Anesthesia and analgesia
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Anesthesia and analgesia · Jun 1999
Patients with malignant osteopetrosis are at high risk of anesthetic morbidity and mortality.
The anesthetic literature contains no focused discussion of the perioperative management and risks of children with malignant autosomal recessive osteopetrosis (osteopetrosis). We retrospectively analyzed the perioperative morbidity and mortality rates encountered in the anesthetic management of children with osteopetrosis. We compared the perioperative mortality rate for this patient population with that for other pediatric patients in our institution and that reported in the literature for children and other high-risk patients. We also investigated the inability to intubate the tracheas of children with osteopetrosis compared with other pediatric patients in our institution. Using Fisher's exact test, patients with osteopetrosis were found to have a higher likelihood of perioperative mortality compared with other children or all ASA physical status III, but not ASA physical status IV, patients (P < 0.05). Finally, we discovered that children with osteopetrosis were more likely to have tracheas that could not be intubated than other pediatric patients in our institution. We conclude that children with osteopetrosis are at risk of adverse respiratory events and mortality associated with these adverse events. ⋯ Osteopetrosis is a rare disease that increases perioperative morbidity and mortality. By performing a retrospective chart review, we found that this increased perioperative morbidity and mortality is primarily related to airway and respiratory factors. Anesthetic management strategies should consider the factors that cause the high frequency of adverse airway events in this patient population.
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Anesthesia and analgesia · Jun 1999
Randomized Controlled Trial Comparative Study Clinical TrialHemodynamic and catecholamine stress responses to insertion of the Combitube, laryngeal mask airway or tracheal intubation.
In a prospective, randomized, and controlled trial, we compared the stress responses after insertion of the Combitube (CT; Kendall-Sheridan Catheter Corp., Argyle, NY), the laryngeal mask airway (LMA), or endotracheal intubation (ET). Seventy-five patients scheduled for routine urological or gynecological surgery were randomly allocated to one of three groups and were ventilated via either an ET, a LMA, or a CT. All three devices could be inserted easily and rapidly, providing adequate ventilation and oxygenation. Insertion of the CT was associated with a significant increase in mean maximal systolic arterial pressure (160+/-32 mm Hg) and diastolic arterial pressure (91+/-17 mm Hg) compared with ET (140+/-24, 78+/-11 mm Hg; P < 0.05, P < 0.01, respectively) or insertion of the LMA (115+/-33,63+/-22 mm Hg, both P < 0.001). The mean maximal epinephrine and norepinephrine plasma concentrations after insertion of the CT (37.3+/-31.1 and 279+/-139 pg/mL, respectively) were significantly higher than those after ET (35.8+/-89.8 and 195+/-58 pg/mL, respectively) or insertion of a LMA (17.3+/-13.3 and 158+/-67 pg/mL, respectively). This might be attributed to the pressure of the pharyngeal cuff of the CT on the anterior pharyngeal wall. We conclude that insertion of the CT causes a pronounced stress response and that precautions should be taken when used in patients at risk of hypertensive bleeding. ⋯ In this study, we showed that the hemodynamic and catecholamine stress responses after insertion of the Combitube (Kendall-Sheridan Catheter Corp., Argyle, NY) were significantly higher compared with laryngeal mask airway or endotracheal intubation. We conclude that the increased stress response to insertion of a Combitube may represent a serious hazard to patients with cardiovascular disease.
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Anesthesia and analgesia · Jun 1999
The age-related effects of epidural lidocaine, with and without epinephrine, on spinal cord blood flow in anesthetized rabbits.
The effect of epidural or spinal epinephrine when added to local anesthetics on spinal cord blood flow (SCBF)are controversial. We evaluated the effects of epidural lidocaine, with or without epinephrine, on spinal cord blood flow in young and adult rabbits receiving 2% plain lidocaine, 2% lidocaine with epinephrine (1:200,000), or saline epidurally. Colored microspheres were injected through the left ventricle 10 min before and 7.5 and 30 min after epidural injection. The organs (brain, heart, kidneys, and the L6-7 segment of the spinal cord) were analyzed for regional blood flow determination. A significant decrease in mean arterial pressure was observed after the administration of lidocaine, with or without epinephrine, in both adult and young animals compared with saline. SCBF did not change over time in adult rabbits. Conversely, a significant decrease in SCBF was observed in the two groups of young rabbits receiving lidocaine. This decrease correlated with the decrease in mean arterial pressure but did not correlate with the use of epinephrine. We conclude that any reduction in blood pressure occurring in pediatric patients receiving a combined epidural-general anesthetic may result in decreased SCBF. ⋯ In young rabbits, any decrease in blood pressure was followed by a decrease in spinal cord blood flow, a decrease that did not correlate to the use of epinephrine and was not observed in adult animals. These data suggest that blood pressure should be monitored closely to promptly treat any decrease in blood pressure when combined epidural-general anesthesia is used in children.
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Anesthesia and analgesia · Jun 1999
Randomized Controlled Trial Clinical TrialEpidural phenylephrine attenuates hypotension induced by alkalinized lidocaine epidural anesthesia.
In this double-blinded, randomized study, we examined the hemodynamic effects of lumbar epidural injection of alkalinized lidocaine with phenylephrine in 81 patients undergoing inguinal herniorrhaphy. Patients assigned to four equal groups received 20 mL of alkalinized lidocaine (17 mL of 2% lidocaine + 3 mL of 7% sodium bicarbonate) with one of four doses of phenylephrine: 0 (Group 1), 50 (Group 2), 100 (Group 3), or 200 microg (Group 4) injected via a lumbar epidural catheter. Blood pressure, heart rate, and skin temperature on the foot were recorded every 5 min for 1 h after injection and were compared among groups. Hypotension was defined as mean arterial pressure < 80% of baseline. The incidence of hypotension was 45%, 55%, 35%, and 15% in Groups 1-4, respectively. Patients in Group 4 showed the smallest reduction in blood pressure compared with Groups 1 and 2 (one-sided Fisher's exact test, P < 0.05). We conclude that the 200-microg dose of epidural phenylephrine (1:100,000 concentration) reduced the incidence of hypotension after epidural anesthesia with alkalinized lidocaine. ⋯ Hypotension after epidural anesthesia is common in general clinical practice. Phenylephrine administered epidurally in combination with alkalinized lidocaine may reduce the incidence of hypotension.
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Anesthesia and analgesia · Jun 1999
Clinical TrialDoes the Murphy eye reduce the reliability of chest auscultation in detecting endobronchial intubation?
Bilateral breath sounds are routinely auscultated after endotracheal intubation to verify that the endotracheal tube (ETT) tip is properly positioned. We conducted the present study to ascertain whether the eye of the Murphy tube has an influence on the reliability of auscultation of breath sounds in detecting endobronchial intubation. Twenty patients undergoing scheduled oral and maxillofacial surgery participated in this study. After the induction of general anesthesia, either the Magill tube or the Murphy tube was inserted through the nose into the trachea. The fiberoptic bronchoscope was inserted through the ETT, and the distance from the nares to the carina of the trachea was measured. When breath sounds from the left side of the chest changed and disappeared while the ETT was being advanced, the distance from the nares to the ETT tip was measured. Unilateral auscultatory change was not observed until the ETT tip was advanced beyond the carina and inserted 1.5+/-0.4 cm into the right mainstem bronchus when the Magill tube was used and 2.0+/-0.4 cm when the Murphy tube was used (P < 0.01). Breath sounds disappeared when the ETT tip was further advanced up to 3.2+/-0.3 cm from the carina. We demonstrated that the eye of the Murphy tube reduces the reliability of chest auscultation in detecting endobronchial intubation. ⋯ The Murphy eye was designed to allow ventilation of the lung when the bevel of the endotracheal tube is occluded. We demonstrated that the eye of the Murphy tube reduces the reliability of chest auscultation in detecting endobronchial intubation.