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 1.
Epidural tramadol for postoperative pain after Cesarean section.
Siddik-Sayyid S, Aouad-Maroun M, Sleiman D, Sfeir M, Baraka A. Department
of Anesthesiology, American University of Beirut, Lebanu. Can J Anaesth
1999 Aug;46(8):731-5.
 PURPOSE:
To
compare the post-operative analgesic effect of 100 mg vs 200 mg epidural
tramadol and saline in patients undergoing elective Cesarean section.
METHODS:
Sixty healthy women undergoing Cesarean delivery with epidural anesthesia
were randomly allocated into three groups (n = 20 in each). Patients received,
at skin closure via the epidural catheter, 100 mg tramadol (Group I), 200
mg tramadol (Group II) or 10 ml saline (Control group). Pain scores and
side effects were evaluated at 1, 2, 4, 8, 12 and 24 hr after surgery.
Mean times to the first analgesic administration, as well as the cumulative
doses of analgesic requirements over 24 hr postoperatively were compared.
RESULTS:
The mean time to first analgesic administration was longer in patients
who received 100 mg tramadol (4.5 +/- 3.1 hr) and the 200 mg tramadol (6.6
+/- 3.4 hr) than in those who received placebo (2.8 +/- 2 hr). The mean
cumulative doses of meperidine over 24 hr were less in the 100 mg tramadol
group (0.3 +/- 0.3 mg x kg(-1)) and the 200 mg tramadol group (0.3 +/-
0.3 mg x kg(-1)) than in the control group (0.7 +/- 0.4 mg x kg(-1)). Also,
the mean doses of diclofenac over 24 hr were less in the 100 mg tramadol
group (156 +/- 59 mg) and the 200 mg tramadol group (142 +/- 62 mg) than
in the control group (214 +/- 70 mg). However, no difference was obtained
between patients receiving 100 mg and 200 mg tramadol concerning all parameters
studied.
CONCLUSION:
Epidural tramadol 100 mg can provide adequate postoperative analgesia without
respiratory depression in patients after Cesarean delivery [citas] |
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| 2.
Epidural anaesthesia and analgesia: better outcome after major surgery?
Buggy
D. Smith G. BMJ 1999; 319: 530-31. Editorials.
Growing
evidence suggests so: Major surgery induces profounds physiological changes
in the perioperative period, characterised by increases in sympathoadrenal
and other neuroendocrine activity and also increased cytokine production.
Because epidural anaesthesia can attenuate this "stress response" to surgery,
improve the quality of postoperative analgesia in comparison with systemic
opioids, and hasten recovery of gut function, it has been suggested that
conducting surgery under epidural anaesthesia (either as the sole anaesthetic
or in combination with general anaesthesia) may reduce perioperative morbidity
and mortality compared with general anaesthesia alone (1). Indeed, in a
study of high risk patients undergoing major vascular surgery those who
received combined general and epidural anaesthesia with postoperative epidural
analgesia had significantly lower cardiac morbidity than those receiving
general anaesthesia alone with postoperative systemic opioid analgesia.(2)
Unfortunately, subsequent studies have failed to confirm this finding.
This uncertainty probably relates to the design, small size, and inadequate
number of relevant studies for a meta-analysis of outcome; hence investigators
in Australia are currently undertaking a large, multicentre study to address
this question. Though the effects of epidural anaesthesia on mortality
and cardiac morbidity have been disappointing so far, the evidence that
epidural anaesthesia decreases thromboembolic, pulmonary, and gastrointestinal
postoperative complications is much more encouraging. A meta-analysis showed
a significant reduction in venous thromboembolism in patients undergoing
surgery for hip fracture under regional (epidural or spinal) anaesthesia
compared with general anaesthesia, but showed only a marginally better
effect on early mortality.(3) Another meta-analysis of randomised controlled
trials on the influence of different anaesthetic and postoperative analgesic
regimens on pulmonary outcome found that thoracic epidural anaesthesia
and analgesia using opioids and local anaesthetics was associated with
a decreased incidence of atelectasis, pulmonary infections, and hypoxaemia
compared with systemic opioids.(4) Perhaps surprisingly, there were no
differences in physiological lung volumes. The mechanism by which thoracic
epidural anaesthesia improves pulmonary morbidity is unclear but may be
related to improved analgesia and alertness, allowing patients to sigh,
cough, and change position more easily. Diaphragmatic dysfunction, a consequence
of reflex muscle spasm after surgery, may also be attenuated by thoracic
epidural anaesthesia, hence improving pulmonary function.(5) It is in gastrointestinal
surgery, however, that epidurals have most often shown favourable effects
on outcome. Postoperative ileus is a ubiquitous complication after major
abdominal surgery, inhibiting gut motility for up to 72 hours and prolonging
admission. In a randomised trial patients undergoing major abdominal surgery
using combined general and thoracic epidural anaesthesia had earlier recovery
of gut function than those receiving general anaesthesia alone followed
by standard systemic opioid analgesia.(6) Optimum results ar achieved when
the epidural regimen combines local anaesthetics and opioids, as sole use
of epidural morphine may delay recovery of gut motility and cause pruritus
and nausea. (6, 7) The mechanism of its apparent efficacy could be due
to segmental block of dermatomes T5-T12, antagonising sympathetically mediated
peristaltic inhibition while preserving vagal and sacral parasympathetic
outflow. As postoperative pain may be a potent cause of adverse events
in many organ systems,(8) the improved postoperative analgesia afforded
by continuing epidural analgesia has prompted investigations on whether
it facilitates resumption of oral nutrition, mobilisation, and earlier
discharge from hospital or intensive care units. Improved patient activity
at 3.5 weeks and less pain enduring to 9.5 weeks after operation have been
shown in a prospective, double blind study of patients undergoing radical
prostatectomy with pre-emptive epidural anaesthesia.(9) Another retrospective
investigation in patients undergoing oesophagectomy showed that those who
received intraoperative and postoperative thoracic epidural anaesthesia,
early tracheal extubation,and intensive physiotherapy were mobilised and
discharged from intensive care more rapidly than those receiving conventional
management.(10). Though these reports are promising, translating improvements
in physiological variables achieved by epidurals into significantly better
postoperative clinical outcomes may be difficult and may be confounded
by cultural or psychological factors.Patients undergoing major surgery
may expect to stay in hospital for 7-10 days, necessitating that carers
in these outcome studies should be blind to such factors as whether conventional
or laparoscopic surgery was conducted.(11) Indeed, the combination of epidurals,
laparoscopic surgery, and a multimodal approach to aggressive postoperative
rehabilitation may dramatically reduce hospital stay, as shown in nine
elderly patients who stayed in hospital for only two to three days after
colonic surgery, compared with the normal 10 days.(12) This was, however,
an open investigation, and larger studies, necessary for proper evaluation
of this multimodal approach, have not yet materialised. Consideration of
these studies raises the question of the adequacy of current outcome variables
for evaluating recovery. Modern anaesthetic practice inherently safe and
differences in mortality between techniques may be difficult to detect,even
in high-risk patients. Thus future postoperative outcome studies may need
to focus on patients' own views of recovery, including their assessment
of their overall well being and return to preoperative energy and activity
levels. Despite the evidence that use of epidural anaesthesia is associated
with some improvements in postoperative outcome, it carries the risk of
serious neurological complications. These are rare, but vigilance in the
postoperative period is required to detect the triad of back pain, progressive
motor weakness, and incontinence which may herald an epidural haematoma
or abscess. Modern practice using dilute concentrations of local anaesthetics
or opioids in epidural infusions (thereby reducing motor weakness) is helpful
in aiding diagnosis of this potentially devastating complication. If suspected,
immediate radiological investigation (with magnetic resonance imaging)
and surgery are required to relieve spinal cord compression. Thus, the
balance of available evidence in the form of relatively few randomised
trials and meta-analyses suggests that epidural anaesthesia and postoperative
analgesia may facilitate earlier recovery and improved outcome by reducing
the incidence of thromboembolic, pulmonary, and gastrointestinal complications
after major surgery. A multidisciplinary approach to rehabilitation may
help to capitalise on this improved postoperative physiological state,
but further prospective evaluation is warranted.
Donal
J Buggy, senior lecturer. Graham Smith, professor.
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| 3.
Safety of Continous Epidural Anesthesia during Heart Surgery. Change of
Coagulation and Fibrinolysis under Heparinization. Maeda
M, Kosaka Y,Kushizuki H, Yamamori Y, Haishimoto K, Saito Y. Department
of Anesthesia. Shimare Medical University. Izumo. Japan. Masaui. 1999;
48: 723-30.
To
confirm the safety of continuous epidural anesthesia during extracorporeal
circulation under heparinization, we investigated epidural hematoma formation
following the cardiopulmonary bypass in both humans and dogs. In fifteen
dogs, divided into three groups, heparin was administered at the dose of
300, 600, or 900 U/kg, respectively. In fourteen patients, a dose of 300
U/kg heparin was administered for cardiopulmonary bypass. Although blood
coagulation-fibrinolysis dropped into abnormal ranges following heparinization,
no epidural hematoma was observed in dog and no patient revealed spinal
complication associated with epidural hematoma. These data indicate that
continuous epidural anesthesia would be a safe tool for intraoperative
anesthesia even during extracorporeal circulation under heparinization
[citas] |
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| 4.
Rectal Indomethacin reduces postoperative
pain and morphine use after cardiac surgery. Rapanos
T, Murphy P, Szalai JP, Burlacoff L, Lam-McCulloch J, Kay J. Department
of Anaesthesia, Sunnybrook and Women's College Health Sciences Centre,
University of Toronto, Ontario, Canada. Can J Anaesth. 1999; 46: 725-30.
PURPOSE:
To
evaluate the combination of rectal indomethacin with patient controlled
intravenous morphine analgesia (PCA) on postoperative pain relief and opioid
use after cardiac surgery.
METHODS:
With
institutional ethics approval, 57consenting adults undergoing elective
aortocoronary bypass
surgery were randomly assigned preoperatively in a double-blind fashion to receive either placebo (n =26) or indomethacin 100 mg suppositories (n = 31), 2-3 hr postoperatively, and12 hr later. Both groups utilized PCA morphine. Pain scores in the two treatment groups were assessed on a 10-cm visual analogue scale (VAS) (at rest and with cough) at 4, 6, 12, 18 and 24 hr after initial dosing, and were analyzed through a 2 x 5 repeated measures of variance. The 24 hr analgesic consumption, 12 and 24 hr chest tube blood loss, and time to tracheal extubation were also recorded, and compared for the two treatment arms through Student's t test on independent samples. RESULTS:
Postoperative
morphine consumption in the first 24 hr was 38% less in the indomethacin
group (22.40+/- 12.55 mg) than the placebo group (35.99 +/- 25.84 mg),
P = 0.019. Pain scores, measured with a VAS, were 26% to 66% lower in the
indomethacin vs placebo group at rest (P = 0.006), but not with
cough, for all times assessed. There was no difference in blood loss (at 12 hr) or time to tracheal extubation for both groups. CONCLUSION:
The
combination of indomethacin with morphine after cardiac surgery results
in reduced postoperative pain scores and opioid use without an increase
in side effects [citas] |
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| 5.
Subarachnoid fentanyl with diluted small-dose bupivacaine for cesarean
section delivery. KanFC- Tsai YC.Chang PJ.Chen
TY. Acta Anaesthesiol Sin 1998 36 ; 4 :207-14. Department of Anesthesiology,
National Cheng Kung University, College of Medicine,Taiwan, R.O
BACKGROUND:
The
use of neuraxial opioid was very popular in recent years and they augment
the analgesia produced by local anesthetic through direct binding
with the spinal opioid receptors. Hemodynamic stability is very important
during sesarean section. Theoretically, the reduction of local anesthetic
by addition of fentanyl would provide better hemodynamic stability and
good anesthetic status.
METHODS:
Thirty
healthy parturients undergoing cesarean section were assessed in a randomized
fashion. They were divided into two groups. Each subject received 5 mg
hyperbaric bupivacaine plus 25 micrograms fentanyl (0.5 ml) and cerebrospinal
fluid (CSF) 0.6 ml (Group M + F) or 8 mg hyperbaric bupivacaine plus 0.5
ml of CSF (Group M). The effects of hemodynamic stability, side effects,
and complete analgesic duration were observed.
RESULTS:
It
was disclosed that the hemodynamic status was more stable in group M +
F. The incidence of nausea and vomiting appeared to be not statistically
significant between groups. The incidence of pruritus was apparently higher
in group M + F (93.5% vs. 0) but the incidence of shivering was much lower
in group M + F (0 vs. 33.3%). The complete analgesic duration was longer
in group M +F (146 +/- 47 min vs. 104 +/- 44 min). There were no significant
differences in the anesthetic and surgical status, 1-min and 5-min Apgar
scores, and the time of regression of sensory level to T10.
CONCLUSIONS:
The
combination of small-dose bupivacaine with fentanyl could provide more
stable hemodynamic status, longer postoperative analgesia, and lower incidence
of shivering. The incidence of pruritus in group M + F was high, but it
was usually mild [citas] |
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| 6.
Postdural puncture headache is not an age-related symptom in children:
a prospective, open randomized, parallel group study comparing a 22-gauge
Quincke with a 22-gauge Whitacre needle. Kokki
H, Salonvara M, Hrerrgard E, Onen P. Paediatr. Anaesth. 1999; 9:5.429-434.
Many
reports have shown a low incidence of postdural puncture headache (PDPH)
and other complaints in young children. The objective of this open-randomized,
prospective, parallel group study was to compare the use of a cutting point
spinal needle (22-G Quincke) with a pencil point spinal needle (22-G Whitacre)
in children. We studied the puncture characteristics, success rate and
incidence of postpuncture complaints in 57 children, aged 8 months to 15
years, following 98 lumbar punctures (LP). The patient/parents completed
a diary at 3 and 7 days after LP. The response rate was 97%. The incidence
of PDPH was similar, 15% in the Quincke group and 9% in the Whitacre group
(P=0.42). The risk of developing a PDPH was not dependent on the age (r<0.00,
P=0.67). Eight of the 11 PDPHs developed in children younger than 10 years,
the youngest being 23-months-old [citas] |
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| 7.
Prevention of hypotension after spinal anesthesia for cesarean section:
dextran 40 versus
lactated Ringer's solution. Lin CS, Lin TY, Huang CH, LIN YH. Lin CR. Chan WH, Tsai SK. Acta Anesthesiol Sin. 1999; 37; 55-59. BACKGROUND:
This
study was designed to compare the efficacy of 10% dextran 40 with lactated
Ringer's (LR) solution in reducing the incidence and severity of hypotension
after spinal anesthesia for Cesarean section.
METHODS:
Sixty
ASA grade patients scheduled for Cesarean section were randomized into
two groups in a double-blind fashion to receive either 500 ml of dextran
40 or 1000 ml of LR solution prior to induction of spinal
anesthesia. RESULTS:
The
incidence of hypotension was 16 in 30 (53.3%) in the LR solution group
and 8 in 30 (26.7%) in the dextran group (P< 0.05). The required dose
of ephedrine for treatment of hypotension was significantly greater in
the LR solution group than in the dextran group (15.5 mg versus 3.2 mg,
P<0.05). Neonatal outcome, as determined by Apgar score, was good and
similar in both groups.
CONCLUSIONS:
We
concluded that 500 ml of dextran 40 is more effective than 1000 ml of lactated
Ringer's solution in reducing the incidence of hypotension induced by spinal
anesthesia [citas] |
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| 8.
Double-blind evaluation of optimal dosage for analgesia after major lumbar
spinal surgery. Boezaart AP, Eksteen JA, Spuy
GV, Rossouw P, Knipe M. Spine 1999; 24: 1131-1137.
STUDY
DESIGN: A prospective,
randomized, double-blind study.
OBJECTIVES:
To
evaluate the efficacy and safety of three different dosages of intrathecal
morphine sulfate for postoperative analgesia after lumbar spinal fusion.
SUMMARY
OF BACKGROUND DATA: Analgesia
and respiratory depression after intrathecal morphine sulfate injection
are dose related. The optimal dose to use for major spinal surgery is not
known.
METHODS:
Sixty
patients undergoing posterolateral lumbar fusion with or without decompression
were divided randomly into 3 groups of 20 patients each. Anesthesia, monitoring,
and surgery were similar for all patients. Just before closing of the wound,
morphine sulfate was injected into the dural sack under direct visualization.
Patients in groups 1-3 received 0.2 mg, 0.3 mg, and 0.4 mg morphine, respectively.
Routine analgesia, consisting of diclofenac, was prescribed to use if necessary.
Measurements were made and compared between the groups at zero hours (on
admission to the Intensive Care Unit), 6 hours, 12 hours, 18 hours, and
24 hours after surgery.
RESULTS:
At
zero hours and at 12 hours after surgery, pain levels were similar in groups
2 and 3, but were significantly higher in group 1 (P<0.05). The respiratory
rate was significantly lower in group 3 than in the other two groups (P<0.05),
and the arterial CO2 tension (PaCO2) was consistently higher in group 3.
PaCO2 decreased in all three groups over the first 24 hours. Pruritus and
nausea did not differ among the three groups.
CONCLUSIONS:
For
adult patients undergoing posterolateral lumbar fusion, 0.3 mg (0.004 mg/kg)
is probably the optimal dose of intrathecal morphine to manage pain [citas] |
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9.
Very low dose intrathecal morphine (ITM) provide effective analgesia and
minimazes side effects (SE) after coronary artery bypass graft surgery
(CABG). Goldstein S, Cocozello K, Pantin E, Hessen
A, Grubb W. Vanstrum GS et al. Anesth Analg 1988;67:261-7.
INTRODUCTION:
(ITM)
provides effective analgesia after CABG (1). However, (SE) limit it's use.
The goal of this study was to determine if very low dose ITM would provide
effective analgesia and minimize SE.
METHODS:
After
informed consent, 35 patients (pts) for CABG were prospectively randomized
in a double blind fashion to group1 IT saline (ITS), (group 2) 4.25ucg/kg
ITM, or (group 3) 7 ucg/kg ITM. Anesthetic was standardized. Postop, patients
had IV PCA morphine (IV PCA M). Visual analogue scale (0-10) was used to
score: chest pain (CP), leg pain (LP), (N), and pruritis (P) every 4 hrs
for 48 hrs. RR/min was measured at the same intervals. Groups were compared
for mcg/kg IV PCA M for 48 hrs (MS48) and hrs in ICU until patients performed
3 extubation criteria (ExtubCrit): negative inspiratory pressure - 30 cmH2O,
vital capacity 12 cc/kg, and 5 sec head lift. Means ± SD were compared
between groups. Statistical analysis: Kruskal-Wallace ANOVA, P Š 0.05 significant.
If significant differences found, Wilcoxon Rank Sum Test with Bonferroni
correction.
RESULTS:
Chest
pain was less in group 2 (0.9 ± 0.74), n=13, vs Grp 1 (2.4 ±
1.45), n=13, (p=0.02). Group 3 chest pain (1.2 ± 1.08), n = 9, fell
just short of statistical significance vs group 1 (2.4 ± 1.45) (p=0.06).
There was no difference in chest pain in groups 2 and 3 (NS) ). Leg pain
was less in group 2 (0.1 ± 0.14) vs group 1 (1.0 ± 1.71)
(p=0.02). LP in group 3 (0.3 ± 0.64) was not different vs group
1 (1.0 ± 1.71) (p = 0.42), or group 2 (p = NS) (see table1). N (p=0.3),
P (p=0.3), RR (p=0.6), ExtubCrit (p=0.8) and MS 48 (0.13) were not different
between groups.
DISCUSSION:
4.25
mcg/kg ITM improved analgesia vs placebo, and did not worsen N, pruritus,
extubation criteria, or respiratory rate. Reports of side effects may be
due to excess dosing. Chest pain in 7 mcg/kg ITM group was not different
from 4.25 mcg/kg group. 4.25 mcg/kg ITM provides effective analgesia after
CABG and minimizes side effects.
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| 10.
Epidural anesthesia has general anesthetic effects. Peter
S. Hodgson, M.D.; Spencer S. Liu, M.D.; Troy W. Gras, B.S. Virginia Mason
Medical Center, Seattle, WA, USA.
BACKGROUND:
During
combined epidural/general anesthesia, surprisingly low end-tidal concentrations
of volatile agents suppress consciousness. Neuraxial anesthesia exhibits
sedative properties which may reduce requirements for general anesthesia.
(Anesth Analg:81:525-8, 1995 2.Anesthesiology:80:253-260, 1994.) We tested
whether epidural lidocaine reduces volatile anesthetic requirements as
measured by the MAC of sevoflurane using a noxious stimulus cephalad to
the sensory block.
METHODS:
After
receiving midazolam 0.02 mg/kg and fentanyl 1mcg/kg, 44 patients were randomized
to 300 mg epidural lidocaine (group E), epidural saline (group C), or epidural
saline/intravenous lidocaine infusion (group I). Tracheal intubation followed
a standard induction with thiopental 4mg/kg, succinylcholine 1 mg/kg, and
sevoflurane. After 10 minutes of stable end-tidal sevoflurane, 10 seconds
of 50Hz, 60 mA tetanic electrical stimulation were administered in the
C5 dermatomal distribution. (2) The MAC for each group was determined
by the up-and-down method and probit analysis based on patient movement.
RESULTS:
MAC
of sevoflurane for group E, 0.52 ±0.18% (± 95%CI), differed
significantly from group C, 1.18 ± 0.18% (p<0.0005), and from
group I, 1.04 ± 0.18% (p<0.001). The plasma lidocaine levels
in groups E and I were comparable (approx. 3 mcg/ml).
CONCLUSIONS:
Lidocaine
epidural anesthesia reduced the MAC of sevoflurane by approximately 50%.
This MAC-sparing is most likely due to central sedative effects of spinal
deafferentation and not to systemic effects of lidocaine or direct neural
blockade. The apparent general anesthetic effects of epidural anesthesia
should allow decreased use of volatile agent during combined epidural/general
anesthesia, which may prevent hemodynamic inestability and hasten emergence
and recovery [citas] |
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| 11.
Wrist and finger blood pressures compared to arterial line measurements.Michael
C. Bartfield, MD, S.J. Carlan, MD, Gregory Zittel, MD, Terrence Peppy,
MD, Rachel Humphrey, MD. (Obstet Gynecol 1999;93:24.
© 1999 by The American College of Obstetricians and Gynecologists.)
Orlando Regional Healthcare System, Orlando, FL, USA.
PURPOSE:
To
determine the accuracy and precision of finger and wrist blood pressure
measurements when compared to direct cutaneous intraarterial measurements
in pregnant women.
METHODS:
All
patients were at greater than 20 weeks of gestation withan intraarterial
line in place for reasons other than the study. Measurements using Dinamap,
standard wall mercury sphygmomanometer, electronic digital blood pressure,
and digital wrist blood pressure were obtained in rapid succession on the
extremity opposite the arterial line.
RESULTS:
Fourteen
women were enrolled in the study, and there were 1,289 observations recorded.
Mean maternal age was 25.7 years, and mean gestational age was 33.9 weeks;
93% of the patients were on magnesium sulfate and 71% on labetalol at the
time of the study. There is no significant difference between direct arterial
measurements and wrist systolic (-2.3 ± 23.3 mm Hg), wrist diastolic
(-3.8 ± 12.3 mm Hg), and finger diastolic (4.6 ± 5.9 mm Hg)
measurements.
CONCLUSIONS:
1)
Although the mean values confirmed that there was no overall satistical
significance between selected important measurements, the range of values
between intraarterial values in both the finger and wrist cuff measurements
was very wide, suggesting caution should be used when interpreting individual
results. 2) These devices may be helpful in measuring serial blood pressures
because they are relatively inexpensive and
easy to use [citas] |
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| 12.
The incidence of unanticipated difficult intubation in 6742 General
Surgical patients. Kayoko Okazaki, MD; Noriaki
Kanaya, MD; Yukitoshi Niiyama, MD; Yasuyuki Honma, MD; Akiyoshi Namiki,
MD.
Sapporo Medical University School of Medicine, Sapporo, Japan. INTRODUCTION:
Occasional
difficulty in tracheal intubation (INT) is a feature of clinical anesthesia.
Although the incidence of the difficult INT is low (1-4%) in general surgical
and obstetrical patients, interruption of gas exchange can result in catastrophic
outcomes such as brain damage or death. Especially, unanticipated difficult
INT can cause a life-threatening scenario because of less preparation including
alternative to mask ventilation, and absence of breathing. However, there
have been no systematic approach to examine the incidence of unanticipated
difficult INT in large number of patients. The purpose of this study was
to examine the incidence of unanticipated difficult INT in all patients
attended by anesthesiologists.
METHODS:
During
a three year period (1996-1998), the incidence of difficult INT was monitored
via a quality assurance data collection system. Difficult INT was defined
by the ASA Task Force as occurring when "proper insertion of the tracheal
tube with conventional laryngoscopy requires more than three attempts or
more than 10 minutes". Prediction of difficult INT was assessed by the
visibility of oropharyngeal structures (Class I-IV in Mallampati Classification,
Samsoon modified). Direct laryngoscopic view was determined by Cormack
and Lehane Classification. Patients with pre-existing airway abnormality
(e.g. limitation of mouth opening and head extension, et.al.) were excluded
in this study.
RESULTS
AND CONCLUSIONS: For
6742 patients following a direct laryngoscopy, tracheal INT was difficult
in 4.9%. The incidence of difficult INT in patients with a good (Class
I and II) and poor (Class III and IV) oropharyngeal view was 3.4% and 1.5%,
respectively. In the patients with a good oropharyngeal view, achieving
a good laryngoscopic view (Grade 1/2 in 72%) was greater than a poor view
(Grade 3/4 in 28%). These results suggests that unanticipated difficult
INT is more commonly seen in total difficult INT than anticipated difficult
INT. A good view during direct laryngoscopy does not guarantee success
INT. Thus, every anesthesiologists should be familiar with and well practiced
in a variety of the techniques for unanticipated difficult INT [citas] |
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| 13.
The anesthetic management of a preterm infant weighing 500 grams undergoing
ligation of patent ductus arteriosus (case report). Acta
Anesthesiol Sin 1999; 37: 89-92. Department of Anesthesiology, China Medical
College Hospital, Taichung,Taiwan. Chen KB, Tu KT, Cheng HC, WU YL, Chang
JS.
PDA
(patent ductus arteriosus) is a common congenital heart disease. Usually
surgical intervention through left thoracotomy or recently through video
assisted thoracoscopy will be recommended if the preceding or intent medical
treatment fails or is contraindicated. However, once surgical intervention
is decided, various complications are still a real fear in the mind of
the surgeon and the anesthesiologist, particularly if the infant is premature
or very sick. Here we report an anesthetic management in a female preterm
infant weighing 500 grams, who underwent PDA ligation. She was born at
gestation age of 28 weeks at our hospital, and since her birth she was
noted to have infant respiratory distress syndrome associated with renal
dysfunction. She was admitted to the neonatal intensive care unit (NICU)
straightaway. After thorough examination, a severe PDA was disclosed. The
possibility of pulmonary hemorrhage and heart failure could be predicted
in view of the large left to right shunt. Worst of all was that her poor
renal function contradicted a medical treatment. So we decided to carry
out the ligation procedure at once although she was premature and only
5 days old. The NICU was chosen as the operation theater for transferring
concerns. General anesthesia was induced and maintained by atropine 0.01
mg, pancuronium 0.1 mg, fentanyl 2 micrograms, and ketamine 0.15 mg intravenously.
Supplemental oxygen was given throughout the operation. The PDA was ligated
through left thoracotomy and blood loss was minimal. The peri-operative
course was uneventful. The patient recovered well following surgery and
anesthesia [citas] |
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| 14.
Farmacología del rapacuronio. Un nuevo relajante muscular no despolarizante.
El presente es un artículo que se publicará en la Revista
Argentina de Anestesióloga en su No.5 (noviembre). Miguel
Angel Paladino, Marcelo Nigro.
INTRODUCCION:
Los
nuevos relajantes no despolarizantes deben brindar al anestesiólogo
la posibilidad de elegir el fármaco preciso en cada una de las diversas
intervenciones quirúrgicas, con escasos riesgos y adecuada estabilidad
hemodinámica. Los estudios clínicos farmacológicos
en el campo de estas drogas se orientan a conseguir modificaciones en algunos
de los siguientes aspectos: 1. Rapidez en el comienzo de acción
para permitir una rápida intubación traqueal; 2. Cambios
posibles en la previsibiliad del fin de la acción sin bloqueo
neuromuscular residual; 3. Disminuir los efectos cardiovasculares y autonómicos;
4. Diversas farmacocinéticas acordes con diversas patologías,
y, 5. Distintos tiempos de acción para adaptarlos a diversas situaciones
clínicas y terapéuticas. Durante décadas, se intentó
encontrar un relajante muscular no despolarizante que tuviera un tiempo
de latencia o comienzo de acción ultracorto similar a la succinilcolina,
pero libre de los posibles efectos colaterales que ésta puede producir.
Con la aparición del rocuronio, relajante muscular no despolarizante
aminoesteroideo, se avanzó en algunos de los aspectos considerados.
Su inicio de acción es rápido, a los sesenta segundos el
paciente puede ser intubado, en condiciones similares a la succinilcolina
sin liberación de histamina, sin cambios hemodinámicos, ni
a nivel vagal y ganglionar. Un nuevo relajante de este grupo se ha estado
estudiando durante la década del 90, bajo la sigla de ORG9487, cuyo
nombre genérico es rapacuronio o rapacuronium. Diversos estudios
se han realizado y llegó a la fase 3 de estudio clínico en
1996. El rapacuronio fue introducido para su uso en clínica
en 1998, y constituye la última novedad en relajantes musculares.
Diversos artículos en las principales revistas de la especialidad
han sido publicados en los últimos meses. Esto ha llevado
al comité de redacción de la revista conjuntamente con el
Cop de medicamentos a presentar sus principales características,
y su perfil farmacológico. La misma probablemente esté disponible
comercialmente en nuestro país en el año 2000 o 2001. Las
modificaciones en el grupo éster 17 y en la estructura cicloamino
de los sustituyentes del esqueleto androstano del vecuronio, llevó
a la síntesis del rocuronio (propionato análogo del vecuronio).
Se diferencia del vecuronio y del rocuronio por su muy alto aclaramiento
plasmático y menor tiempo medio de estadía en el receptor.
En plasma se detecta el metabolito 3-OH que posee actividad relajante muscular.
Su principal característica es que al ser antagonizado con
neostigmina a los dos minutos de administrado, la duración de su
efecto es aproximadamente de 10 a 20 minutos. Su potencia farmacológica
es baja. Esta característica le confiere la mayor parte de sus propiedades
diferenciales con el resto de los relajantes antidespolarizantes, salvo
el rocuronio.
FARMACODINAMIA:
Los
relajantes musculares no despolarizantes de menor potencia (los que necesitan
mayor número de moléculas para producir un efecto similar
a otro) tendrán un comienzo de acción más rápido
que los de menor potencia. Para determinar la velocidad de comienzo y la duración de la acción clínica de los relajantes los factores fundamentales a tener en cuenta son: 1. La perfusión de la unión neuromuscular, y por lo tanto la difusión desde del compartimento central (plasma) a la hendidura sináptica donde está el receptor; 2. La velocidad de asociación del compuesto con el receptor; 3. La unión con receptores inespecíficos. El primer punto depende fundamentalmente de variables hemodinámicas del paciente como gasto cardiaco, presión de perfusión del músculo, resistencias periféricas etc. El segundo y tercer punto, vemos que, rápidas velocidades de comienzo dependen de rápidas velocidades de asociación con el receptor y de la incapacidad de unirse a receptores inespecíficos. Por otra parte, para que se produzca bloqueo neuromuscular se necesita que un gran número de receptores se encuentre ocupado por moléculas de relajante, por lo tanto teóricamente, cuanto mayor sea el número de moléculas administradas o menor sea su volumen de distribución, más rápido resultará el comienzo de acción. La DE90 del rapacuronio se ha establecido en 1.15 mg/kg, siendo la dosis utilizada normalmente en clínica 1.3 x DE90 (1.5 mg/kg.). Otra característica de la droga es que el comienzo de acción, es más rápido en musculatura laríngea que en musculatura periférica; 52 vs 62 segundos, la intensidad del bloqueo es menor en laringe que en la musculatura periférica (86 vs 97%), siendo la duración del efecto menor en la región laríngea que en periférica (3.7 vs 10.2 minutos). Se ha postulado que su capacidad para inhibir los canales de calcio voltaje dependiente permite una vasodilatación, con aumento de flujo sanguíneo arterial al músculo y aumento en la velocidad en la tasa de equilibrio entre plasma y biofase, que puede explicar el rápido comienzo del efecto que produce, sobre todo en los músculos cortos como los laríngeos. FARMACOCINETICA:
Tiene
el aclaramiento mayor de todos los relajantes musculares (8.45 ml/kg/min).
Con un alto valor de ke0, lo que le permite un rápido equilibrio entre plasma y biofase, con una t1/2 de distribución rápida, extraordinariamente corta que permite un comienzo de acción similar a la succinilcolina. Se excreta por riñón en cantidades aproximadas al 17%, el resto lo hace por bilis y por metabolización. Su metabolito activo 3-OH, se acumula. El uso de rapacuronio por un tiempo de más de una hora, puede ser causante de prolongación de su efecto [citas] |
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| 15.
Anesthesia for in vitro fertilization. A comparision of 1.5% and 5% spinal
for ultrasonically guided oocyte retrieval. Manica,
Virgil S., MD; Bader, Angela M., MD; Fragneto, Regina, MD; Gilbertson,
Lesley, MD; Datta, Sanjay, MD. Anesthesia
& Analgesia. 1993; 77 :3. Department of Anesthesia, Harvard Medical
School, Brigham and Women's Hospital, Boston, Massachusetts Accepted for
publication June 4, 1993. Address correspondence and reprint requests to
Dr. Bader, Department of Anesthesia, Brigham and Women's Hospital, 75 Francis
Street, Boston, MA 02115.
ABSTRACT:
In
many institutions, spinal anesthesia is used for surgery involving ultrasonically
guided transvaginal oocyte retrieval. Because this relatively short procedure
is performed on an outpatient basis, the optimal spinal technique would
allow good surgical anesthesia with a short recovery time. The relative
regression of equal doses of different concentrations of hyperbaric spinal
lidocaine is presented. We compared 1.5% and 5% hyperbaric lidocaine (7.5%
dextrose) as spinal drugs for use in this procedure. Fifty-six patients
were randomized to receive 60 mg of hyperbaric solutions of either
1.5% or 5% lidocaine in combination with 10 mcg of spinally administered
fentanyl. Visual analog scale pain scores were zero throughout the procedures
for all patients. There were no significant differences between the groups
with regard to sensory level, maximum motor block, intravenous sedation
requirements, time to two-segment regression, and time to full sensory
recovery. The group receiving 1.5% lidocaine had significantly shorter
times to ambulation (141 ± 21 min vs 162 ± 29 min; P <
0.05), voiding (147 ± 21 min vs 174 ± 28 min; P < 0.05),
full motor recovery (86 ± 21 min vs 111 ± 22 min; P <
0.0001), and discharge (170 ± 38 min vs 201 ± 41 min; P <
0.05). The use of 1.5% hyperbaric lidocaine for transvaginal oocyte retrieval
provides a significantly shorter recovery time when compared to 5% hyperbaric
lidocaine and is a good choice for spinal anesthesia for this procedure,
is relatively short and patients are sent home the same day, the anesthetic
method chosen should provide a quick recovery time. Although local anesthesia
with sedation can be used, there are some reports of patient dissatisfaction
as well as excessive drowsiness. Spinal block would provide excellent surgical
anesthesia with minimal need for sedation. The present study compares two
hyperbaric lidocaine solutions used in spinal anesthesia for transvaginal
ultrasound guided oocyte retrieval with respect to quality of sensory and
motor block, side effects, and recovery times. The results of this study
provide information not previously published regarding relative regression
of equal milligram doses of different concentrations of hyperbaric spinal
anesthetics.
METHODS:
The
study was approved by the hospital's Committee for the Protection of Human
Subjects and written informed consent was obtained from all participants.
Fifty-six ASA I and II patients scheduled for ultrasonically guided oocyte
retrieval procedures were enrolled. Patients were excluded if height was
less than 60 in or greater than 72 in, or if weight was more than 91 kg.
Subjects were randomized in a double-blinded fashion to receive spinal
anesthesia with either 60 mg of hyperbaric 1.5% lidocaine (4 mL) or 60
mg of hyperbaric 5% lidocaine (1.2 mL) in combination with 10 mg of preservative-free
fentanyl. The investigator recording data did not perform the spinal, and
so was unaware of which lidocaine concentration had been used. All patients
received at least 500 mL of intravenous (IV) lactated Ringer's solution
before induction of the anesthetic. They were then taken to the operating
room and routine monitors were applied. Spinal anesthesia was induced with
subjects in the right lateral decubitus position at either the L2-L3 or
L3-L4 interspace, using a 25-gauge Whitacre spinal needle. Patients were
immediately placed in lithotomy position. They were provided with supplemental
IV sedation with midazolam or fentanyl if required. Sensory level to pinprick
measured at the midclavicular line, motor block using Bromage scale (),
and pain score on a linear visual analog scale (VAS) () were recorded by
an investigator at 1, 2, 3, 4, 5, 10, and 15 min, and then every 15 min
after the spinal injection until complete resolution of anesthesia. Side
effects and amount of supplemental medication required were noted. Other
data collected included duration of the egg retrieval procedures, times
to two-segment regression of sensory anesthesia and complete regression
of sensory anesthesia, and times from spinal injection to ambulation, voiding,
and discharge from the postanesthetic care unit. Criteria for ambulation
included stable vital signs, absence of sedative effects, and complete
resolution of motor and sensory block. After these criteria were met, patients
were discharged when they had voided and were in no discomfort from the
surgical procedure. Statistical analysis of the data recorded from the
two groups was carried out using Student's t-test, c2 test, and Mann-Whitney
test where appropriate. A P value <0.05 was considered statistically
significant.
RESULTS:
Both
groups of patients were similar with regard to weight, height, and age.
The egg retrieval procedures lasted an average of 29 min in both groups.
There were no differences in the amount of ephedrine used or the number
of patients in each group receiving IV supplementation. The sedation received
generally consisted of 1–2 mg of midazolam for relief of anxiety
before the procedure. No patient recorded a VAS score greater than zero
during the procedures. There were no significant differences in maximum
motor and sensory levels or in time to achieve maximum motor and sensory
levels. Times to two-segment regression and full sensory recovery were
similar. The group receiving 1.5% lidocaine did have a significantly shorter
time to full motor recovery. This group also demonstrated a significantly
shorter time to ambulation, voiding, and discharge from the postanesthetic
care unit. No significant side effects were reported and none of the patients
experienced a postdural puncture headache.
DISCUSSION:
Ultrasound
guided oocyte retrieval procedures are generally short and performed on
an outpatient basis. The optimum anesthetic technique should provide rapid
onset of anesthesia, with a solid anesthetic level during the procedure,
followed by a rapid recovery with a minimum recovery room stay. A variety
of anesthetic methods have been used. General anesthesia is usually reserved
for gamete intrafallopian transfer (GIFT) procedures, which involve laparoscopy
and immediate replacement of the oocyte and spermatozoa in the distal fallopian
tube. There is concern that general anesthesia may reduce the rate of fertilization
and cleavage of human oocytes. The duration of oocyte exposure to different
inhaled agents adversely influenced oocyte quality. Epidural anesthesia
has been proposed as an alternative, but the technique is somewhat more
time consuming, which makes this less desirable for a procedure that usually
requires a rapid turnover between cases. Local anesthesia with or without
IV sedation may be used; however, patients may move at critical times during
the procedure and may require significant amounts of sedatives to keep
them comfortable, resulting in excessive drowsiness and prolonged recovery
room stays. The prolactinemia that occurs after the administration of general
anesthetics, droperidol and fentanyl, has been associated with lower plasma
progesterone levels and may adversely influence the outcome of the in vitro
fertilization procedure. Spinal anesthesia would seem to be an optimal
choice, providing good pain relief with minimal exposure of the eggs to
anesthetic agents. There are no previous data on the relative regression
of equal milligram solutions of different concentrations of hyperbaric
spinal lidocaine. The current study shows that 1.5% hyperbaric lidocaine
provides shorter recovery and discharge times than 5% hyperbaric lidocaine.
Because the total dosage of lidocaine given to either group was the same
(60 mg), the reasons for these differences in recovery must depend upon
other
factors, such as the different volumes injected (4 vs 1.2 mL) and the different concentrations of the solutions (5% vs 1.5%). The same microgram dose of fentanyl was administered in both groups, resulting in different concentrations of fentanyl in the two volumes used. We would not expect this concentration difference to affect sensory and motor recovery. Both groups of patients had excellent analgesia during the procedures, as VAS scores demonstrated. The effects of different volumes of injectate on onset times and extent of block have been examined. A previous study by Vucevic and Russell compared women who received 3 mL of 0.5% isobaric bupivacaine with women receiving 12 mL of 0.125% isobaric bupivacaine for cesarean delivery. Women who received the higher volume had a significantly wider spread of sensory anesthesia initially, but all differences were absent after 5 min. Unfortunately, this study did not assess patients after 60 min of anesthesia, so differences in recovery time could not be determined. There are no similar studies involving hyperbaric local anesthetic solutions. We are the first to compare onset and recovery times when different volumes, but the same dose of local anesthetic, are used for spinal anesthesia. There are no currently published data that would help to elucidate the mechanism underlying the differences in behavior of these two local anesthetic solutions. We can postulate that the higher volume solution may have a higher initial spread into the upper dermatomes, resulting in less total drug per segment and a less dense block overall. The group receiving 1.5% lidocaine did show a trend toward a shorter time to maximum sensory level, although this difference was not statistically significant. The lesser volume of the more highly concentrated solution of 5% lidocaine may have a tendency to settle initially in the lower part of the spinal canal, producing a more dense motor block in the lower extremities with a longer regression time. The higher concentration may also result in more penetration of the nerves closer to the site of injection. Although no differences in maximum motor block were demonstrated between the two solutions, two of the patients in the group receiving 1.5% lidocaine did not achieve a Bromage score of 1. The density of motor block is difficult to evaluate with the Bromage scale, which measures completeness of motor block, but does not adequately rate intensity. A tendency toward longer duration of sensory regression was demonstrated in the 5% lidocaine group (151 min vs 138 min), although this difference did not prove to be statistically significant. In summary, 1.5% hyperbaric lidocaine (60 mg) provides significantly shorter recovery times than does an equal dose of 5% hyperbaric lidocaine for spinal anesthesia for transvaginal oocyte procedures. The differences in regression times between the two solutions provide further information about the actions of spinal anesthetics [citas] |
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| 16.
An evaluation of the effect of anesthetic technique on reproductive success
after laparoscopic pronucleas stage transfer. Propofol - nitrous oxide
versus isoflurane - nitrous oxide. Vincent, Jr.,
Robert D., M.D.*; Syrop, Craig H., M.D.†; VanVoorhis, Bradley
J., M.D.; Chestnut, David H., M.D.§; T.Sparks, Amy E., Ph.D. McGrath,
Joan M., M.D.#; Choi, Won W., M.D.**; Bates, James N., M.D. Ph.D. &
dagger; Penning, Donald H., M.D.* Anesthesiology.1995; 82:2.
ABSTRACT:
Background:
Laparoscopic pronuclear stage transfer (PROST) is the preferred method
of embryo transfer after in vitro fertilization in many infertility programs.
There are scant data to recommend the use or avoidance of any particular
anesthetic agent for use in women undergoing this procedure. The authors
hypothesized that propofol would be an ideal anesthetic for laparoscopic
because of its characteristic favorable recovery profile that includes
minimal sedation and a low incidence of postoperative nausea and vomiting.
The purpose of the study was to compare propofol and isoflurane with respect
to postanesthetic recovery and pregnancy outcomes after laparoscopic
PROST.
METHODS:
One
hundred twelve women scheduled for laparoscopic PROST were randomized to
receive either propofol/nitrous oxide or isoflurane/nitrous oxide for maintenance
of anesthesia. Results: Visual analog scale scores for sedation were lower
in the propofol group than in the isoflurane group at all measurements
between 30 min and 3 h after surgery. More women experienced emesis and
were given an antiemetic during recovery in the isoflurane group than in
the propofol group. However, the percentage of pregnancies with evidence
of fetal cardiac activity was 54% in the isoflurane group compared with
only 30% in the propofol group (P = 0.023). Also, the ongoing pregnancy
rate was greater in the isoflurane group than in the propofol group (54%
vs. 29%, P = 0.014). Conclusions: Propofol/nitrous oxide anesthesia was
associated with lower clinical and ongoing pregnancy rates compared with
isoflurane/nitrous oxide anesthesia. (Key words: Anesthetics, inhalational:
isoflurane; nitrous oxide. Anesthetics, intravenous: propofol. Assisted
reproductive techniques: pronuclear stage transfer.) IN 1986, Blackledge
et al. introduced pronuclear stage transfer (PROST) as a method to enhance
the incidence of successful pregnancies in couples with male factor infertility.
Subsequently, indications for PROST have expanded, and many reproductive
endocrinologists favor this technique for the transfer of preimplantation
embryos after in vitro fertilization. Pronuclear stage transfer involves
the placement of several one-cell embryos into the distal segment of a
fallopian tube during laparoscopic surgery. Several authors have reported
that each embryo transferred in this manner has about twice the chance
of eventually implanting into the uterine wall compared with those transferred
directly into the uterine cavity. Indeed, some studies have found that
the incidence of reproductive success after PROST was greater than after
transcervical intrauterine embryo transfer. For example, Hammitt et al.
reported a clinical pregnancy rate of 52% after PROST procedures compared
with only 20% after intrauterine embryo transfers. Despite the increased
popularity of PROST, there are no human data to unequivocally promote the
use or avoidance of any specific anesthetic agent or technique for the
purpose of anesthetizing women for this procedure. Others have noted an
adverse effect of isoflurane on preimplantation mouse embryos in vitro.
However, the applicability of their findings to human embryo development
is questionable because our infertility program has reported high PROST
pregnancy rates despite the routine use of isoflurane anesthesia for laparoscopic
tubal transfers. Propofol is an excellent anesthetic for outpatient laparoscopic
surgical procedures because patients tend to recover quickly with little
sedation and nausea. Preliminary laboratory data suggest that it does not
harm preimplantation mouse embryos in vitro, but we are not aware of any
published clinical data to confirm its safety in humans when administered
during embryo transfer procedures. The purpose of the current study was
(1) to evaluate measures of reproductive success after administration of
either propofol or isoflurane anesthesia for PROST and (2) to confirm whether
propofol anesthesia resulted in a more rapid recovery with fewer postoperative
side effects compared with isoflurane anesthesia when given for laparoscopic
PROST.
METHODS:
The
protocol was approved by the University of Iowa Human Subjects Review Committee.
After hormonal stimulation, preovulatory oocytes were harvested transvaginally
followed by insemination with spermatozoa in vitro. Autologous PROST cycles
were defined as those transfers in which the oocyte donor and the embryo
recipient were the same individual. Donor-recipient PROST cycles were defined
as transfers in which oocytes were anonymously donated by a woman other
than the one receiving the pronuclear stage embryos. If evidence of successful
fertilization (i.e., the presence of two intracellular pronuclei) was present
16—18 h after insemination, the patient was prepared for laparoscopic
PROST. Before surgery, written informed consent was obtained from all women
participating in the study protocol. At that time, each participant was
randomized to receive either propofol/nitrous oxide or isoflurane/nitrous
oxide anesthesia for laparoscopic transfer. Randomization was performed
by opening one of a series of sequentially numbered opaque envelopesthat
contained the group assignment. The patient, but not the anesthesiologist,
was blinded to the group assignment. Individuals who failed to conceive
after participating in the study were eligible for a second randomization
during a subsequent PROST procedure. Anesthetic Technique General anesthesia
was induced with an intravenous bolus of 50—100 mg fentanyl followed
by either 2— 2.5 mg/kg propofol (propofol group) or 3—
6 mg/kg sodium thiopental (isoflurane group). Before laryngoscopy and tracheal
intubation, 0.4—0.5 mg/kg atracurium was administered intravenously.
A continuous infusion of propofol (£200 mg×kg-1×min-1)
was used for maintenance of anesthesia in the propofol group. Isoflurane
(£2% inspired) was used for maintenance of anesthesia in the isoflurane
group. Nitrous oxide (50%) in oxygen was administered to all patients throughout
surgery. In both groups, an additional 50—100 mcg fentanyl was
given during surgery as determined by the attending anesthesiologist. Incremental
doses of atracurium were given to maintain adequate neuromuscular relaxation
intraoperatively. At the end of surgery, residual neuromuscular blockade
was reversed with intravenous glycopyrrolate and neostigmine. Nitrous oxide
administration was discontinued at the time of skin closure. (This was
defined as time zero for all postoperative measurements.) Surgical Technique
After establishing pneumoperitoneum with carbon dioxide, the proximal end
of one fallopian tube was identified during laparoscopy and was cannulated
with an introducer sleeve. Subsequently, a transfer catheter was advanced
through the sleeve, and two or more pronuclear stage embryos were injected
into the ampullary portion of the fallopian tube. After verifying that
all embryos had been expelled from the transfer catheter, pneumoperitoneum
was released and the puncture wounds were closed. All surgeries were performed
by one of two faculty reproductive endocrinologists (C.H.S. or B.J.V.)
Postoperative Management The first 84 patients were instructed to remain
recumbent during the initial 4 h after surgery. (Patients were instructed
to refrain from ambulating for several hours after surgery with the hope
that this practice would limit any migration of the conceptus within the
fallopian tube. Later, this period of strict immobilization was reduced
from 4 to 3 h after all
other gamete or embryo transfer procedures. At that time, we decided to
incorporate this change into our methodology so that the study protocol
would be more relevant to current clinical practice at The University of
Iowa Hospitals and Clinics. Hence the final 28 women were required to remain
recumbent for only 3 h after surgery.) In the recovery room, ice chips
and clear liquids were given orally as tolerated. Intravenous morphine
(2—3 mg) or oral acetaminophen with codeine was given as needed
to treat postoperative pain. Metoclopramide (10 mg) was administered intravenously
for the treatment of persistent nausea. Patients who continued to experience
nausea and vomiting after an initial dose of metoclopramide were given
either a second intravenous dose of 10 mg metoclopramide or 0.625 mg droperidol
at the discretion of the attending anesthesiologist. Patients were discharged
from the hospital when they had voided and were able to ambulate, unless
they were experiencing significant somnolence, nausea, or pain. Intramuscular
progesterone (25—50 mg) was given daily until results of the
chemical pregnancy test(s) were known. If a chemical pregnancy was detected,
progesterone administration was continued for at least 2 weeks more. Measurements
Patient visual analog scale (VAS) scores for nausea (0 = no nausea and
100 = worst possible nausea) and sedation (0 = wide awake and 100 = almost
asleep) were obtained at 15, 30, 60, 120, 180, and 240 min after surgery.
(VAS scores at 240 min were not obtained in the final 28 study patients.)
At discharge, patients were asked to describe their overall satisfaction
with the anesthetic technique as very satisfied (0), somewhat satisfied
(1), somewhat dissatisfied (2), or very dissatisfied (3). Patients were
unaware of their group assignment until after completion of the discharge
questionnaire. Fifteen days after surgery, maternal plasma b-human chorionic
gonadotropin concentrations were determined from samples of maternal venous
blood to establish whether PROST had resulted in a chemical pregnancy.
Positive results were verified with an additional plasma b-human chorionic
gonadotropin measurement 48 h later. If a chemical pregnancy was still
evident at this time, a vaginal ultrasound examination was performed 24
days after surgery to note the presence and number of gestational sacs
within
the uterine cavity. If present, an additional ultrasound examination was
performed 10 days later to determine whether viable fetal cardiac activity
(³100 beats/min) was present. Clinical pregnancies were defined as
evidence of viable fetal cardiac activity at that time. Ongoing pregnancies
were defined as clinical pregnancies in which spontaneous abortion (of
all fetuses) had not occurred. Each gestational sac with fetal cardiac
activity was defined as a successful implantation. Implantation rate was
calculated as follows: number of successful implantations divided by total
number of embryos transferred. Reproductive data were not included in the
analysis of pregnancy results if the patient received gamete intrafallopian
transfer simultaneous with PROST. Statistical Analysis Comparisons of continuous
data between the two groups were made using unpaired t tests. Nonparametric
comparisons between groups were made using the chi-square test (2 ´
2) with contingency correction or the Mann-Whitney U test. Bonferroni adjustments
were used in comparing nausea and sedation measurements at specific times.
P<0.05 was considered statistically significant.
RESULTS:
One
hundred twelve PROST cycles were studied between June 1992 and May 1994.
Ninety-four women were enrolled once in the study, and nine agreed to participate
during two laparoscopic PROST procedures. Among the nine patients who consented
to randomization on two instances, three received propofol twice, two received
isoflurane twice, and four were given each anesthetic once. There were
no significant differences in patient demographic data or infertility factors
between the two groups ( and ). Also, the number of embryos transferred
during PROST was similar in the two groups (median 4, range 2—6;
for each group). VAS scores for nausea did not differ significantly between
the two groups at any time. However, the incidences of vomiting and antiemetic
administration were smaller (P<0.05) in the propofol group than in the
isoflurane group. The intervals elapsed from the end of surgery until patients
could tolerate ice chips or ambulate were each shorter (P<0.05) in the
propofol group than in the isoflurane group. Patient VAS sedation scores
were significantly lower (P<0.05) in the propofol group than in the
isoflurane group at all measurements between 30 min and 3 h after surgery.
Also, the interval between the end of surgery and hospital discharge was
shorter (P<0.05) after propofol anesthesia than after isoflurane anesthesia.
Overall patient satisfaction was high in both groups but was slightly higher
(P<0.05) in the propofol group. Four women were not included in the
analysis of pregnancy data because extensive tubal disease discovered during
laparoscopy precluded successful tubal transfer. Also, two women (isoflurane
group) were excluded because they received a gamete intrafallopian transfer
procedure in addition to PROST. One of these two patients achieved a singleton
ongoing pregnancy. The incidence of chemical pregnancies did not differ
significantly between the two groups. However, the percentage of gestations
with evidence of fetal cardiac activity was greater (P = 0.023) in the
isoflurane group than in the propofol group. Also, the ongoing pregnancy
rate was greater (P = 0.014) in the isoflurane group than in the propofol
group (54% vs. 29%). The difference in implantation rate after PROST did
not differ significantly between the two groups. If the statistical analysis
is repeated without reproductive data from all rerandomized transfers,
both the incidence of PROSTs resulting in fetal cardiac activity and the
implantation rates differed significantly between the two groups (59% vs.
29% and 21% vs. 11%, respectively, in the isoflurane and propofol groups).
Discussion Results of laboratory studies could cause one to question the
use of isoflurane anesthesia for women undergoing laparoscopic PROST. For
example, Chetkowski et al. observed that 30 min of exposure to 1.5% isoflurane
reduced the percentage of two-cell mouse embryos developing to the blastocyst
stage from 79% to 44%. Despite the accumulation of laboratory data demonstrating
potential embryo toxicity from isoflurane, many anesthesiologists continue
to administer isoflurane to women undergoing laparoscopic PROST. (Perhaps
many, like ourselves, are reluctant to abandon the use of an established
anesthetic when pregnancy rates after PROST are already high in their own
infertility programs.) The current findings strongly support our earlier
clinical impression that isoflurane probably does not exert a substantial
detrimental effect on subsequent embryo development and implantation when
given during PROST procedures. There are at least two possible reasons
why our results appear to contradict earlier studies of mouse embryo development
after exposure to isoflurane in vitro. First, because embryos are transferred
into the fallopian tube near the conclusion of surgery, concentrations
and durations of isoflurane exposure used in laboratory studies may have
substantially exceeded the exposure that occurs during PROST. Second, others
have challenged the accuracy of the two-cell mouse embryo assay with regard
to its ability to predict human reproductive toxicity. However, most of
these criticisms have been directed at the assay's low sensitivity not
its specificity. Nevertheless, the current results suggest that the two-cell
mouse embryo assay has limited clinical application with regard to anesthetic
choice for laparoscopic embryo transfer procedures. Others have reported
that propofol administration to women undergoing ultrasound-guided transvaginal
oocyte retrieval or gamete
intrafallopian transfer does not impair reproductive success. Although these studies involve exposure to human oocytes and not embryos, we hypothesized that pregnancy outcomes after PROST would not be adversely effected by propofol anesthesia. Unexpectedly, pregnancy rates were significantly lower in the propofol group than in the isoflurane group. A random selection bias did not appear to have produced this difference because the number of embryos transferred and the etiologies of infertility were similar in both groups. Ideally, one would prefer to randomize participants based upon the number of embryos transferred and each couple's specific source of infertility (e.g., male factor, ovarian failure, age, immunologic, endometriosis). For pragmatic reasons, we did not stratify the randomization procedure for source(s) of infertility since this is often not apparent until the time of surgery (i.e., endometriosis). Regardless of the reasons responsible for the differences in pregnancy outcomes observed in the present study, our results suggest the need for careful review of reproductive outcomes in programs that are using propofol anesthesia for PROST procedures. The current investigation did not specifically address the controversy of nitrous oxide administration during PROST. There are conflicting data on the exposure of preimplantation embryos to nitrous oxide. Chetkowski et al. reported that nitrous oxide had no effect on the development of mouse two-cell embryos to the blastocyst stage after exposure in vitro. In contrast, Warren et al. found that 30 min of nitrous oxide exposure inhibited the development of mouse two-cell embryos when given just before the expected onset of cleavage. Our findings add support to the use of nitrous oxide (especially when given with isoflurane) in women anesthetized for embryo transfer procedures. We acknowledge that other factors might have contributed to the observed difference in reproductive success between groups. For example, thiopental was given to all women in the isoflurane group, and metoclopramide was used nearly 10 times as often in the isoflurane group as in the propofol group. Although we find it unlikely that any anesthetic drug increases the probability of reproductive success after PROST, we cannot exclude this possibility. Also, women in the propofol group ambulated sooner than their counterparts in the isoflurane group. It is conceivable that premature ambulation in the propofol group led to extratubular embryo migration. We observed that patients in the isoflurane group were more likely to experience emesis and receive metoclopramide than were women in the propofol group. However, nausea measurements did not differ significantly between the two groups at any time, and no patient required overnight admission for persistent nausea and vomiting. This indicates that, although women in the isoflurane group were more likely to have emesis, their symptoms often resolved rapidly-either spontaneously or in response to metoclopramide. Exogenous hormonal stimulation may have contributed to the lack of severe, persistent nausea in the current study. Beattie et al. observed that perioperative nausea and vomiting were less likely among women who were not close to their time of menstrual bleeding compared to women who were perimenstrual (i.e., cycle days 25 through 4). All women in the current study were in the periovulatory phase (i.e., cycle days 12—16) of their menstrual cycle as a result of exogenous hormonal stimulation to induce superovulation. Thus, intractable postoperative nausea requiring overnight admission is not a likely event after laparoscopic PROST with either isoflurane or propofol anesthesia. SUMMARY:
Women
who received propofol - nitrous oxide anesthesia had less postoperative
sedation and vomiting than similar women given isoflurane - nitrous oxide
anesthesia for PROST. However, the clinical and ongoing pregnancy rates
after isoflurane/nitrous oxide anesthesia were higher than those after
propofol/nitrous oxide anesthesia. Hence, the marginal benefits of propofol
anesthesia on postoperative recovery appear trivial given the possibility
that propofol unfavorably affects the probability of achieving pregnancy
after PROST. These results have prompted us to suspend the use of propofol
anesthesia for laparoscopic PROST procedures until the effects of propofol
on human preimplantation embryos are better understood.
The authors thank Karen Holmes, R.N., for her efforts ensuring the accurate and complete collection of all postoperative data. Also, the authors thank Franklin Dexter, M.D., for his advice concerning the statistical methods used in this manuscript, and Michael M. Todd, M.D., for his support of this project. REFERENCES:
*Assistant Professor, Department of Anesthesia. †Associate Professor, Department of Obstetrics and Gynecology. `Assistant Professor, Department of Obstetrics and Gynecology. §Professor and Chairman, Department of Anesthesiology, University of Alabama at Birmingham. ï÷Associate Research Scientist, Department of Obstetrics and Gynecology. #Associate, Department of Anesthesia. **Professor, Department of Anesthesia. ††Associate Professor, Department of Anesthesia. Received from the University of Iowa College of Medicine, Iowa City, Iowa. Submitted for publication August 2, 1994. Accepted for publication October 6, 1994. Presented in part at the annual meeting of the Society for Obstetric Anesthesia and Perinatology, Philadelphia, Pennsylvania, May 14, 1994. Address correspondence to Dr. Vincent: Department of Anesthesia, University of Iowa College of Medicine, 200 Hawkins Drive, Iowa City, Iowa 52242 [citas] |
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| 17.
Comparison of haemodinamic changes in women with severe preeclampsia
receiving combined spinal-epidural for labor analgesia vs cesarean.
Ramanathan J. MD, Arunkumar V. MD. A. University
of Tennessee, Memphis, Memphis, TN, USA. ASA Meeting Oct 1999. Obstet Gynecol
1998; 86:193-99.
Combined
spinal-epidural anesthesia (CSE) can be safely used for cesarean delivery
in women with severe preeclampsia (1). The purpose of our study was to
compare maternal hemodynamic changes in preeclamptic women receiving CSE
for labor analgesia (LA) with those receiving CSE for cesarean delivery
(CS).
METHODS:
The
study was approved by the IRB. Of the 61 patients with severe preeclampsia
(SBP>160 mm Hg, DBP >110 mm Hg or proteinuria 3+ or 4+), 30 delivered vaginally
and 31 underwent CS. For labor analgesia (LA group, n=30), after hydration
with 800 ml of plain LR, CSE was given with a mixture of 1.25 mg of plain
bupivacaine (BUP) and 25 µg of fentanyl (fent) intrathecally followed
by 0.0625% BUP with 4µg fent/ml epidurally at 12-15 ml /hr. In the
CS group (n = 31), after hydration with1500 ml of LR, 7.5 mg of hyperbaric
BUP with 25 µg of fent was given intrathecally and 2% lidocaine epidurally
as needed to maintain > T4 block. Maternal SYST, DIAST, MAP and heart rate
(HR) were recorded before and after CSE in both groups. Statistical analysis
was performed using t-test, Chi-square analysis and p< 0.05 was considered
significant
RESULTS:
Baseline
MAP was similar in two groups (114 +/-14 mm Hg in LA group vs.119 +/-13
mm Hg in CS group). After CSE, MAP decreased significantly in both groups
(96 +/- 13 mm Hg in LA group vs. 100 +/-16 mm Hg in CS group p<0.01).
There were no significant differences in MAP values after CSE between groups.
In addition, the percent changes in MAP from baseline ( - 16 +/- 9% in
LA group vs. -15 +/- 13% in CS group) were similar.
CONCLUSIONS:
Our
results indicate that MAP decreases significantly in preeclamptic women
receiving CSE for CS or LA. However, despite the higher levels of sympathetic
blockade in the CS group, the severity of hypotension associated with CSE
in the CS group and LA group are quite similar [citas] |
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| 18.
Complications with 25 G and 27 G Whitacre Needles during combined-spinal
epidural analgesia in labor. Ruth Landau, MD;
Christopher F Ciliberto, MD; Stephanie R Goodman, MD; Susan HK Kim-Lo,
MD; Richard M Smiley, MD, PhD. Columbia University College of Physicians
and Surgeons, New York, NY. ASA Meeting Oct 1999. Anesth Analg 86:520-522,
1998.
INTRODUCTION:
We
have noted a high incidence of paresthesias during placement of the spinal
needle during a combined spinal-epidural (CSE) procedure. It has been reported
that needle size may influence the incidence of paresthesia and other complications
during CSE (1). We compared the occurrence of paresthesia and postdural
puncture headache (PDPH) in parturients who received a CSE for labor analgesia
with either a 25G or 27G Whitacre needle.
METHODS:
With
IRB approval, we performed a prospective observational study on the CSE
procedure with kits containing either a 4 5/11" 25G Whitacre or 4 5/11"
thin-walled "high flow" 27G Whitacre spinal needle (Becton Dickinson, Franklin
Lakes, NJ). Data from 478 consecutive women receiving labor analgesia was
gathered; in the first 199 subjects CSE was performed with the 25 G needle;
in the remaining 279 subjects the 27G needle was used. We recorded the
incidence of paresthesia upon spinal needle placement, the duration and
character of any paresthesia, and the incidence and treatment of PDPH.
Categorical data was analyzed by Chi-squared or Fisher's exact test (p<0.05).
RESULTS:
The
incidence of paresthesia was similar between the two needles (16%) (Table).
Approximately one-fourth of the paresthesias were described as "electric"
with no difference between groups. There was a higher incidence of PDPH
in the 25G group (4% v 0.7%). Three patients in the 25G group received
an epidural blood patch (EBP), versus 1 in the 27G group.
DISCUSSION:
We
confirmed the relatively high incidence (16%) of paresthesia during the
CSE procedure. Our data suggest that with Whitacre needles, 27G needles
might be preferable over 25G in reducing the rate of PDPH in parturients
but do not alter the incidence of transient paresthesia [citas] |
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| 19.
Patient selection bias contributes to an increased incidence of fetal bradycardia
after combined spinal/epidural analgesia for labor. Edward
T Riley, MD; Tracey M Vogel, MD; Yasser Y El-Sayed, MD; Paul M Meyer, MD;
Sheila E Cohen, MB, ChB. Stanford University School of Medicine, Stanford,
CA, U.S.A. ASA Meeting Oct 1999.
Labor
analgesia with the combined spinal/epidural (CSE) technique has been associated
with fetal bradycardia (FB) secondary to uterine hypertonus caused by decreased
circulating catecholamines. In contrast to our clinical observations, recent
studies have not demonstrated an increased incidence of FB with CSE vs.
epidural analgesia (e.g. Anesth Analg 1996;83:742-7). To assess the significance
of this problem in our practice, we collected a non-randomized, prospective
database on 196 laboring women requesting analgesia. They received either
an epidural (n=98) or CSE (n=98) block based on the clinical judgment of
the attending anesthesiologist. CSE was often chosen for women in severe
pain or in more advanced labor. Fetal monitoring strips were evaluated
by an obstetrician blinded to technique. FB was defined as an acute decrease
in FHR to <120 bpm lasting >2 min. Patients given the CSE technique
were in more pain and had a greater cervical dilation prior to the block.
They also had better pain relief (faster onset and less treatment for inadequate
analgesia), more uterine hypertonus, a higher incidence of FB (17% vs 5%;
P <0.05), more itching, and more hypotension compared to the epidural
group. If pain relief and decreased circulating catecholamines lead to
FB, then patients in greater pain may be more prone to have FB after analgesia,
as was found in this study. Thus, patient selection bias, rather than the
analgesic technique itself, most likely explains these results[citas] |
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| 20.
Gravity flow epidural block versus combined spina epidural (CSE) for cesarean
section. Is the addition of spinal anesthesia necessary?. S
Cohen, MD; B Hronkova, MD; M Croitoru, MD; E Burley, BS; W. Urie, BS. UMDNJ-RWJUH,
New Brunswick, NJ, USA. ASA Meeting Oct 1999. S. Cohen et al. Anesth Analg
86:5364, 1998.
INTRODUCTION:
Epidural
{1} admin. of local a. by gravity via the needle has been assoc. with a
higher success rate than injection through the catheter. To determine if
this gravity technique is assoc. with higher success rate than the CSE
technique, we studied 106 consenting parturients who received neuroaxial
(NA) block for C/S.
METHODS:
The
pt's were randomly allocated. GI (n=54) epidural solution by gravity into
the needle before insertion of the catheter. GII (n=52) spinal solution
via ESPOCAN 25g needle (B. Braun Medical Inc.) inserted through epidural
needle before insertion of the catheter. GI pt's received 3, 5, 5, 5 &
3ml (total of 21ml) of 75%
ropivacaine (R) with 5mcg/ml epinephrine (E) & 5mcg/ml fentanyl (F). GII pt's received 10mg R with 100mcg E & 25mcg F intrathecally followed by catheter insertion. RESULTS:
Values
are mean [SD]. Groups did not differ in age, height, parity, duration of
surgery, incidence of itching, sedation, nausea, hypotension or APGAR scores.
There were 11 pt's in GII & none in GI (p<0.0001) for whom NA block
was unsuccessful (due to failure to pierce the dura). Time to incision
was (41.9[9.6] & 35.6[6.9]) for GI & II respectively (p<0.0005).
More pt's in GII had vomiting (13 vs. 7, p<0.04) & catheter paresthesia
(23 vs. 12, p<0.004). 9 of 41 pt's in GII & 4 of 54 in GI the block
alone did not provide satisf. analgesia (p<0.04).
CONCLUSION:
These
data show that gravity technique via the needle has a higher success rate,
better quality of anesthesia, & fewer paresthesias than CSE technique
for C/S [citas] |
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| 21.
Dose and response of intrathecal sufentanil added to bupivacaine for labor
analgesia.Cynthia A. Wong, MD; B. M. Scavone,
MD; M. Loffredi, MD; J. N. Ganchiff, RN; W. Y. Wang, MD. Northwestern University
Medical School, Chicago, IL, USA. ASA Meeting Oct 1999.
INTRODUCTION:
Bupivacaine
added to intrathecal (IT) sufentanil for labor analgesia improves the quality
and duration of analgesia (Anesth Analg 81:305-9, 1995.) The purpose of
this study was to determine the optimal dose of IT sufentanil added to
bupivacaine 2.5 mg for CSE labor analgesia.
METHODS:
Multiparous
patients scheduled for induction of labor, with cervical dilation >3 and
5 cm, gave informed consent to participate in this IRB-approved, double-blind
study. Patients were randomly assigned to receive sufentanil 0 (G1), 2.5
(G2), 5 (G3), 7.5 (G4) or 10 ug (G5) added to bupivacaine. A blinded nurse
evaluated VAS and side-effects at 15 min intervals until the patient requested
additional analgesia. Data were analyzed by Chi square, Fisher exact, ANOVA
and Kruskal-Wallace tests. P < 0.05 was considered significant.
RESULTS:
169
patients participated. Groups were similar for age, height, weight, baseline
VAS, and duration of labor. VAS was higher for G1 at all time periods,
including the VAS at rebolus. Twelve G1, 2-G2, 3-G3, 0-G4 and 2-G5 patients
had a VAS > 20 mm at 15 min. Duration of action was significantly shorter
for G1 compared to G2-5 (39+/-25 vs 93+/-32, 93+/-47, 94+/-33, 100+/-37
min). Patients in G4-5 had more severe pruritus compared to G2-3. Significantly
fewer patients in G1-4 had nausea and vomiting compared to G5.
CONCLUSIONS:
IT
bupivacaine without sufentanil did not provide satisfactory analgesia for
multiparous patients with cervical dilation at 3-5 cm. Bupivacaine combined
with sufentanil 2.5 ug provided analgesia comparable to higher doses with
less severe pruritus, and a lower incidence of nausea and vomiting. The
optimal dose of sufentanil combined with bupivacaine for CSE is 2.5 ug
[citas] |
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| 22.
Subsequent epidural injection of lidocaine extends rostral anesthetic level
after intrathecal fentanyl but not bupivacaine with fentanyl. Dan
Choi, MD; C Qiu, MD; R Weitzner, MD; H Westbrook, MD; A Malinow, MD. U
of Maryland, Baltimore, MD, USA. ASA Meeting Oct 1999.
INTRODUCTION:
In
dosing a CSE, does epidural injection of local anesthetic produce unpredictable
results in a patient with existing spinal anesthesia?
METHODS:
59
OB patients gave written informed consent to an IRB approved protocol.
As part of their standardly performed CSE, patients were randomly assigned
to receive a stadard volume of: fentanyl (25 mcg)-(F)- mixed with one of
four doses of plain bupivacaine (B): 0 mg (FB0); 2.5 mg (FB2.5); 3.75 mg
(FB3.75) ; or, 7.5 mg (FB7.5). Resultant levels of sensory anesthesia to
pin and lower extremity motor block (mod. Bromage score 0 = none, 3=full)
were recorded for 20 min. Then, 10 ml of 1.5% lidocaine/epi (L) were epidurally
injected. Data were recorded for 20 min. more. Data were subjected to chi-square,
ANOVA and Scheffe's post hoc analysis. * p<0.05 was significant.
RESULTS:
All
sensory levels and Bromage scores were biateral and equal. Change (20 min
after spinal injection to 20 min after epidural) in elicited: Rostral (median)
level of anesthesia:FB0 (T5-T2)*;FB2.5 (T2-T2); FB3.75 (T2-T2); FB7.5 (T2.5-T2).
Bromage (median) scores: FB0(0-1)*;FB2.5(0-1)*;FB3.75(1.5-2); FB7.5(2.5-2).
CONCLUSIONS:
These
results suggest: 1) epidural L will extend intrathecal F- but not FB-induced
sensory anesthesia; 2) epidural injection with up to 10 mL L after spinal
anesthesia will not produce "high" levels or unwanted "intense" motor block;
3) any "dural puncture flux" of L is clinically insignificant [citas] |
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| 23.
The incidence of pruritus during labor analgesia with intrathecal fentanyl
and bupivacaine. The effect of decreasing fentantyl dose.Regina
Y. Fragneto, M.D.; Charles H. Moore, Ph.D.; Peter H. Pan, M.D.; Vernon
H. Ross, M.D.; Leslie Reese, M.S. Medical College of Virginia of VCU, Richmond,
VA, USA. ASA Meeting Oct 1999.
Intrathecal
(IT) fentanyl + bupivacaine (bup) provides effective pain relief for labor
but pruritus often occurs. This study was designed to determine if decreasing
the dose of IT fentanyl could decrease the incidence of pruritus while
providing satisfactory analgesia. IRB approval & written informed consent
were obtained. 45 laboring women (15/group) were randomized in a double-blind
fasion to receive IT bup 2.5 mg & fentanyl: 15 µg (Grp I); 25
µg (Gr pII); or 35 µg (Grp III). A CSE technique was performed.
Duration of IT analgesia, VAS pain & pruritus scores, duration &
onset of pruritus, & need for pruritus treatment were assessed. Parametric
data were analyzed by ANOVA & Tukey's multiple comparison test. Nonparametric
data were analyzed by chi square. P<0.05 was considered significant.
The duration of analgesia in min (Grp I 106±29, Grp II 124±59,
GrpIII 137 ± 36) & the number of patients requiring treatment
for pruritus (Grp I 1/15, Gr pII 2/15, Grp III 3/15) were similar among
groups. The number of patients experiencing no itching was significantly
less (Grp I 5/15, GrpII 5/15, GrpIII 0/15 p=0.04) & the duration of
pruritus in min was greater (Grp I 33±26, Grp II 33±28, GrpIII
68 ± 28 p=0.002) for GrpIII compared to Grps I & II. Fentanyl
35 µg is not recommended since the duration & incidence of pruritus
is greater without any improvement in duration or quality of analgesia.
The use of 15 µg fentanyl + bup might be preferable over 25 µg
since the same effect is achieved with less drug [citas] |
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| 24.
The effect of epidural clonidine added to sufentanil for labor pain management.Robert
K. Parker, D.O.; Neil Roy Connelly, M.D.; Tanuja Mainkar, M.D.; Raja R
Venkata, M.D.; Mervat El-Mansoury, M.D. Baystate Medical Center, Tufts
School of Medicine, Springfield, MA, USA. ASA Meeting Oct 1999.
INTRODUCTION:
It
has been shown that the use of epidural sufentanil(S) following a dose
of lidocaine(L) and epinephrine(E) provides similar analgesia compared
to intrathecal S, although with a lower incidence of pruritis. Clonidine(C)
has been added to intrathecal S to increase analgesic duration. We thus
undertook this
study to determine whether epidural C would alter the duration of analgesia when given with epidural S. METHODS:
IRB
approved. 40 primiparous pts, >32 weeks,<5cm cervical dilatation. Baseline
VAS obtained, lumbar epidural placed, test dose of 3ml 1.5% L with E. Patients
were given one of two injections: Group S: S 20 ug with NS 10 ml. Group
SC: S 20 ug+ C 75 ug. with NS 10 ml, VAS and side effects were recorded
5,10,15,20,30 min, and every 30 min thereafter. Demographic data-ANOVA.
Pain scores-Mann Whitney U. Significance p<0.05
RESULTS:
No
demographic difference between groups. The duration of analgesia was 153±
78 in S and 178± 55 in SC. Three patients in SC delivered comfortably
without need for a redose, whereas none in S did so. The incidence of C
section was not different (2 in S, 3 in SC).
DISCUSSION:
We
believe epidural S technique has advantages over CSE no added needle cost
and avoiding an intentional dural puncture with concomitant headache risk.
C added to epidural S does not significantly prolong the analgesic duration
for the management of labor pain [citas] |
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| 25.
Intrathecal ropivacaine 1.25 mg VS 2.5 mg for labor-analgesia. Comparison
of maternal and fetal complications. JW Chiu,
DEAA; JL Chong, MMed; TH Sia, MMed; PF White, PhD, MD; CC Loo, FRCA. KK
Women & Childrens’ Hospital, Singapore and UT Southwestern Medical
Center, Dallas, TX, USA. ASA Meeting Oct 1999.
INTRODUCTION:
Ropivacaine
may prove advantageous for labor analgesia because of its decreased propensity
for cardiotoxicity and motor block. The effects of two different doses
of intrathecal (IT) ropivacaine combined with sufentanil for labor analgesia
were compared using a combined spinal-epidural (CSE) technique.
METHODS:
Fifty
consenting primiparous parturients in early labor received either 1.25
mg (Gp R1) or 2.5 mg (Gp R2) of IT ropivacaine in combination with sufentanil
5mcg according to an IRB-approved randomized double-blind trial. The differences
in the duration and intensity of sensory blockade, incidence of maternal
hypotension, motor block and side effects, as well as patient satisfaction
were evaluated.
RESULTS:
There
was a significant increase in the incidence of hypotension (40% vs. 20%)
and shivering (40% vs 20%) in Gp R2 compared to Gp R1 [p<0.05]. Fetal
bradycardia (12% vs 0%) was also more common in Gp R2 (p<0.05). Visual
analog pain and satisfaction scores, quality and duration (115 ±
54 min vs 143 ± 40 min for Gp R1 and R2 respectively, p=NS) of analgesia,
incidence of motor block and level of sensory block were similar in both
groups. However, spontaneous delivery rates were significantly higher in
Gp R1 (48% vs. 28%, p<0.05)
CONCLUSION:
When
intrathecal ropivacaine is used with sufentanil 5 mcg for labor analgesia,
a dose of 1.25 mg is recommended to minimize side effects[citas] |
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| 26.
Labor analgesia from spinal neostigmine, sufentanil, bupivacaine and clonidine.R
D’Angelo, MD; L Dean, MD; G Meister, MD; K Nelson, MD. Wake Forest University,
Winston-Salem, NC, USA- ASA Meeting Oct 1999.
Since
spinal clonidine and spinal neostigmine each enhance analgesia from spinal
opioids and local anesthetics, this study was designed to assess the analgesic
efficacy and side effects of spinal neostigmine combined with spinal sufentanil,
bupivacaine, and clonidine. After IRB approval and informed consent, 30
nulliparous women in early labor requesting analgesia were randomized to
receive a 2.5 ml hyperbaric solution of sufentanil 10 mcg, bupivacaine
2.5 mg, and clonidine 50 mcg, with and without neostigmine 10 mcg. A CSE
technique was utilized with each patient in the lateral position. Sensory
levels to pinprick, objective and subjective motor block, VAS pain, nausea,
pruritus, sedation, oxygen saturation, and maternal hemodynamics were assessed
until more analgesia was requested. Also, duration of analgesia, ephedrine
use, and Apgar scores were recorded. Data were analyzed as indicated; P<0.05
was considered significant. Women administered neostigmine were significantly
older than women in the control group (29+/-6 vs 25+/-4 yrs); otherwise,
demographic variables were similar between groups. The duration of spinal
analgesia was similar between groups (215+/-60 [control] vs 205 ±
62 [neostigmine]). Women administered neostigmine experienced significantly
more severe nausea (53% vs 13%); otherwise, the incidence of side effects
was similar between groups. Spinal neostigmine 10 mcg produces nausea without
enhancing labor analgesia when combined with spinal sufentanil, bupivacaine,
and
clonidine [citas] |
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| 27.
Documenting Central nerve Blockade. Tong-Khee
Tan, FRCA. Royal Infirmary, Glasgow, Scotland, UK. ASA Meeting Oct 1999.
INTRODUCTION:
Central
nerve blockade (CNB) has the potential to inflict morbidity and mortality.
The litiginous climate requires anaesthetists to keep contamporaneous records.
This preliminary study surveys type / quality of information recorded by
anaesthetists performing CNB.
METHOD:
66
records of anaesthetics which involved CNB in a University Hospital were
prospectively reviewed, with anaesthetists unaware of this study. Obstetric
and Chronic Pain procedures were excluded.
RESULTS:
25.6%
were subarachnoid block(SAB), 19.8% combined spinal-epidural block(CSE),
54.6% epidurals. 45.5% of these patients had surgery under CNB alone while
54.5% had CNB with general anaesthesia. Standard information (dedicated
space on anaesthetic chart) for injection site, needle size and type, substance,
volume and concentration of injectate, epidural catheter details were recorded
in almost all charts reviewed. Additional information (AI) individual remarks
recorded by anaesthetists like recording pre-operative explanation of procedure
(39.4%), sensory level established (65%) and post-operative instructions
re-CNB(56%) was less complete though 96% of records had notes on position
of patient during block procedure and the presence/absence of flow of cerebro-spinal
fluid and blood. 74% remarked on asepsis.
CONCLUSION:
Pre-determined
spaces on standard charts help improve information recording and may improve
recording of vital information like those in AI. Further data gathering,
disseminating this study findings and redesigning the anaesthetic chart
will improve quality of information recording by anaesthetists[citas] |
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