Order this document
Anesth Analg 2002 Nov;95(5):1219-23, table of contents
Department of Anesthesiology, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010, USA. sverghes@cnmc.org
In this study we compared the intensity and level of caudal blockade when two different volumes and concentrations of a fixed dose of bupivacaine were used. Fifty children, 1-6 yr old, undergoing unilateral orchidopexy received a caudal block with a fixed 2 mg/kg dose of bupivacaine immediately after the induction. Group 1 (n = 23) received 0.8 mL/kg of 0.25% bupivacaine, whereas Group 2 (n = 27) received 1.0 mL/kg of 0.2% bupivacaine. Epinephrine 1:400,000 and 0.1 mL of sodium bicarbonate per 10 mL of local anesthetic solution were added. There were no statistically significant differences between the two groups in their anesthesia, surgery, recovery, and discharge times. Fifteen patients (65.2%) in Group 1 required an increase in inspired halothane concentration to block hemodynamic and/or ventilatory response during spermatic cord traction, as compared with 8 patients (29.6%) in Group 2 (P = 0.022). In the recovery room, four (17.4%) patients in Group 1 required rescue treatment with fentanyl, versus two (7.4%) in Group 2 (P = 0.372). In children undergoing orchidopexy, a caudal block with a larger volume of dilute bupivacaine is more effective than a smaller volume of the standard 0.25% solution in blocking the peritoneal response during spermatic cord traction, with no change in the quality of postoperative analgesia. IMPLICATIONS: In children undergoing orchidopexy, a caudal block with a larger volume of dilute bupivacaine is more effective than a smaller volume of the more concentrated solution in blocking the peritoneal response during spermatic cord traction, with no change in the quality of postoperative analgesia.
Publication Types:
PMID: 12401597, UI: 22288616
Other Formats:
Anesth Analg 2002 Nov;95(5):1207-14, table of contents
Department of Anesthesiology, Baskent University Faculty of Medicine, No. 45 Bahcelievler, 06490 Ankara, Turkey. arashpirat@hotmail.com
Systemic large-dose opioids are widely used in pediatric cardiac anesthesia, but there are no randomized, prospective studies regarding the use of intrathecal (IT) opioids for these procedures. In this randomized, prospective study, we compared cardiovascular and neurohumoral responses during IT or IV fentanyl anesthesia for pediatric cardiac surgery. Thirty children aged 6 mo to 6 yr were anesthetized with an IV fentanyl bolus of 10 micro g/kg. This was followed by a fentanyl infusion of 10 micro g. kg(-1). h(-1) (Group IV; n = 10), 2 micro g/kg of IT fentanyl (Group IT; n = 10), or combined IV and IT protocols (Group IV + IT; n = 10). Heart rate, mean arterial blood pressure, additional fentanyl doses, time to first analgesic requirement, COMFORT and Children's Hospital of Eastern Ontario Pain Scale scores, and extubation time were recorded. Blood cortisol, insulin, glucose, and lactate levels were measured presurgery, poststernotomy, during the rewarming phase of cardiopulmonary bypass (CPB), and 6 and 24 h after surgery. The patients' urinary cortisol excretion rates were also measured during the first postoperative day. The findings in all three groups were statistically similar, except for higher blood glucose levels during CPB in Group IT compared with Group IV (P < 0.004). Group IV + IT was the only group in which the increases in heart rate and mean arterial blood pressure from presurgery to poststernotomy were not significant. The 24-h urinary cortisol excretion rates ( micro g. kg(-1). d(-1)) were 61.51 +/- 39, 92.54 +/- 67.55, and 40.15 +/- 29.69 for Groups IV, IT, and IV + IT, respectively (P > 0.05). A single IT injection of fentanyl 2 micro g/kg offers no advantage over systemic fentanyl (10 micro g/kg bolus and 10 micro g. kg(-1). h(-1)) with regard to hemodynamic stability or suppression of stress response. The combination of these two regimens may provide better hemodynamic stability during the pre-CPB period and may be associated with a decreased 24-h urinary cortisol excretion rate. IMPLICATIONS: In this prospective, randomized study, we investigated the adequacy of a single intrathecal injection of fentanyl for intraoperative analgesia, compared the effects of IT and IV fentanyl on stress response, and assessed for an additive effect of IT and IV fentanyl administration in pediatric cardiac anesthesia. The results with these three different anesthetic regimens were similar regarding anesthesia depth and level of stress response. However, the combination of IT and IV routes may provide better hemodynamic stability and a less pronounced stress response, as reflected by 24-h urinary cortisol excretion.
PMID: 12401595, UI: 22288614
Other Formats: Links:
BMJ 2002 Oct 26;325(7370):941
Centre for Health Services Research, University of Newcastle, Newcastle upon Tyne NE2 4AA, UK. martin.eccles@ncl.ac.uk
OBJECTIVE: To evaluate the use of a computerised support system for decision making for implementing evidence based clinical guidelines for the management of asthma and angina in adults in primary care. DESIGN: A before and after pragmatic cluster randomised controlled trial utilising a two by two incomplete block design. Setting: 60 general practices in north east England. PARTICIPANTS: General practitioners and practice nurses in the study practices and their patients aged 18 or over with angina or asthma. MAIN OUTCOME MEASURES: Adherence to the guidelines, based on review of case notes and patient reported generic and condition specific outcome measures. RESULTS: The computerised decision support system had no significant effect on consultation rates, process of care measures (including prescribing), or any patient reported outcomes for either condition. Levels of use of the software were low. CONCLUSIONS: No effect was found of computerised evidence based guidelines on the management of asthma or angina in adults in primary care. This was probably due to low levels of use of the software, despite the system being optimised as far as was technically possible. Even if the technical problems of producing a system that fully supports the management of chronic disease were solved, there remains the challenge of integrating the systems into clinical encounters where busy practitioners manage patients with complex, multiple conditions.
PMID: 12399345, UI: 22285990
Br J Anaesth 2002 Oct;89(4):562-6
Department of Anaesthesiology, University Hospital of Geneva, CH-1211 Geneva 14, Switzerland.
BACKGROUND: We compared analgesia after intrathecal sufentanil alone, sufentanil with epinephrine 200 microg and sufentanil with clonidine 30 microg in patients after total hip replacement, the endpoints being onset and duration of action. METHODS: We performed a randomized double-blind study of 45 patients for elective total hip arthroplasty using continuous spinal anaesthesia. As soon as a pain score higher than 3 on a 10 cm visual analogue scale was reported, sufentanil 7.5 microg alone, sufentanil 7.5 microg + epinephrine 200 microg or sufentanil 7.5 microg + clonidine 30 micro g in 2 ml normal saline was given intrathecally. Pain scores, rescue analgesia (diclofenac and morphine) and adverse effects (respiratory depression, postoperative nausea and vomiting, itching) were observed for 24 h after surgery. RESULTS: Time to a pain score of <3 [6 (SD 1) vs 6 (1) vs 5 (1) min], time to the lowest pain score [7 (2) vs 8 (2) vs 8 (2) min] and time to the first dose of systemic analgesic for a pain score >3 [281 (36) vs 288 (23) vs 305 (30) min] were similar in all three groups. Adverse effects and analgesic requirements during the first 24 h were also similar. CONCLUSION: After total hip replacement, all three analgesic regimens gave good analgesia with comparable onset and duration of action, and minor adverse effects.
PMID: 12393356, UI: 22280438
Br J Anaesth 2002 Oct;89(4):535-7
PMID: 12393350, UI: 22280432
Br J Anaesth 2002 Aug;89(2):342; discussion 343
PMID: 12378680, UI: 22266345
PMID: 12378679, UI: 22266344
Clin J Pain 2002 Sep-Oct;18(5):324-36
Primary Care Sciences Research Center, Keele University, Keele, Staffordshire, UK. pta05@keele.ac.uk
OBJECTIVE: Little is known of the effectiveness of nonpharmacological interventions for fibromyalgia syndrome (FMS). The authors therefore carried out a systematic review from 1980 to May 2000 of randomized controlled trials (RCTs) of nonpharmacological interventions for FMS. METHOD: A search of computerized databases was supplemented by hand searching of bibliographies of key publications. The methodological quality of studies included in the review was evaluated independently by two researchers according to a set of formal criteria. Discrepancies in scoring were resolved through discussion. RESULTS: The review yielded 25 RCTs, and the main categories of interventions tested in the studies were exercise therapy, educational intervention, relaxation therapy, cognitive-behavioral therapy, acupuncture, and forms of hydrotherapy. Methodological quality of studies was fairly low (mean score = 49.5/100). Most studies had small samples (median for individual treatment groups after randomization = 20), and the mean power of the studies to detect a medium effect ( > or = 0.5) was 0.36. Sixteen studies had blinded outcome assessment, but patients were blinded in only 6 studies. The median longest follow-up was 16 weeks. Statistically significant between-group differences on at least one outcome variable were reported in 17 of the 24 studies. CONCLUSIONS: The varying combinations of interventions studied in the RCTs and the wide range of outcome measures used make it hard to form conclusions across studies. Strong evidence did not emerge in respect to any single intervention, though preliminary support of moderate strength existed for aerobic exercise. There is a need for larger, more methodologically rigorous RCTs in this area.
PMID: 12218504, UI: 22206119
Clin Orthop 2002 Oct;403:248-52
Department of Orthopaedic Surgery, National University of Singapore, Republic of Singapore.
Corticosteroids have been used in the treatment of radiculopathy and postoperative pain after lumbar disc surgery. Although the effects of steroids are thought to be antiinflammatory, the underlying nature of action may be more complex and may involve a direct effect on pain mediators like substance P. A feline model of nerve root compression and decompression was used to study the effect of steroids on the expression of cytokine differentiation antigens 4 and 5, and substance P. Ten adult cats were used. The animals were divided equally into a steroid treatment group and a control group. The sixth lumbar nerve root was compressed surgically and subsequently decompressed followed by local application of betamethasone or saline. The cats then were perfused and the corresponding nerve root and dorsal root ganglion were removed and immunostained for cytokine differentiation antigens 4 and 5, and substance P, respectively. The relative absence of cytokine differentiation antigens 4- and 5-labeled lymphocytes at the compression site in the steroid treated group is consistent with an antiinflammatory effect of the steroid. Substance P expression at the dorsal root ganglion in the steroid treated group was decreased significantly. These findings may help explain clinical observations of efficacy of steroids after spinal nerve root decompression.
PMID: 12360034, UI: 22246370
Clin Orthop 2002 Oct;403:118-26
Department of Orthopedics, Mayo Clinic, Rochester, MN 55905, USA.
Cemented bipolar hemiarthroplasty commonly is used to treat displaced fractures of the femoral neck in elderly patients. The purpose of the current study was to review the results and survivorship of 212 bipolar hemiarthroplasties done in 205 patients for acute femoral neck fracture between 1976 and 1985. The mean age of the patients at the time of surgery was 79 years (range, 61-100 years). The mean followup for the patients who were alive was 11.7 years (range, 5.3-16.8 years) and 5.8 years (range, 51 days-19.4 years) for the entire group. Ten hips (4.7%) were revised or removed: five for aseptic femoral component loosening, one for acetabular erosion, one for chronic dislocation, and three for infection. In living patients with surviving implants, 96.2% had no or slight pain. Ten-year survivorship free of reoperation for any reason was 93.6%, free of revision surgery for aseptic femoral loosening or acetabular cartilage wear was 95.9%, free of revision surgery for aseptic femoral loosening was 96.5%, and free of revision surgery for acetabular cartilage wear was 99.4%. Cemented bipolar hemiarthroplasty for acute femoral neck fracture is associated with excellent component survivorship in elderly patients. The rate of complications was low, and the arthroplasty provided satisfactory pain relief for the lifetime of the majority of elderly patients.
PMID: 12360017, UI: 22246353
Lancet 2002 Oct 19;360(9341):1254-5
PMID: 12401284, UI: 22289629
Spine 2002 Oct 1;27(19):E416-8
Wooridul Spine Hospital, Seoul, Korea. spinejjs@yahoo.co.kr
STUDY DESIGN: Three cases of pulmonary embolism caused by polymethylmethacrylate (PMMA) after percutaneous vertebroplasty are reported, and the literature is reviewed. OBJECTIVES: To report on three cases of pulmonary embolism caused by polymethylmethacrylate after percutaneous vertebroplasty, and to review the literature briefly for reduction of this complication. SUMMARY OF BACKGROUND DATA: Pulmonary embolus caused by polymethylmethacrylate during percutaneous vertebroplasty is a rare complication. However, there is always a potential risk of this complication, which may result in pulmonary infarction. METHODS: Three of 27 patients with malignant spinal tumor experienced pulmonary embolism caused by polymethylmethacrylate after percutaneous vertebroplasty. Cement migration into the venous channel was observed in two patients, but not during the procedure. Two patients had mild dyspnea and chest discomfort, and one was asymptomatic. Pulmonary embolism was confirmed on chest radiographs. Ventilation perfusion scanning was performed to detect perfusion defect in all cases. RESULTS: Ventilation perfusion scanning showed no perfusion defects in any case. The symptoms of dyspnea and chest discomfort in two patients subsided after treatment using supplemental oxygen inhalation and anticoagulants. CONCLUSIONS: Three cases of pulmonary embolism caused by polymethylmethacrylate after percutaneous vertebroplasty are reported. Proper techniques can minimize the risk of pulmonary embolism caused by poly-methylmethacrylate during percutaneous vertebroplasty.
PMID: 12394937, UI: 22282321
Spine 2002 Oct 15;27(20):2299-301; discussion 2299-301
PMID: 12394911, UI: 22282344
Spine 2002 Oct 15;27(20):2240-4
SpineCare Medical Group and The San Francisco Spine Institute, Daly City, California, USA. jschoff@ix.netcom.com
STUDY DESIGN: Retrospective patient identification and prospective data collection were performed. OBJECTIVE: To evaluate the outcome of anterior cervical diskectomy and fusion for discogenic cervical headaches. SUMMARY OF BACKGROUND DATA: Cervicogenic headaches affect up to 2.5% of the population. One cause is discogenic pain. Because anterior cervical diskectomy and fusion may improve neck pain, the effect of this procedure on discogenic cervical headaches was evaluated. METHODS: Nine patients with severe refractory cervicogenic headaches who underwent anterior cervical diskectomy and fusion of the upper cervical discs were retrospectively identified on the basis of clinical, radiographic, and diskography findings. Pain was measured by a numerical rating scale, and function by the Oswestry Disability Index. RESULTS: The study involved six women and three men with a mean age of 52 (range, 35-72 years) and a mean follow-up period of 37 months (range, 24-49 months). Anterior cervical diskectomy and fusion was performed at both C2-C3 and C3-C4 in seven patients, at C2-C3 in one patient, and at C2-C3, C3-C4, and C4-C5 in one patient. Associated symptoms included nausea, arm pain, dizziness, and visual disturbances. All the patients improved. All stated that they would have the same surgery again for the same outcome. The mean numerical rating score improved from 8 (range, 5-10) to 2.7 (range, 0-7) ( < 0.001), and five patients (56%) had total headache relief. The mean Oswestry Disability Index improved from 62 (range, 42-87) to 35 (range, 2-82) ( < 0.009). The associated symptoms resolved in all the patients. There was early moderate to severe dysphagia in three patients, and mild dysphagia in four patients. At the final follow-up assessment, five patients evidenced mild dysphagia. CONCLUSIONS: Anterior cervical diskectomy and fusion appears to be quite effective for discogenic cervical headache, but should be reserved for patients who are extremely impaired and refractory to all other treatments.
PMID: 12394901, UI: 22282334
Spine 2002 Aug 1;27(15):1680-6
Twin Cities Spine Center, Minneapolis, Minnesota 55404, USA.
STUDY DESIGN: This study retrospectively reviewed the outcome of 58 patients all diagnosed with severe low back pain secondary to degenerative disc disease and treated with anterior arthrodesis and posterior instrumented arthrodesis. OBJECTIVES: To evaluate the outcome of a select group of patients with degenerative disc disease treated with this surgical intervention at a minimum of 2 years of follow-up. SUMMARY OF BACKGROUND DATA: Patients with degenerative disc disease who fail nonoperative treatment generally have disappointing outcomes with traditional surgical intervention. The literature analyzing posterior instrumented arthrodesis tends to exhibit the best results, but the numbers of patients with degenerative disc disease in these articles are few, and their outcomes are worse than the other low back conditions. Even patients with solid posterior arthrodesis have been noted to have continued low back pain. No articles have evaluated this specific surgical procedure in a group of patients all with the diagnosis of degenerative disc disease and no previous surgery. METHODS: All patients were diagnosed with degenerative disc disease and had failed prolonged nonoperative treatment (average 4.9 years). Fusion levels were delineated by MRI and provocative discography in correlation with history and physical examination. The senior author (M.R.P.) performed the identical operative procedure on all patients, under a single anesthetic. The arthrodesis solidity was evaluated with radiographic studies and operative posterior exploration when necessary. Final outcomes were determined using a functional and satisfaction questionnaire, return to work, narcotic use, and the rate of solid arthrodesis. Charts, radiographs, and questionnaires were reviewed by an independent evaluator at final follow-up (average 35 months). RESULTS: The solid arthrodesis rate was 95%. The three pseudoarthroses were all in patients with a three-level arthrodesis. Eighty-eight percent of the patients were able to return to work. Nineteen percent of patients required long-term narcotics, whereas 48% of the patient population were on narcotics before surgery. Eighty-six percent of the patients had a "better" rating at final follow-up. This included patients with decreased pain by visual analog scale, improved functional questionnaire, and those who would recommend the procedure to a friend or family member. Ten percent of the patients were "the same," and 3% were "worse." Lumbar lordosis was maintained or improved. Complications did not exceed literature controls. CONCLUSIONS: Selected patients with discography-proven severe low back pain secondary to degenerative disc disease, who failed extensive nonoperative treatment, were treated successfully with anterior-posterior instrumented arthrodesis. The good arthrodesis rate, return to work rate, and patient satisfaction may justify the consideration of this aggressive treatment option in this specific patient population.
PMID: 12163733, UI: 22153934