Anesthesia and analgesia
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Anesthesia and analgesia · Mar 2004
Randomized Controlled Trial Clinical TrialThe effects of different ventilatory settings on pulmonary and systemic inflammatory responses during major surgery.
Mechanical ventilation with high tidal volumes (V(T)) and zero or low positive end-expiratory pressure increased mediator release to inflammatory stimuli or acute lung injury. We studied whether mechanical ventilation modifies the inflammatory responses during major thoracic or abdominal surgery. Sixty-four patients undergoing elective thoracotomy (n = 34) or laparotomy (n = 30) were randomized to receive either mechanical ventilation with V(T) = 12 or 15 mL/kg ideal body weight, respectively, and zero end-expiratory pressure, or V(T) = 6 mL/kg ideal body weight with positive end-expiratory pressure of 10 cm H(2)O. In 62 patients who completed the study, arterial oxygenation was not different between groups. Tumor necrosis factor, interleukin (IL)-1, IL-6, IL-8, IL-10, and IL-12 were determined by cytometric bead array in plasma after 0, 1, 2, and 3 h and in tracheal aspirates after 3 h of mechanical ventilation. Data were log-transformed and analyzed using parametric or nonparametric tests, as indicated. All plasma mediators increased more during abdominal than during thoracic surgery, although the differences were small. However, neither time course nor concentrations of pulmonary or systemic mediators differed between the two ventilatory settings. Our data suggest that the ventilatory settings we studied do not affect inflammatory reactions during major surgery within 3 h. ⋯ In 62 patients undergoing elective major thoracic or abdominal surgery, mechanical ventilation with low tidal volumes and positive end-expiratory pressure or high tidal volumes and zero end-expiratory pressure did not result in different pulmonary or systemic levels of measured inflammatory markers.
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Anesthesia and analgesia · Mar 2004
Randomized Controlled Trial Clinical TrialThe influence of ambulation time on the incidence of transient neurologic symptoms after lidocaine spinal anesthesia.
The cause of transient neurologic symptoms (TNSs) after lidocaine spinal anesthesia remains unclear. It has been proposed that early ambulation after spinal anesthesia contributes to the development of TNSs. We evaluated the influence of ambulation time on the occurrence of TNSs after spinal anesthesia with 50 mg of 2% plain lidocaine for knee arthroscopy. One-hundred-twenty patients undergoing knee arthroscopy (ASA physical status 1-2) were randomized into 3 groups, i.e., early (Group E), 6-h (Group 6-h), or late ambulation (Group L) groups. In Group E, ambulation was allowed as early as possible after regression of spinal block (on average 229 +/- 21 min; range, 135-247 min). In Group 6-h, the patients remained in bed for approximately 6 h after the block and in Group L until the next morning. The patient groups were comparable with respect to demographic, anesthetic, and surgical variables. The overall incidence of TNSs was 16%. TNSs occurred in 3 patients of Group E (7.5%), in 11 patients of Group 6-h (28%), and in 5 patients of Group L (13%). No significant differences were detected between the patients with and without TNSs. Early ambulation was not found to be a risk factor for TNSs after spinal anesthesia with 50 mg of 2% lidocaine. ⋯ This study shows that early ambulation time does not increase the incidence of transient neurologic symptoms after spinal anesthesia with 50 mg of 2% lidocaine for elective knee arthroscopy.
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Anesthesia and analgesia · Mar 2004
Clinical TrialAssessing residual neuromuscular blockade using acceleromyography can be deceptive in postoperative awake patients.
Postoperative awake patients may have significant residual neuromuscular block. In awake patients, the results of accelerometry are affected by extra movements to which the thumb may be subject. In this study, we evaluated the repeatability of train-of-four (TOF) ratio using acceleromyography in 253 patients recovering from anesthesia. Immediately after arrival in the postanesthesia care unit, the ulnar nerve was stimulated with TOF stimulation. The evoked response at the thumb was measured by the TOF-Watch apparatus. The current intensity was 30 mA. Two TOF stimulations were applied and recorded at 30-s intervals. A Bland-Altman test was used. The Kappa (kappa) test for clinical agreement between the two measurements was also calculated according to the presence or absence of a residual neuromuscular blockade, defined as a TOF ratio <0.9. According to the presence of a residual neuromuscular blockade, the paired TOF ratios were discordant in 61 patients (24%; 95% confidence interval, 21%-27%). The kappa test indicated a moderate agreement (k = 0.47). We demonstrated that accelerometry as used in this study is not always accurate. Two isolated acceleromyograph TOF ratios are not an accurate representation of the neuromuscular status of the patient recovering from anesthesia. ⋯ Clinicians should be aware that acceleromyography as used in this study does not always provide precise train-of-four ratio measurements. Two isolated acceleromyograph train-of-four ratios are not an accurate representation of the neuromuscular status of the patient recovering from anesthesia.
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Anesthesia and analgesia · Mar 2004
Cost drivers in patient-controlled epidural analgesia for postoperative pain management after major surgery.
In this retrospective study, we determined efficiency, treatment length, and resource use for postoperative pain management with patient-controlled epidural analgesia (PCEA) in 350 consecutive patients undergoing major abdominal, thoracic, gynecological, or orthopedic surgery. Average pain scores on a visual analog scale were 16 +/- 23 and 9 +/- 16 (visual analog scale range, 0 to 100) on postoperative Days 1 and 3, respectively, and were similar among groups. The treatment length was 4.9 +/- 2.2 days in general surgical, 5.2 +/- 3.1 days in gynecological, and 4.5 +/- 2.8 days in orthopedic patients. The total volumes of the mixture of local anesthetic and opioid received epidurally were 707 +/- 507 mL, 770 +/- 576 mL, and 593 +/- 456 mL in the general surgical, gynecological, and orthopedic groups, respectively. The average total costs for all groups for the full treatment course with PCEA were 447 +/- 218 per case (1 equals approximately US dollar 1). Fifty-one percent of these costs were staff costs, 20% were costs for the applied drugs, 15% were costs for PCEA pumps and pump material, and 13% were costs for the initial catheter insertion. In the light of these costs and the availability of less costly alternatives, measurements for cost containment by using PCEA are recommended. Because treatment length is the main cost driver both for drug and staff costs, close monitoring of treatment length and a predefined migration path to alternative techniques after PCEA should be considered. ⋯ Patient-controlled epidural analgesia is increasingly used as first-line treatment for postoperative pain management. In this study, costs and cost drivers are analyzed for the first time for this new technique, based on 350 cases of pain therapy after major surgery in a university hospital.
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Anesthesia and analgesia · Mar 2004
Clinical TrialContinuous psoas compartment blocks after major orthopedic surgery in children: a prospective computed tomographic scan and clinical studies.
Femoral shaft or hip surgeries are very painful for children. We conducted both computed tomographic (CT) and clinical prospective studies to define new landmarks in children and to evaluate the effectiveness of continuous psoas compartment blocks (CPCBs) using disposable elastomeric pumps. In a preliminary CT scan study of 20 patients, the plexus depth was correlated to patient age and the optimal point of puncture for CPCB was three-quarters of the distance from the spinous process of L4 to a line parallel to the spinal column passing through the posterior superior iliac spine. In a subsequent prospective series, a CPCB was administered before surgery to 15 children for pain relief after femoral and hip osteotomies. After general anesthesia, a 0.5 mL/kg bolus of a mixture of 1% lidocaine with epinephrine (1/200.000) and 0.5% ropivacaine was injected through the CPCB catheter. After contrast media assessment of the catheter location, a disposable pump (Infusor LV); Baxter, Paris, France) with 0.2% ropivacaine was connected and pump flow was adjusted to the patient's weight (0.2 mg x kg(-1) x h(-1)). Postoperative pain was evaluated using a visual analog scale or the Children and Infants Postoperative Pain Score at hour H1, H6, H12, H18, H24, H36, and H48, and in terms of rescue analgesia, adverse events, and motor blocks. All blocks were effective during surgery. Postoperative analgesia was excellent. The median pain scores were 1 for H1 and 0 beginning H6. The motor blockade was minimal before 24 h and absent thereafter. No major adverse event was noted. Parents of 93% of the children were satisfied. We conclude that postoperative analgesia with CPCB is a very effective technique in children after major proximal lower limb orthopedic surgery. The CT scan landmarks described in this study were more medial than the conventional landmarks used in the literature. ⋯ Continuous psoas compartment blocks provide optimal pain relief in children after major orthopedic surgery without major adverse events. The landmarks used, defined in a preliminary computed tomographic scan study, were more medial than conventional landmarks.