Anesthesia and analgesia
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Anesthesia and analgesia · Jul 2001
Randomized Controlled Trial Clinical TrialThe dose-response relationship for clonidine added to a postoperative continuous epidural infusion of ropivacaine in children.
Epidurally administered clonidine enhances the quality and duration of postoperative analgesia when it is used as an adjunct to local anesthetics in children. We investigated the dose-response relationship for epidural clonidine when added to a continuous postoperative epidural infusion of ropivacaine. By use of an observer-blinded design, 55 pediatric patients (1-4 yr old) were randomly given a postoperative epidural infusion of plain ropivacaine 0.1% 0.2 mg. kg(-1). h(-1) (Group R), ropivacaine 0.08% 0.16 mg. kg(-1). h(-1) plus clonidine 0.04 microg. kg(-1). h(-1) (Group RC1), ropivacaine 0.08% 0.16 mg. kg(-1). h(-1) plus clonidine 0.08 microg. kg(-1). h(-1) (Group RC2), or ropivacaine 0.08% 0.16 mg. kg(-1). h(-1) plus clonidine 0.12 microg. kg(-1). h(-1) (Group RC3). A clear dose-response relationship could be identified for a continuous infusion of epidural clonidine, with clonidine dosages in the 0.08-0.12 microg. kg(-1). h(-1) range providing improved postoperative analgesia (reduced Children's Hospital of Eastern Ontario pain score, increased time to first supplemental analgesic demand, and a reduced total number of doses of supplemental analgesics during the first 48 h after surgery). Analgesia was improved without any signs of increased sedation or other side effects. The adjunct use of epidural clonidine in the dosage range of 0.08-0.12 microg. kg(-1). h(-1) appears effective and safe for use in children. ⋯ The addition of clonidine (0.08-0.12 microg.kg(-1).h(-1))to a continuous epidural infusion of ropivacaine was found to improve postoperative pain relief in children. No clinically significant signs of sedation or other side effects were observed.
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Anesthesia and analgesia · Jul 2001
Clinical TrialCardiopulmonary resuscitation performed by bystanders does not increase adverse effects as assessed by chest radiography.
Important adverse effects of bystander cardiopulmonary resuscitation (CPR) are well known. We describe the number of nonmedical professional CPR-related complications in patients surviving cardiac arrest, as assessed by chest radiograph. Within 2 yr, all consecutive patients admitted to the department of emergency medicine at a university hospital who had a witnessed, nontraumatic, normothermic cardiac arrest were studied. Radiologically evaluated adverse effects were compared with Mann-Whitney U-tests between patients who received bystander basic life support (Bystander group) and patients who did not receive bystander basic life support before advanced life support was started (ALS group). For assessment of bystander CPR-associated complications, chest radiographs were used. Of 224 patients, 173 were eligible. The median age was 58 yr (interquartile range, 51-71 yr), and 126 patients (73%) were men. The incidence of adverse effects associated with assisted-ventilation maneuvers and external chest compressions did not differ significantly between groups (severe gastric insufflation, 17% vs 18% between the Bystander group [n = 59] and the ALS group [n = 96], respectively; suspicion of aspiration, 22% vs 17%, respectively; soft tissue emphysema, 2% vs 1%, respectively; and serial rib fractures, 8% vs 8%, respectively). CPR administered by nonmedical personnel did not increase the number of life support-related adverse effects in patients surviving cardiac arrest as assessed by means of chest radiograph on admission. ⋯ Complications related to cardiopulmonary bypass (CPR) are not increased when CPR is administered by nonmedical personnel, as assessed by chest radiograph. These data may be valuable in motivating lay people to perform basic life support.
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Anesthesia and analgesia · Jul 2001
The accuracy of coagulation tests during spinal fusion and instrumentation.
Patients undergoing major spine surgery may acquire a perioperative coagulopathy from dilution of coagulation factors and/or platelets or fibrinolysis. The mechanisms of the coagulopathy and role of coagulation testing during these procedures are poorly defined. Theoretically, coagulation tests could be used perioperatively to determine which patients are at risk for significant bleeding and guide transfusion therapy. We retrospectively evaluated the sensitivity, specificity, and accuracy of coagulation tests in predicting excessive surgical bleeding in 244 consecutive patients undergoing thoracic, lumbar, or sacral spinal fusion with or without instrumentation. Excessive bleeding was reported by the surgeon in 39 of the patients and was defined as recurrent microvascular bleeding despite adequate use of electrocautery and suture or decreased clot formation of blood pooled within the surgical field. Patients with excessive clinical bleeding sustained larger estimated blood losses than those with normal hemostasis. The total number of allogeneic red blood cells, platelets, and fresh frozen plasma units were also larger in patients with excessive bleeding noted during surgery. The intraoperative coagulation tests with the most sensitivity and specificity were the international normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (aPTT). The INR had a sensitivity of 94%, a specificity of 88%, and an accuracy of 0.9 at a value of 1.4 (normal, 0.8-1.2). The PT had a sensitivity of 90%, a specificity of 64%, and an accuracy of 0.73 at a value of 13.5 s (normal, 8.4-12.0 s). The aPTT had a sensitivity of 85%, a specificity of 64%, and an accuracy of 0.71 at a value of 30.9 s (normal, 23-37 s). The thromboelastogram values were of marginal use. We conclude that the INR, PT, and aPTT may be helpful in guiding transfusion therapy in patients undergoing major spine surgery. ⋯ Patients undergoing major surgery to the spine often acquire a perioperative coagulopathy. The prothrombin time and activated partial thromboplastin time had the greatest sensitivity and specificity for predicting bleeding in major surgery of the spine. The test values that differentiated normal from excessively bleeding patients could be used to guide transfusion therapy during surgery.