousse, Tunisia. olfa.kaabachi@gnet.tn
BACKGROUND: Coadministration of clonidine with local anesthetics is associated with improvement of the quality of peripheral nerve block and significant prolongation of postoperative analgesia. Better analgesia has been reported with clonidine in ilioinguinal nerve block compared with caudal use. The object of this study was to determine whether adding of 1 microg.kg(-1) clonidine to bupivacaine 0.25% in ilioinguinal-iliohypogastric nerve block prolongs postoperative analgesia in children. METHODS: Ninety-eight children ASA I-II aged between 1 and 12 years, scheduled for elective outpatient herniorrhaphy or orchidopexy were randomly allocated to receive an ilioinguinal-iliohypogastric nerve block either with 0.3 ml.kg(-1) bupivacaine 0.25% plus 1 microg.kg(-1) clonidine or only bupivacaine. Postoperative analgesic needs, time to the first analgesic supplementation and sedation score were assessed in hospital for 6 h postoperatively and at home by telephone call. RESULTS: Demographic data were similar in both groups. There was no statistical difference in the rate of rescue analgesia between the two groups during the first six postoperative hours (20.4% group clonidine vs 30.6% group no clonidine) (P = 0.17). A slight decrease in systolic blood pressure during surgery was reported in the clonidine group. There was no difference in the scores of sedation between the two groups. At home, 10 patients in the clonidine group and nine patients in the nonclonidine group received analgesic medication. There was no difference between the two groups regarding the number of patients receiving analgesic rescue during the first 24 h (log rank = 0.39). Parental satisfaction was high in both groups. CONCLUSIONS: Our study failed to demonstrate any advantage in addition of 1 microg.kg(-1) clonidine to 0.25% bupivacaine for ilioinguinal-iliohypogastric nerve block compared with bupivacaine 0.25% alone.
Publication Types:
PMID: 15960643 [PubMed - indexed for MEDLINE]
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Comparison of the effects of clonidine and ketamine added to ropivacaine on stress hormone levels and the duration of caudal analgesia.
Akbas M, Akbas H, Yegin A, Sahin N, Titiz TA.
Department of Anaesthesiology, Akdeniz University Medical Faculty, Antalya, Turkey. akbasmert@akdeniz.edu.tr
BACKGROUND: The purpose of this study was to compare the analgesic quality and duration of ropivacaine 0.2% with the addition of clonidine (1 microg.kg(-1)) with that of ropivacaine 0.2% and the addition of ketamine (0.5 mg.kg(-1)) to that of ropivacaine 0.2% and also compare the postoperative cortisol, insulin and glucose concentrations, sampled after induction and 1 h later following caudal administration in children. METHODS: According to the randomization, patients in the ropivacaine group (R; n = 25) received ropivacaine 0.2%, 0.75 ml.kg(-1); those in the clonidine group (RC; n = 25) received ropivacaine 0.2% 0.75 ml.kg(-1) plus clonidine 1 microg.kg(-1) and those in the ketamine/ropivacaine group (RK; n = 25) ropivacaine 0.2% 0.75 ml.kg(-1) plus ketamine 0.5 mg.kg(-1) (10 mg.ml(-1) concentration). Drugs were diluted in 0.9% saline (0.75 ml.kg(-1)) and prepared by a staff anesthesiologist not otherwise involved in the study. In all groups, the duration of analgesia, analgesic requirements, sedation and insulin, glucose, cortisol concentrations were recorded and statistically compared. RESULTS: There were no significant differences among the three study groups with respect to age, weight or duration of surgery. Caudal administration of clonidine 1 microg.kg(-1) or ketamine 0.5 mg.kg(-1) induced a longer duration of analgesia (P < 0.05) compared with ropivacaine alone. Insulin levels were increased and cortisol reduced in all groups. Glucose concentration was increased in all groups and statistically significant (P < 0.05). CONCLUSIONS: Addition of ketamine and clonidine to ropivacaine 0.2% 0.75 ml.kg(-1), when administered caudally in children, prolongs the duration of postoperative analgesia. The need for subsequent postoperative analgesic is also reduced. Caudal analgesia attenuates or allows partial changes to postoperative cortisol, insulin or blood glucose responses to surgery.
Publication Types:
PMID: 15960642 [PubMed - indexed for MEDLINE]
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Preoperative blood pressure management of children with catecholamine-secreting tumors: time for a change.
Tobias JD.
Publication Types:
PMID: 15960635 [PubMed - indexed for MEDLINE]
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Unusual obstruction of nasotracheal tube.
Karaaslan D, Peker TT, Karaduman AI, Altindis NT, Oguzhanoglu E.
Publication Types:
PMID: 15910361 [PubMed - indexed for MEDLINE]
Comment on:
Vertical infraclavicular brachial plexus block in children: a preliminary study.
Marhofer P.
Publication Types:
PMID: 15910359 [PubMed - indexed for MEDLINE]
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Perioperative management of face-to-face craniopagus twins separation.
Pietrini D, Valenti M, Pusateri A, Scorzoni M, Tosi F, Forte E, Barbi S, Caresta E, Caldarelli M, Di Rocco C, Piastra M.
Pediatric Neuroanesthesiology, Catholic University Medical School, Rome, Italy. domenicopietrini@inwind.it
Craniopagus conjoining represents a complex and challenging issue for neurosurgeons as well as for anesthesiologists. A rare face-to-face case of conjoined twins underwent surgical separation and presented peculiar differences compared with those already reported in the literature. Even in cases lacking large cerebrovascular sinus connections, the impending risk of large blood loss and hemorrhagic shock in the infant requires a high level of surveillance and the institution of invasive monitoring.
Publication Types:
PMID: 15910356 [PubMed - indexed for MEDLINE]
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Severe hemoptysis in a child after the Fontan procedure.
Deisenberg M, Stayer SA.
Department of Anesthesiology, University of Munich, Munich, Germany. markus.deisenberg@med.uni-muenchen.de
There is an increased incidence of pulmonary hemorrhage and hemoptysis among patients with congenital heart disease (CHD). The pathophysiology of pulmonary hemorrhage in CHD includes pulmonary hypertension, pulmonary venous congestion, aorto-pulmonary collaterals, pulmonary arteriovenous malformations, and dilated bronchial arteries. We present the case of a 6-year old boy who required treatment for massive hemoptysis after staged palliation for hypoplastic left heart syndrome (HLHS). Effective management of this life threatening entity is described as well as the anesthetic implications of performing rigid bronchoscopy in a patient with the Fontan circulation and massive hemoptysis.
Publication Types:
PMID: 15910355 [PubMed - indexed for MEDLINE]
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Cerebral oxygenation monitoring using near infrared spectroscopy during controlled hypotension.
Shear T, Tobias JD.
School of Medicine, University of Missouri, Columbia, MO 65212, USA.
BACKGROUND: Controlled hypotension (CH) is used to limit intraoperative blood loss and decrease the need for homologous transfusions. Despite the efficacy of the technique, hypotension has the potential to affect cerebral perfusion and oxygen delivery. There are no data providing a direct measurement of cerebral oxygenation during this technique. METHODS: The current study prospectively evaluated cerebral oxygenation during CH using near infrared spectroscopy. Nineteen patients ranging in age from 6 to 18 years were enrolled in the study. CH was provided using a combination of intravenous opioids and sevoflurane supplemented with labetolol as necessary. RESULTS: There were a total of 268 readings obtained from the cerebral oximeter. The baseline cerebral oximeter reading was 81+/-8% on the right and 82+/-7% on the left. During CH (mean arterial pressure of 65-69, 60-64, 55-59, and <54 mmHg), the right cerebral oximeter values were 80+/-9, 78+/-8, 78+/-10, and 84+/-9%, respectively while the left cerebral oximeter values were 79+/-7, 80+/-7, 78+/-8, and 78+/-8%, respectively. Of the 268 readings, there were 11 points (4%) at which either the left or right cerebral oximeter was 10-19 less than the baseline value and no points at which the reading was 20 or more from the baseline value. CONCLUSIONS: Our preliminary data with a measurement of cerebral oxygenation demonstrates the safety of CH within the accepted mean blood pressure recommendations of 55-65 mmHg.
PMID: 15910352 [PubMed - indexed for MEDLINE]
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Intraoperative low-dose S-ketamine has no preventive effects on postoperative pain and morphine consumption after major urological surgery in children.
Becke K, Albrecht S, Schmitz B, Rech D, Koppert W, Schuttler J, Hering W.
Department of Anaesthesia, University Hospital of Erlangen, Erlangen, Germany.
BACKGROUND: Clinical studies suggest low-dose ketamine may have preemptive effects on postoperative pain in adults. The objective of this study was to determine whether intraoperative low-dose S-ketamine reduces postoperative pain and morphine consumption in children undergoing major urological surgery. MATERIALS: Thirty children scheduled for major urological surgery were included in this prospective study. Anesthesia was performed as total intravenous anesthesia (TIVA) with alfentanil and propofol. Fifteen patients additionally received an intravenous bolus of S-ketamine (0.2 mg.kg-1) followed by a continuous infusion of 5 microg.kg-1.min-1, which was stopped immediately after skin closure (Ketamine Group). Another 15 patients received an infusion of saline (Control group). After transfer to the PACU, pain intensity was evaluated using a numeric rating scale (NRS). First patient controlled analgesia (PCA) request, cumulative morphine consumption and pain intensities within the first 72 h were compared. RESULTS: Morphine consumption was not significantly different during the first 72 h (Control: 0.4 mg.kg-1, 0.24-0.51 mg.kg-1, Ketamine: 0.32 mg.kg-1, 0.19-0.61 mg.kg-1; median, 25-75% percentile; n.s.). However, differences were found in pain intensity during the first postoperative hour (Control: 4.0, 3.2-4.6, Ketamine: 2.5, 1.3-3.5; median, 25-75% percentile; P<0.05) and in the time to first PCA use (Control: 37, 28-46 min, Ketamine: 62, 38-68 min; median, 25-75% percentile; P<0.05). CONCLUSIONS: Intraoperative low-dose S-ketamine had no effect on morphine consumption during the first 72 h after surgery. The differences in pain intensity and time to first PCA use probably reflect additional sedation and antinociceptive effects of S-ketamine rather than a true 'prevention' of pain.
Publication Types:
PMID: 15910349 [PubMed - indexed for MEDLINE]
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The addition of clonidine 2 microg.kg-1 does not enhance the postoperative analgesia of a caudal block using 0.125% bupivacaine and epinephrine 1:200,000 in children: a prospective, double-blind, randomized study.
Wheeler M, Patel A, Suresh S, Roth AG, Birmingham PK, Heffner CL, Cote CJ.
Department of Anesthesiology, Children's Memorial Hospital, The Feinberg School of Medicine, Northwestern University, Chicago, IL 60614, USA. mwheeler@northwestern.edu
BACKGROUND: In this prospective, randomized, double-blind study, we compared the efficacy of 0.125% bupivacaine and epinephrine 1:200,000 with and without clonidine 2 microg.kg-1 for 'single shot' pediatric caudal analgesia. METHODS: Thirty ASA I and II children, ages 2-8 years, undergoing outpatient surgical procedures below the umbilicus received 1 ml.kg-1 0.125% bupivacaine with fresh epinephrine 1:200,000 and clonidine 2 microg.kg-1 (group-C) or 1 ml.kg-1 0.125 % bupivacaine with epinephrine 1:200 000 (group-NC). All patients received a standardized general anesthetic (induction with 67% N2O in O2 and sevoflurane followed by isoflurane maintenance). Primary outcome measures were time to first rescue analgesic and number of patients requiring rescue analgesic at 4, 6, 8, 12, and 24 h after caudal placement. Secondary outcome measures included: extubation times, Objective Pain Scale (OPS) scores, sedation scores, time in postanesthesia care unit (PACU), discharge time, number of analgesic doses given in 24 h following caudal blockade, and adverse effects (vomiting, hypotension, and bradycardia). RESULTS: There were no differences in demographics, investigated parameters, or adverse effects between groups. CONCLUSIONS: We found that the addition of clonidine 2 microg.kg-1 to 0.125% bupivacaine with fresh epinephrine 1:200,000 for caudal analgesia did not significantly delay the time to first rescue analgesic or decrease the overall need for rescue analgesics in children 2-8 years undergoing surgical procedures below the umbilicus.
Publication Types:
PMID: 15910348 [PubMed - indexed for MEDLINE]
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Sevoflurane (12% and 8%) inhalational induction in children.
Chawathe M, Zatman T, Hall JE, Gildersleve C, Jones RM, Wilkes AR, Aguilera IM, Armstrong TS.
Anaesthetics and Intensive Care Medicine, University of Wales College of Medicine, Cardiff, Wales, UK.
BACKGROUND: Sevoflurane induction of anesthesia is frequently used in children. Rapidly performed inhalational induction may reduce excitation during early anesthesia. Increasing the total anesthetic MAC delivered to patients can be achieved by increasing volatile concentration or adding nitrous oxide. The latter reduces inspired oxygen concentration delivered, which may not be desirable. Even 8% sevoflurane induction is associated with excitation. A system capable of delivering 12% sevoflurane using two tandem vaporizers has been developed. METHODS: A randomized double blind study was undertaken to assess whether 12% sevoflurane offered any advantage over 8% in time and quality of induction. Sixty children aged 5-10 years were recruited and received either 12 or 8% sevoflurane. Time to loss of eyelash reflex, central pupils, incidence of adverse events, induction quality, systolic blood pressure and heart rate were recorded. RESULTS: Twelve percent sevoflurane reduced time to loss of eyelash reflex compared with 8% [mean (sd): 35 (12) and 46 (14) P<0.05], but the reduction was only 10% higher than the error in the measurement (assessment every 10 s). Twelve percent sevoflurane offered significantly better quality of induction (P<0.05). There was no difference in cardiovascular stability between groups, although heart rate rose significantly in both groups. Maintaining sevoflurane at 12% for 4 min caused significant amounts of apnea (69% with 12% and 38% with 8%, P<0.05). CONCLUSION: Twelve percent sevoflurane offers a smoother anesthesia induction than 8% in children of this age with no additional consequences for the cardiovascular system.
Publication Types:
PMID: 15910347 [PubMed - indexed for MEDLINE]
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Psoas compartment block (PCB) in children: Part II--generation of an institutional learning curve with a new technique.
Schuepfer G, Johr M.
International Research Center, UZ Gent, University of Gent, Gent, Belgium.
BACKGROUND: Literature concerning institutional learning processes for anesthesia procedures in pediatric anesthesia is rare. Until recently only small series of psoas compartment blocks (PCB) in children have been reported. We report on a series of 100 consecutive blocks using new landmarks and the institutional learning process. METHODS: In 100 consecutive children (5.9-106 kg) PCB was performed using a nerve stimulator. In the lateral position, the needle was inserted between the medial 2/3 and the lateral 1/3 on a line from the spinous process of L4 to the posterior superior iliac spine. Residents unfamiliar with PCB were instructed by one single staff member without manual intervention. Failure was defined as a bloody tap, more than one skin perforation with the needle or relinquishing the procedure to senior staff. To evaluate the institutional learning process the cumulative sum (CUSUM) statistical technique was used. CUSUM analysis was performed using an acceptable failure rate of 10%. A learning curve using a bootstrap technique and a least square fit model was also used. RESULTS: Although all blocks were clinically successful, only in 64% was a single attempt sufficient. In 16% vascular puncture occurred. Surprisingly the CUSUM analysis showed a clear institutional learning phenomenon. Applying a strict definition for a successful block, more than 100 PCB in an institution may be necessary. Using the generated learning curve, for a success rate of 70% a case load of at least 55 attempts is required. CONCLUSIONS: Although the described new technique had a very high success rate with a low complication rate, PCB in children is not easily implemented into clinical practice when strict criteria of success were used, despite a well-controlled environment. Training programs could use CUSUM to track the progress of their institutional learning in order to guarantee adequate experience.
PMID: 15910346 [PubMed - indexed for MEDLINE]
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Psoas compartment block in children: Part I--description of the technique.
Schuepfer G, Johr M.
International Research Center, UZ Gent, University of Gent, Gent, Belgium.
BACKGROUND: Until recently only small series of psoas compartment blocks (PCB) in children have been reported. A high incidence of epidural spread as an important side effect was noted. A series of 100 consecutive blocks using new standardized landmarks is reported. METHODS: In 100 consecutive children (5.9-106 kg) PCB was performed using a nerve stimulator. In the lateral position, the needle was inserted between the medial 2/3 and the lateral 1/3 on a line from the spinous process of L4 to the posterior superior iliac spine. The blocks were performed by residents in training under supervision of one specific designated pediatric anesthetist. RESULTS: All blocks were clinically successful. In 64% only one attempt was necessary, in 26 patients two attempts were necessary and in 10 patients more than two attempts were necessary. In 16% a vascular puncture occurred. In one patient with a dense unilateral block a partial epidural spread occurred. No serious complications were observed during the perioperative period. CONCLUSIONS: The described new technique has a very high success rate with no relevant side effects. Although only one case of epidural spread occurred, PCB remains an invasive technique with the potential for serious complications.
PMID: 15910345 [PubMed - indexed for MEDLINE]
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Herbal and homeopathic medication use in pediatric surgical patients.
Everett LL, Birmingham PK, Williams GD, Brenn BR, Shapiro JH.
Department of Anesthesiology, Children's Hospital and Regional Medical Center, University of Washington, USA. lucyeverett@comcast.net
BACKGROUND: Patients who present for surgery may be using herbal or homeopathic preparations; adverse effects of some of these substances include bleeding, cardiovascular changes, and liver dysfunction. Little information is available on the frequency of use in the pediatric surgical population. METHODS: With institutional approval, a survey was conducted to assess the use of vitamins, nutritional supplements, or herbal or homeopathic preparations in children presenting for surgery in five geographically diverse centers in the USA. RESULTS: A total of 894 completed surveys showed that overall, 3.5% of pediatric surgical patients had been given herbal or homeopathic medications in the 2 weeks prior to surgery. Most substances were prescribed by parents. The use of these medications did not differ between children with coexisting diseases and those without; use was also not different among ethnic groups or by residence setting (city, suburban, rural). There was a significant difference between the west coast centers in the study compared with the rest of the country (7.5% of patients in Palo Alto, CA; 5.5% of patients in Seattle, WA; 1.5% of patients in Chicago, IL; and 1.9% in Virginia and Delaware used herbal or homeopathic remedies). The most prevalent substance given to children presenting for elective surgery was Echinacea. CONCLUSIONS: Herbal and homeopathic medications are used by a small percentage of pediatric patients presenting for elective pediatric surgery patients. Use of these substances should be addressed in the preoperative history.
Publication Types:
PMID: 15910344 [PubMed - indexed for MEDLINE]
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