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[Patients with ornithine transcarbamylase deficiency Anaesthesiological and intensive care management.]
[Article in German]
Schmidt J, Schroth M, Irouschek A, Birkholz T, Kurzai M, Krober S, Meisner M, Albrecht S.
Klinik fur Anasthesiologie, FAU, Erlangen-Nurnberg.
Ornithine transcarbamylase deficiency (OTCD) is the most common inborn urea cycle disorder. Patients with OTCD are at risk of acute metabolic decompensation with hyperammonemia and subsequent encephalopathy, coma and death. Symptoms may be triggered by infections, drugs and stress, evoked by trauma, pain, fear, surgery and anaesthesia or by episodes of protein catabolism, i.e. fasting-induced, post partum or during gastrointestinal bleeding. Several specific considerations must be made for anaesthetic and intensive care management in patients with this disease in order to avoid metabolic decompensation. We report the intensive care management of the first manifestation of late-onset OTCD in a 16-year-old girl and a course of inconspicuous general anaesthesia with midazolam, s-ketamine, fentanyl and isoflurane in a 22-year-old girl with known OTCD.
PMID: 16136341 [PubMed - as supplied by publisher]
A case of a power failure in the operating room.
Yasny J, Soffer R.
Department of Anesthesiology, Box 1010, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA.
In the operating room, safely administering anesthesia amidst a major power failure can instantly present one with a formidable challenge. A case is presented involving a 23-year-old healthy woman who underwent a complex oral and maxillofacial surgery to correct a dentofacial deformity. Three hours into the case and with the patient's maxilla downfractured, the overhead surgical lights blacked out, and there was an apparent loss of the anesthesia machine's ability to function. Providing adequate oxygenation, ventilation, anesthesia levels, monitoring of vital signs, and transportation of the patient were some of the challenges faced, and the response to this unexpected event is recounted. The importance of one's familiarity with an anesthesia machine's backup battery supply, routinely checking machinery, ensuring that appropriate and sufficient supplies are readily available, exercising calm leadership with clear communication, and formulating a clear plan with backup alternatives are discussed. Various recommendations are proposed with respect to the preparation for and the prevention of a power failure in the operating room. This report's account of events is aimed to "shed some light" on this topic, serve as a check of one's own preparedness, and facilitate the optimal management of a similarly unexpected incident.
Publication Types:
PMID: 16048154 [PubMed - indexed for MEDLINE]
Midazolam premedication in children: a pilot study comparing intramuscular and intranasal administration.
Lam C, Udin RD, Malamed SF, Good DL, Forrest JL.
Advanced Pediatric Dentistry Program, University of Southern California School of Dentistry, 925 W 34th St, Los Angeles, CA 90089-0641, USA.
The purpose of this study was to compare the effectiveness of intramuscular and intranasal midazolam used as a premedication before intravenous conscious sedation. Twenty-three children who were scheduled to receive dental treatment under intravenous sedation participated. The patients ranged in age from 2 to 9 years (mean age, 5.13 years) and were randomly assigned to receive a dose of 0.2 mg/kg of midazolam premedication via either intramuscular or intranasal administration. All patients received 50% nitrous oxide and 50% oxygen inhalation sedation and local anesthetic (0.2 mL of 4% prilocaine hydrochloride) before venipuncture. The sedation level, movement, and crying were evaluated at the following time points: 10 minutes after drug administration and at the times of parental separation, passive papoose board restraint, nitrous oxide nasal hood placement, local anesthetic administration, and initial venipuncture attempt. Mean ratings for the behavioral parameters of sedation level, degree of movement, and degree of crying were consistently higher but not significant in the intramuscular midazolam group at all 6 assessment points. Intramuscular midazolam was found to be statistically more effective in providing a better sedation level and less movement at the time of venipuncture than intranasal administration. Our findings indicate a tendency for intramuscular midazolam to be more effective as a premedication before intravenous sedation.
Publication Types:
PMID: 16048152 [PubMed - indexed for MEDLINE]
Comment on:
Arterial oxygen desaturation after induction of anesthesia.
Drummond GB.
Publication Types:
PMID: 16129997 [PubMed - indexed for MEDLINE]
5: id: 16129996 Error occurred: Document retrieval error: document is empty
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Obstetric anesthesia workforce survey: twenty-year update.
Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA.
University of Colorado School of Medicine, Denver, Colorado 80262, USA. brenda.bucklin@uchsc.edu
PMID: 16129992 [PubMed - indexed for MEDLINE]
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Postpolio syndrome and anesthesia.
Lambert DA, Giannouli E, Schmidt BJ.
Department of Anesthesia, University of Manitoba, Canada.
The development of polio vaccines 50 yr ago essentially halted childhood polio epidemics in the industrialized world. During the past quarter century, a constellation of delayed neuromuscular symptoms, called postpolio syndrome, became recognized among the aging polio survivors. The prevalence of postpolio syndrome in the U.S. population is estimated to be in the hundreds of thousands. The most common symptoms are fatigue, pain, and new onset weakness thought to be related to delayed deterioration of motor neuron function. When a patient with postpolio syndrome presents for surgery, special precautions are warranted, because these patients may have respiratory impairment, sleep apnea, swallowing difficulties, and cold intolerance. This article first reviews clinical features and some pathoetiologic theories of postpolio syndrome and then focuses on anesthetic considerations including the use of common anesthetics, neuromuscular blockade, regional anesthesia, and general anesthetic management strategies.
Publication Types:
PMID: 16129991 [PubMed - indexed for MEDLINE]
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Nerve stimulator-guided paravertebral blockade combined with sevoflurane sedation versus general anesthesia with systemic analgesia for postherniorrhaphy pain relief in children: a prospective randomized trial.
Naja ZM, Raf M, El Rajab M, Ziade FM, Al Tannir MA, Lonnqvist PA.
Department of Anesthesia and Pain Medicine, Makassed General Hospital, Beirut, Lebanon. zouhnaja@yahoo.com
BACKGROUND: Improvement of the duration of postoperative analgesia is desirable in children undergoing inguinal hernia repair. METHODS: Fifty children aged 5-12 yr were prospectively randomized to receive either paravertebral nerve blockade or general anesthesia (sevoflurane-fentanyl-nitrous oxide-oxygen) combined with standardized postoperative systemic analgesia, both combined with light sevoflurane anesthesia, for inguinal hernia repair. RESULTS: Mean pain scores were significantly lower in paravertebral nerve blockade patients compared with patients treated with systemic analgesia during the entire 48-h observational period (P < 0.05). Analgesic consumption was significantly higher in the systemic analgesia group (88%) compared with the paravertebral nerve blockade group (32%) (P < 0.001). Parental satisfaction was significantly higher (80 vs. 48%; P < 0.05) and same-day discharge was possible in a higher proportion of patients in the paravertebral blockade group (80% vs. 52%; P < 0.05). CONCLUSIONS: Paravertebral nerve blockade was associated with improved postoperative pain relief; reduced analgesic consumption, and faster hospital discharge compared with a systemic analgesia protocol in children undergoing herniorrhaphy.
Publication Types:
PMID: 16129986 [PubMed - indexed for MEDLINE]
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Sniffing position improves pharyngeal airway patency in anesthetized patients with obstructive sleep apnea.
Isono S, Tanaka A, Ishikawa T, Tagaito Y, Nishino T.
Department of Anesthesiology, Graduate School of Medicine, Chiba University, Chiba, Japan. isonos-chiba@umin.ac.jp
BACKGROUND: Appropriate bag-and-mask ventilation with patent airway is mandatory during induction of general anesthesia. Although the sniffing neck position is a traditionally recommended head and neck position during this critical period, knowledge of the influences of this position on the pharyngeal airway patency is still inadequate. METHODS: Total muscle paralysis was induced with general anesthesia in 12 patients with obstructive sleep apnea, eliminating neuromuscular factors contributing to pharyngeal patency. The cross-sectional area of the pharynx was measured endoscopically at different static airway pressures. Comparison of static pressure-area plot between the neutral and sniffing neck positions allowed assessment of the influence of the neck position change on the mechanical properties of the pharynx. RESULTS: The static pressure-area curves of the sniffing position were above those of neutral neck position, with increasing maximum cross-sectional area and decreasing the closing pressure at both retropalatal and retroglossal airways. The beneficial effects of the sniffing position were greater in obstructive sleep apnea patients with higher closing pressure and smaller body mass index. CONCLUSIONS: Sniffing position structurally improves maintenance of the passive pharyngeal airway in patients with obstructive sleep apnea and may be beneficial for both mask ventilation and tracheal intubation during anesthesia induction.
PMID: 16129972 [PubMed - indexed for MEDLINE]
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Motivation and maternal presence during induction of anesthesia.
Caldwell-Andrews AA, Kain ZN, Mayes LC, Kerns RD, Ng D.
Department of Anesthesiology, Center for the Advancement of Perioperative Health, New Haven, CT 06510, USA.
BACKGROUND: The authors developed a measure to determine whether maternal motivation to be present during induction (Motivation for Parental Presence during Induction of Anesthesia [MPPIA]) is related to children's anxiety during the induction process. METHODS: Mothers and children (aged 2-12 yr) undergoing outpatient, elective surgery and general anesthesia were enrolled in this study (n = 289 dyads). Items to assess motivation for parental presence during induction were selected by experts in anesthesiology, psychology, and child development; mothers completed the resulting 14-item measure as well as assessments of anxiety and coping style. Children's anxiety and compliance was assessed during induction of anesthesia. Factor analysis was performed, and maternal motivation was then examined against children's anxiety during induction of anesthesia. RESULTS: Factor analysis resulted in four scales with a total variance of 72.3%: MPPIA-Desire, MPPIA-Hesitancy, MPPIA-Anxiety, and MPPIA-Preparation. Analysis supported the reliability (0.89-0.94) and validity of the MPPIA. The authors found that mothers with high MPPIA-Desire and low MPPIA-Hesitancy had children with significantly higher anxiety (P < 0.0001) during induction of anesthesia, as compared with mothers with low MPPIA-Desire and MPPIA-Hesitancy. The authors also found that highly motivated mothers reported significantly higher levels of anxiety (P = 0.007). CONCLUSION: Clinicians should be aware that many mothers who have a high desire to be present in the operating room are very anxious and that their children are likely to exhibit high anxiety levels during induction of anesthesia.
PMID: 16129970 [PubMed - indexed for MEDLINE]
Comment in:
Collapsibility of the upper airway at different concentrations of propofol anesthesia.
Eastwood PR, Platt PR, Shepherd K, Maddison K, Hillman DR.
West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology, Sir Charles Gairdner Hospital, and School of Anatomy and Human Biology, University of Western Australia. peter.eastwood@health.wa.gov.au
BACKGROUND: This study investigated the effect of varying concentrations of propofol on upper airway collapsibility and the mechanisms responsible for it. METHODS: Upper airway collapsibility was determined from pressure-flow relations at three concentrations of propofol anesthesia (effect site concentration = 2.5, 4.0, and 6.0 mug/ml) in 12 subjects spontaneously breathing on continuous positive airway pressure. At each level of anesthesia, mask pressure was transiently reduced from a pressure sufficient to abolish inspiratory flow limitation (maintenance pressure = 12 +/- 1 cm H2O) to pressures resulting in variable degrees of flow limitation. The relation between mask pressure and maximal inspiratory flow was determined, and the critical pressure at which the airway occluded was recorded. Electromyographic activity of the genioglossus muscle (EMGgg) was obtained via intramuscular electrodes in 8 subjects. RESULTS: With increasing depth of anesthesia, (1) critical closing pressure progressively increased (-0.3 +/- 3.5, 0.5 +/- 3.7, and 1.4 +/- 3.5 cm H2O at propofol concentrations of 2.5, 4.0, and 6.0 microg/ml respectively; P < 0.05 between each level), indicating a more collapsible upper airway; (2) inspiratory flow at the maintenance pressure significantly decreased; and (3) respiration-related phasic changes in EMGgg at the maintenance pressure decreased from 7.3 +/- 9.9% of maximum at 2.5 microg/ml to 0.8 +/- 0.5% of maximum at 6.0 microg/ml, whereas tonic EMGgg was unchanged. Relative to the levels of phasic and tonic EMGgg at the maintenance pressure immediately before a decrease in mask pressure, tonic activity tended to increase over the course of five flow-limited breaths at a propofol concentration of 2.5 microg/ml but not at propofol concentrations of 4.0 and 6.0 microg/ml, whereas phasic EMGgg was unchanged. CONCLUSIONS: Increasing depth of propofol anesthesia is associated with increased collapsibility of the upper airway. This was associated with profound inhibition of genioglossus muscle activity. This dose-related inhibition seems to be the combined result of depression of central respiratory output to upper airway dilator muscles and of upper airway reflexes.
PMID: 16129969 [PubMed - indexed for MEDLINE]
Comment in:
Kinetics and extravascular retention of acetated ringer's solution during isoflurane or propofol anesthesia for thyroid surgery.
Ewaldsson CA, Hahn RG.
Department of Anesthesiology, South Hospital, Karolinska Institute, Stockholm, Sweden.
BACKGROUND: In sheep, isoflurane causes extravascular accumulation of infused crystalloid fluid. The current study evaluates whether isoflurane has a greater tendency than propofol to cause extravascular retention in surgical patients. METHODS: Thirty patients undergoing thyroid surgery lasting for 143 +/- 32 min (mean +/- SD) received an intravenous infusion of 25 ml/kg acetated Ringer's solution over 30 min. Anesthesia was randomized to consist of isoflurane or propofol supplemented by fentanyl. The distribution and elimination of the infused fluid was estimated using volume kinetics based on the fractional dilution of blood hemoglobin over 150 min. Extravascular retention of infused fluid was taken as the difference between the model-predicted elimination and the urinary excretion. The sodium and fluid balances were measured. RESULTS: The fractional plasma dilution increased gradually to approximately 30% during the infusion and thereafter remained at 15-20%. Urinary excretion averaged 11% of the infused volume. Mean arterial pressure was 10 mmHg lower in the isoflurane group (P < 0.001). The excess fluid volumes in the central and peripheral functional body fluid spaces were virtually identical in the groups. The sum of water losses by evaporation and extravascular fluid retention amounted to 2.0 +/- 2.5 ml/min for isoflurane and 2.2 +/- 2.1 ml/min for propofol. The sodium balance refuted that major fluid shifts occurred between the extracellular and intracellular spaces. CONCLUSIONS: The amount of evaporation and extravascular retention of fluid was small during thyroid surgery, irrespective of whether anesthesia was maintained by isoflurane or propofol.
PMID: 16129968 [PubMed - indexed for MEDLINE]
Comment on:
Upper airway collapsibility: an emerging paradigm for measuring the safety of anesthetic and sedative agents.
Litman RS.
Publication Types:
PMID: 16129966 [PubMed - indexed for MEDLINE]
Comment on:
"The proper study of mankind is man"--rather, men and women undergoing anesthesia and surgery.
Prough DS.
Publication Types:
PMID: 16129965 [PubMed - indexed for MEDLINE]
15: id: 16129964 Error occurred: Document retrieval error: document is empty
[Postobstructif pulmonary oedema after endotracheal extubation at the recovery of general anaesthesia.]
[Article in French]
Samet A, Fossard JP, Samet H, Hirchi M, Fuchs-Buder T.
Departement d'anesthesie-reanimation, CHU de Brabois, rue du Morvan, 54511 Vandoeuvre-Les-Nancy, France.
We report two cases of postobstructif pulmonary oedema occurring after extubation at the recovery of general anaesthesia and presenting some similarities. The young age of the patient and the occurrence of upper airway obstruction after extubation, as well as the radiologic nondependent distribution of alveolar pattern are typical. The underlying pathophysiology seems to be the mechanical disruption of the alveolar-capillary membrane.
PMID: 16125360 [PubMed - as supplied by publisher]
Combined nebulization and spray-as-you-go topical local anaesthesia of the airway.
Williams KA, Barker GL, Harwood RJ, Woodall NM.
Department of Anaesthesia, Norfolk and Norwich University Hospital, UK.
BACKGROUND: Twenty-five anaesthetists underwent awake fibreoptic intubation using a combination of nebulization and topical local anaesthesia. Plasma lidocaine concentrations were measured and the quality of the local anaesthesia was assessed. METHODS: After i.v. glycopyrrolate 3 microg kg(-1) and intranasal xylometolazone 0.1%, lidocaine 4% 200 mg was administered by nebulizer. Supplementary lidocaine to a maximum total of 9 mg kg(-1) was applied directly and via a fibreoptic endoscope. Nasotracheal intubation was performed once the vocal cords became unreactive. Heart rate, non-invasive blood pressure and oxygen saturation were recorded at 5-min intervals. Blood sampling commenced with a baseline sample and continued at 10 min intervals until 60 min after final administration of local anaesthetic. Subjects graded levels of anxiety, pain and coughing using written and visual analogue scales. RESULTS: Conditions for fibreoptic endoscopy and intubation were good. Seventeen received the maximum lidocaine dose of 9 mg kg(-1). The average dose used was 8.8 mg kg(-1). All plasma lidocaine concentrations assayed were below 5 mg litre(-1). Four volunteers reported feeling lightheaded after the procedure, despite normal blood pressure. Of these, two had the highest plasma lidocaine concentrations recorded: 3.5 and 4.5 mg litre(-1). Twenty-two of the 25 subjects found endoscopy and intubation acceptable, three found it enjoyable and no subject rated it as distressing. CONCLUSIONS: This method of airway anaesthesia was acceptable to this small group of unsedated subjects. It produced good conditions for fibreoptic intubation. A maximum calculated lidocaine dose of 9 mg kg(-1) did not produce toxic plasma concentrations of lidocaine.
PMID: 16126785 [PubMed - in process]
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High thoracic epidural with general anesthesia for combined simultaneous on-pump coronary artery bypass grafts and abdominal aortic aneurysm repair.
Barker J, Jain R.
Publication Types:
PMID: 16130081 [PubMed - in process]
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Cardiac anesthesia management of a patient with Bartter's syndrome.
Vetrugno L, Cheli G, Bassi F, Giordano F.
Department of Cardiothoracic Anesthesia and Postsurgical Transplant Intensive Care, S.M. Misericordia Hospital, Udine, Italy. vetrugnoluigi@katamail.com
PMID: 16130069 [PubMed - in process]
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Anesthesia for cardiac surgery on a patient with stiff person syndrome.
Ferrandis R, Belda J, Llau JV, Belda C, Bahamonde JA.
Department of Anesthesiology and Critical Care, Hospital Clinic Universitari, Valencia, Spain. raquelferrandis@ono.com
PMID: 16130068 [PubMed - in process]
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Thoracic epidural analgesia or intravenous morphine analgesia after thoracoabdominal esophagectomy: a prospective follow-up of 201 patients.
Rudin A, Flisberg P, Johansson J, Walther B, Lundberg CJ.
Department of Anesthesiology and Intensive Care, Lund University Hospital, Sweden. asa.rudin@skane.se
OBJECTIVE: Thoracoabdominal esophagectomy is a major surgical procedure that carries significant postoperative morbidity and mortality. Because the choice of analgesic technique may influence outcome, the impact of thoracic epidural or intravenous analgesia was investigated after esophagectomy. DESIGN: Prospective observational study during January 1996 until January 2002. SETTING: University hospital. PARTICIPANTS: All patients undergoing thoracoabdominal esophagectomy during the 6-year period. INTERVENTIONS: Patients were prospectively monitored during a 6-year period. Duration of surgery, intraoperative blood loss, fluid administration, postoperative intubation time, intensive care unit (ICU) stay, pain relief and related side effects, postoperative complications, hospital stay, and in-hospital and long-term mortality were compared in relation with the analgesic technique. MEASUREMENTS AND MAIN RESULT: Thoracic epidural analgesia with bupivacaine/morphine was used in 166 patients, and intravenous morphine analgesia was used in 35 patients. Postoperative intubation time and ICU stay were similar in both groups. Patients with epidural analgesia experienced less pain. Sedation, respiratory depression, hallucinations, and confusion were more common in the intravenous morphine group. Postoperative weight did not differ between the groups, despite fluid replacement that was higher in the epidural group during the first 24 hours. The in-hospital mortality rate was 0.5%. CONCLUSIONS: No differences in morbidity/mortality rates depending on analgesic treatment were observed in patients undergoing thoracoabdominal esophagectomy. Thoracic epidural analgesia provided better pain relief with fewer opioid-related side effects than intravenous morphine analgesia. However, postoperative epidural analgesia was associated with more technical difficulties.
PMID: 16130063 [PubMed - in process]
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Anesthetic-induced alteration in expression of myocardial calcium cycling proteins.
Heerdt PM, The AH, Markov NP.
Department of Anesthesiology, Weill Medical College of Cornell University, Memorial Sloan-Kettering Cancer Center, New York, New York, USA. pmheerd@mail.med.cornell.edu
OBJECTIVE: The purpose of this study was to test the hypothesis that anesthesia alone or in combination with high F(I)(O)2 alters expression of the myocardial calcium cycling proteins, sarcoplasmic endoreticular calcium adenosine triphosphatase subtype 2a (SERCA2a), and the sarcolemmal sodium-calcium exchanger (NCX). DESIGN: Multigroup comparison of protein expression using analysis of variance. SETTING: University research laboratory. SUBJECTS: Twenty-seven New Zealand white rabbits. INTERVENTIONS: After sedation and the induction of anesthesia, animals underwent either tracheal intubation and ventilation for 5 hours with 1.0% end-tidal halothane in oxygen (HAL-O(2) , n = 5) or air (HAL-air, n = 5) or time-control recovery while spontaneously breathing oxygen (TC-O(2) , n = 5) or air (TC-air, n = 5) for 5 hours. Halothane dose was based on pilot data from 2 rabbits. Animals were then sacrificed, and the hearts were removed for Western blot analysis. Data were normalized to those from a group of rabbits immediately sacrificed (n = 5) without any prior treatment. MEASUREMENTS AND MAIN RESULTS: In comparison to their respective time controls, SERCA2a was decreased 23 % in both HAL-air and HAL-O(2) groups, whereas NCX was increased 34% and 122%, respectively. Expression was distinctly different between HAL-air and HAL-O(2) for both SERCA2a (p = 0.009) and NCX (p < 0.001), indicating an influence of high F(I)O(2). Similarly, SERCA2a in the TC-O(2) group was reduced 25% relative to the TC-air group. CONCLUSION: Halothane alters the expression of myocardial calcium cycling proteins, and this effect is potentiated by high F(I)O(2) . These data offer the broad conclusion that perioperative interventions may influence the study of myocardial molecular remodeling and suggest the possibility of anesthetic-induced myocardial molecular remodeling.
PMID: 16130061 [PubMed - in process]
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Anesthetic management and outcome of complex late arterial-switch operations for patients with transposition of the great arteries and a systemic right ventricle.
Akpek EA, Miller-Hance WC, Stayer SA, Rice CL, East DL, Fraser CD, McKenzie ED, Andropoulos DB.
Division of Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital/Baylor College of Medicine, Houston, 77030, USA.
OBJECTIVE: For patients with transposition of the great arteries and a systemic right ventricle, complex late arterial-switch operations (double switch, switch conversion, Senning-Rastelli) after the newborn period have been described recently to restore the morphologic left ventricle to the systemic circulation. The purpose of this study was to describe the anesthetic management and perioperative outcome of this group of patients and to compare them with a control group of patients who had primary arterial-switch operations in the neonatal period. DESIGN: Retrospective database and medical record review with 3:1 control:case ratio. SETTING: Tertiary care academic children's hospital. PARTICIPANTS: Patients undergoing complex late-arterial switch operations after the newborn period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirteen patients were identified in the complex late-switch group and 43 in neonatal arterial-switch group. There were no perioperative deaths, no new gross neurologic deficits, and all patients were discharged home in both groups. Anesthetic and bypass times were significantly longer in the late-switch group (745 v 558 minutes, p < 0.001, and 382 v 243 minutes, p < 0.001, respectively). Transfusion requirements were similar between the groups. The incidence of arrhythmia (92% v 9%, p < 0.001), use of pacing systems (69% v 9%, p < 0.001), cardioversion (15% v 0%, p = 0.05), and pharmacologic treatment of arrhythmias (69% v 0%, p < 0.01) intraoperatively were significantly higher in the complex late-switch group. CONCLUSIONS: Patients presenting for complex late corrective operations for transposition of the great arteries require long and complex anesthetics. Despite these challenges, perioperative outcomes are excellent.
PMID: 16130058 [PubMed - in process]
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A randomized controlled clinical trial of real-time needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department.
Augoustides JG, Horak J, Ochroch AE, Vernick WJ, Gambone AJ, Weiner J, Pinchasik D, Kowalchuk D, Savino JS, Jobes DR.
Department of Anesthesia, Cardiothoracic Section, Hospital of the University of Pennsylvania, PA 19104, USA. yiandoc@hotmail.com
OBJECTIVE: The purpose of this study was to evaluate needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department, to determine cumulative cannulation success by method, to determine first-pass cannulation success by method and operator, and to determine arterial puncture by method and operator. STUDY DESIGN: Prospective, observational, and randomized. Blinding was not possible. Cohort size was calculated for 80% power to detect a technique difference, with significance defined as p < 0.05. SETTING: Operating rooms of the Hospital of the University of Pennsylvania. PARTICIPANTS: Elective surgical patients requiring internal jugular venous cannulation. INTERVENTIONS: Cannulation of the internal jugular vein occurred by needle-guided ultrasound (NGU) or by ultrasound without a needle guide. MAIN RESULTS: Four hundred thirty-four procedures were studied in 429 patients. NGU significantly enhances cannulation success after first (68.9%-80.9%, p = 0.0054) and second (80.0%-93.1%, p = 0.0001) needle passes. Cumulative cannulation success by the seventh needle pass is 100%, regardless of technique. The needle-guide specifically improves first-pass success in the junior operator (65.6%-79.8%, p = 0.0144). Arterial puncture averages 4.2%, regardless of technique (p > 0.05) or operator (p > 0.05). CONCLUSIONS: Although the needle guide facilitates prompt cannulation with ultrasound in the novice operator, it offers no additional protection against arterial puncture. This may be because of a lack of control of needle depth rather than needle direction. A possible solution may be biplanar ultrasound for central venous cannulation.
PMID: 16130056 [PubMed - in process]
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Conscious cardiac surgery with cardiopulmonary bypass using thoracic epidural anesthesia without endotracheal general anesthesia.
Chakravarthy M, Jawali V, Patil TA, Jayaprakash K, Kolar S, Joseph G, Das JK, Maheswari U, Sudhakar N.
Wockhardt Heart Institute, Bangalore, Karnataka, India. chakravarthy@vsnl.com
OBJECTIVE: The purpose of this study was to evaluate the feasibility of thoracic epidural anesthesia as an alternative technique to general anesthesia in patients undergoing cardiac surgery under cardiopulmonary bypass. DESIGN: A prospective study. SETTING: Tertiary referral heart hospital. PARTICIPANTS: Eleven patients underwent cardiac surgical procedures requiring cardiopulmonary bypass under thoracic epidural anesthesia from February to April 2004. INTERVENTIONS: An epidural catheter was inserted at C7 to T2 intervertebral space on the day before the operation. Subsequently, cardiac surgery was performed using cardiopulmonary bypass. MEASUREMENTS AND RESULTS: The midsternotomy approach was used in all the patients. Anticoagulation was achieved with 300 units/kg of heparin. Under normothermic cardiopulmonary bypass, 6 patients underwent closure of atrial septal defect, 3 underwent valve replacements, and 2 underwent coronary artery bypass surgery combined with valve replacements. Soon after establishing cardiopulmonary bypass, all but 1 patient developed apnea, which was reversed after termination of cardiopulmonary bypass. The mean cardiopulmonary bypass time was 102 +/- 28 minutes, the aortic cross-clamp time was 58 +/- 28 minutes, and the total duration of surgery was 229 +/- 64 minutes. There was no mortality or morbidity in this series. CONCLUSION: Cardiac surgical procedures requiring cardiopulmonary bypass may be performed under thoracic epidural anesthesia, without endotracheal general anesthesia.
PMID: 16130054 [PubMed - in process]
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Oral to nasal endotracheal tube exchange following reconstructive surgery of the oral cavity by means of vascularized free flaps.
Gonzalez-Garcia R, Rodriguez-Campo FJ, Naval-Gias L, Sastre-Perez J.
Publication Types:
PMID: 16094603 [PubMed - indexed for MEDLINE]
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The analgesic efficacy of intravenous versus oral tramadol for preventing postoperative pain after third molar surgery.
Ong CK, Lirk P, Tan JM, Sow BW.
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore. cliffong@pacific.nat.sg
PURPOSE: The aim of this study was to compare the analgesic efficacy of single-dose preoperative intravenous versus oral tramadol for preventing pain after third molar surgery. PATIENTS AND METHODS: Seventy-two patients undergoing elective third molar surgery were randomized to receive either intravenous (n = 36) or oral (n = 36) tramadol 50 mg. The intravenous group received an oral placebo capsule followed by intravenous tramadol 50 mg preoperatively. The oral tramadol group received a 50-mg oral tramadol capsule followed by intravenous placebo saline preoperatively. In both groups, a standard intravenous sedation technique was administered and the impacted third molars were removed under local anesthesia. The difference in postoperative pain was assessed by 4 primary end points: hourly pain intensity as measured by a 100-mm visual analog scale for 8 hours, time to rescue analgesic, postoperative acetaminophen consumption, and a 5-point global assessment scale (0 = poor, 1 = fair, 2 = good, 3 = very good, and 4 = excellent). RESULTS: Throughout the 8-hour investigation period, patients reported significantly lower pain intensity scores in the intravenous versus oral group (15.9 +/- 9.6 mm versus 36.9 +/- 17.2 mm, P = .03). Patients also reported significantly longer time to rescue analgesic (7.0 hours versus 3.5 hours, P = .00001), lesser postoperative acetaminophen consumption (1,823 +/- 1,266 mg versus 3,558 +/- 1,418 mg, P = .000006), and better global assessment (2.6 +/- 0.9 versus 1.1 +/- 0.8, P = .01) for the intravenous versus oral group. CONCLUSIONS: We conclude that preoperative intravenous tramadol is superior to oral tramadol for preventing postoperative pain following third molar surgery. However, it should be noted that there is a difference in the bioavailability between the 2 formulations of up to 30%, which may explain the findings.
Publication Types:
PMID: 16094585 [PubMed - indexed for MEDLINE]
Comment on:
Methods of detoxification and their role in treating patients with opioid dependence.
O'Connor PG.
Publication Types:
PMID: 16118388 [PubMed - indexed for MEDLINE]
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Fetal pain: a systematic multidisciplinary review of the evidence.
Lee SJ, Ralston HJ, Drey EA, Partridge JC, Rosen MA.
School of Medicine, Department of Anatomy, University of California, San Francisco, CA 94143-0648, USA.
CONTEXT: Proposed federal legislation would require physicians to inform women seeking abortions at 20 or more weeks after fertilization that the fetus feels pain and to offer anesthesia administered directly to the fetus. This article examines whether a fetus feels pain and if so, whether safe and effective techniques exist for providing direct fetal anesthesia or analgesia in the context of therapeutic procedures or abortion. EVIDENCE ACQUISITION: Systematic search of PubMed for English-language articles focusing on human studies related to fetal pain, anesthesia, and analgesia. Included articles studied fetuses of less than 30 weeks' gestational age or specifically addressed fetal pain perception or nociception. Articles were reviewed for additional references. The search was performed without date limitations and was current as of June 6, 2005. EVIDENCE SYNTHESIS: Pain perception requires conscious recognition or awareness of a noxious stimulus. Neither withdrawal reflexes nor hormonal stress responses to invasive procedures prove the existence of fetal pain, because they can be elicited by nonpainful stimuli and occur without conscious cortical processing. Fetal awareness of noxious stimuli requires functional thalamocortical connections. Thalamocortical fibers begin appearing between 23 to 30 weeks' gestational age, while electroencephalography suggests the capacity for functional pain perception in preterm neonates probably does not exist before 29 or 30 weeks. For fetal surgery, women may receive general anesthesia and/or analgesics intended for placental transfer, and parenteral opioids may be administered to the fetus under direct or sonographic visualization. In these circumstances, administration of anesthesia and analgesia serves purposes unrelated to reduction of fetal pain, including inhibition of fetal movement, prevention of fetal hormonal stress responses, and induction of uterine atony. CONCLUSIONS: Evidence regarding the capacity for fetal pain is limited but indicates that fetal perception of pain is unlikely before the third trimester. Little or no evidence addresses the effectiveness of direct fetal anesthetic or analgesic techniques. Similarly, limited or no data exist on the safety of such techniques for pregnant women in the context of abortion. Anesthetic techniques currently used during fetal surgery are not directly applicable to abortion procedures.
Publication Types:
PMID: 16118385 [PubMed - indexed for MEDLINE]
Changes in fetal position during labor and their association with epidural analgesia.
Weiniger CF, Ginosar Y.
Publication Types:
PMID: 16135608 [PubMed - in process]
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Changes in fetal position during labor and their association with epidural analgesia.
Lieberman E, Davidson K, Lee-Parritz A, Shearer E.
PMID: 16135607 [PubMed - in process]
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Effectiveness of intrauterine anesthesia for pain relief during fractional curettage.
Rattanachaiyanont M, Leerasiri P, Indhavivadhana S.
Gynecologic Endocrinology Unit, Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand. simrt@mahidol.ac.th
OBJECTIVE: To study the effectiveness of intrauterine anesthesia for pain relief during fractional curettage. METHODS: A double-blinded, randomized, placebo-controlled trial was conducted in 66 patients with abnormal uterine bleeding undergoing fractional curettage under paracervical block, using 10-mL 1% lidocaine plus intrauterine 5-mL 2% lidocaine (n = 33) or saline (n = 33). The primary outcome was the maximum pain score measured with a 10-cm visual analog scale. Other outcomes measured included pain profile, number of patients with pain score more than 4, each patient's global satisfaction index, adverse events, and serum lidocaine profile. RESULTS: The 2 groups were comparable in age, body mass index, education, socioeconomic status, menopausal status, and parity. Compared with the saline group, the lidocaine group had a significantly lower median value for the maximum pain score (2.3 versus 4.7, P = .022) and fewer patients with a pain score more than 4 (33.3% versus 60.6%, P = .026). The pain scores were lower at the endocervical curettage and the uterine curettage steps. There was no difference between the 2 groups in other outcomes. The number needed to treat to prevent a case with a pain score more than 4 was 3.7 (95% confidence interval 2.4-38.5). CONCLUSION: The addition of intrauterine anesthesia to paracervical block can further reduce pain during fractional curettage without increasing adverse effects. LEVEL OF EVIDENCE: I.
PMID: 16135583 [PubMed - in process]
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Simpson, Semmelweis, and transformational change.
Grant GJ, Grant AH, Lockwood CJ.
Department of Anesthesiology, New York University School of Medicine, New York, New York 10016, USA. gilbert.grant@med.nyu.edu
The first anesthetic for childbirth and the first recognition of the importance of hand hygiene in obstetrics coincidentally occurred within 5 months of one another in 1847. More than 150 years later, one would have thought that these milestone events would have been fully integrated into practice. However, individuals resist transformational change, which is defined as a fundamental alteration in their beliefs, attitude, and behavior, even when they are confronted with incontrovertible facts. This resistance to change may explain why, in 2005, a large percentage of health care providers still do not practice acceptable hand hygiene, and the pain of childbirth continues to be extolled by some as a necessary part of womanhood, just as pharmacologic pain relief is discouraged.
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Personal Name as Subject:
PMID: 16055591 [PubMed - indexed for MEDLINE]
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Continuous compared with intermittent epidural infusion on progress of labor and patient satisfaction.
Salim R, Nachum Z, Moscovici R, Lavee M, Shalev E.
Department of Obstetrics and Gynecology, Ha'Emek Medical Center, Afula, Israel.
OBJECTIVE: To compare continuous with intermittent epidural infusion on the duration of labor and patients' satisfaction in nulliparous women. METHODS: Nulliparous women who requested epidural analgesia during labor were randomly allocated to receive either a continuous infusion of 0.125% bupivacaine with 2 microg/mL fentanyl at a rate of 8 mL/h (group A) or intermittent bolus of 10 mL of 0.25% bupivacaine on demand (group B). Controls were nulliparous women who did not receive epidural analgesia (group C). Included were singleton term pregnancies with cervical dilatation between 2 cm and 5 cm. A comparison was made between the groups regarding the duration of the active phase and the second stage of labor and patients' satisfaction. Secondary outcomes investigated were the mode of delivery, analgesia-related complications, and intrapartum and postpartum complications. Cord pH and Apgar score measured neonatal outcome. RESULTS: Sixty-three parturients were randomly assigned to receive continuous infusion, and 64 received intermittent bolus infusion. Sixty-three patients served as controls. Mean duration of the active phase and the second stage of labor were not statistically different between groups A and B. Each technique produced comparable analgesia, achieving equivalent maternal satisfaction, with no apparent complications. The active phase of labor was prolonged by an average of 60 minutes and the 2nd stage by an average of 36 minutes regardless of the type of epidural compared with controls. The mode of delivery and maternal and neonatal outcome were not significantly different among the 3 groups. CONCLUSION: This study provides evidence that both continuous and intermittent epidural infusion produce comparable analgesia achieving equivalent maternal satisfaction with no difference regarding the duration of labor between them. Although patients receiving epidural analgesia experienced longer labors compared with controls, both mothers and neonates were unharmed.
Publication Types:
PMID: 16055579 [PubMed - indexed for MEDLINE]
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Massive subdural or intrathecal anesthesia?
Balestrieri PJ.
Publication Types:
PMID: 16135357 [PubMed - in process]
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Effects of subtenon anesthesia combined with general anesthesia on perioperative analgesic requirements in pediatric strabismus surgery.
Steib A, Karcenty A, Calache E, Franckhauser J, Dupeyron JP, Speeg-Schatz C.
Department of Anesthesiology, 1 place de l'hopital, Hopital Civil, University Hospital, 67091 Strasbourg cedex, France. Annick.Steib@chru-strasbourg.fr
BACKGROUND AND OBJECTIVES: Pediatric strabismus surgery leads to undesirable intraoperative and postoperative side effects that include pain, postoperative nausea and vomiting (PONV), and oculocardiac reflex (OCR). We hypothesized that subtenon anesthesia performed before the start of surgery and combined with general intravenous anesthesia would reduce these adverse effects. METHODS: Forty children (2.5 to 6 years of age, ASA status I to II) were prospectively randomized to receive either subtenon bupivacaine 0.5% or a saline injection before the beginning of surgery in a double-blind manner. Perioperative analgesic requirements, pain scores (CHEOPS scale), hemodynamics, and incidence of OCR and PONV were compared. RESULTS: Postoperative pain scores were lower (P < .001) at removal of the laryngeal mask and 30 minutes later in the bupivacaine group. Intraoperative and postoperative analgesic requirements were significantly reduced in this group (P < .01). The incidence of OCR and PONV were also significantly decreased (P < .01). Intraoperative values of blood pressure were significantly higher in the saline group at 20 minutes (P < .02). CONCLUSION: We conclude that preoperative subtenon bupivacaine 0.5% compared with a saline injection contributed to reduction of perioperative pain and undesirable side effects in pediatric strabismus surgery performed under general anesthesia.
PMID: 16135353 [PubMed - in process]
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Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total-hip arthroplasty.
Singelyn FJ, Ferrant T, Malisse MF, Joris D.
Department of Anesthesiology, Universite Catholique de Louvain School of Medicine, St Luc Hospital, Brussels, Belgium.
BACKGROUND AND OBJECTIVES: Regional analgesic techniques allow better postoperative rehabilitation and shorter hospital stay after major knee surgery. The authors tested the hypothesis that similar results could be obtained after total-hip arthroplasty. METHODS: Forty-five patients scheduled for THA under general anesthesia were randomly divided into 3 groups. Postoperative analgesia was provided during the first 48 hours, with intravenous patient-controlled analgesia (IV PCA) induced by morphine (dose, 1.5 mg; lockout interval, 8 min) in group IV, continuous femoral nerve sheath block in group FNB, and continuous epidural analgesia in group EPI. The day after surgery, the 3 groups started identical physical therapy regimens. Pain scores at rest and on movement, supplemental analgesia, side effects, daily degree of maximal hip flexion and abduction, day of first walk, and duration of hospital stay were recorded. RESULTS: Population data, quality of pain relief, postoperative hip rehabilitation, and duration of hospital stay were comparable in the 3 groups. When compared with the two other techniques, continuous FNB was associated with a lower incidence of side effects (no nausea/vomiting, urinary retention, arterial hypotension, or catheter problem during the first 48 hours in 20%, 60%, and 13% of patients in groups IV, FNB, and EPI, respectively). CONCLUSIONS: This study suggests that IV PCA with morphine, continuous FNB, and continuous epidural analgesia provide similar pain relief and allow comparable hip rehabilitation and duration of hospital stay after total-hip arthroplasty (THA). As continuous FNB is associated with less side effects, it appears to offer the best option of the three.
PMID: 16135349 [PubMed - in process]
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An economic evaluation of bupivacaine plus fentanyl versus ropivacaine alone for patient-controlled epidural analgesia after total-knee replacement procedure: a double-blinded randomized study.
Pitimana-aree S, Visalyaputra S, Komoltri C, Muangman S, Tiviraj S, Puangchan S, Immark P.
Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok 10700, Thailand. sispm@mahidol.ac.th
BACKGROUND AND OBJECTIVES: Total-knee replacement (TKR) surgery is one of the most painful orthopedic procedures after surgery. Opioid has been commonly combined with a local anesthetic to improve the quality of pain relief, but the treatment has opioid-related side effects. This study compared the cost effectiveness of patient-controlled epidural analgesia (PCEA) with 0.0625% bupivacaine plus fentanyl (BF) 3 microg/mL versus 0.15% ropivacaine alone (R) during the first 48 hours after TKR procedure. METHODS: This prospective randomized double-blinded study was performed on 70 patients who underwent unilateral TKR procedure and received either BF or R after surgery. Visual analog scale (VAS) pain score at rest and upon movement, side effects, and cost of treatment were compared. RESULTS: Overall pain at rest and upon movement between groups was not significantly different (P = 0.58, 95% CI = 4.4 to -7.8 and P = 0.8, 95% CI = 6.4 to -8.2, respectively). Patients in the BF group experienced more pruritus and had more vomiting episodes than those in the R group (P = .015), whereas no difference occurred in other side effects. Nevertheless, patient satisfaction with pain management was higher in the BF group compared with that in the R group. In addition, pain treatment with bupivacaine and fentanyl was 18% less costly compared with ropivacaine alone. CONCLUSIONS: Considering the economic evaluation, we conclude that PCEA with 0.0625% bupivacaine plus fentanyl 3 microg/mL is more cost effective and provides more patient satisfaction than PCEA with ropivacaine alone. However, use of epidural ropivacaine alone causes fewer opioid-related side effects, particularly pruritus and vomiting.
PMID: 16135348 [PubMed - in process]
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