Anesthesia and analgesia
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Anesthesia and analgesia · Mar 2004
Randomized Controlled Trial Comparative Study Clinical TrialDextromethorphan-associated epidural patient-controlled analgesia provides better pain- and analgesics-sparing effects than dextromethorphan-associated intravenous patient-controlled analgesia after bone-malignancy resection: a randomized, placebo-controlled, double-blinded study.
Pain after bone malignancy surgery is intense and requires large amounts of analgesics. The augmented antinociceptive effects of dextromethorphan (DM), a N-methyl-D-aspartate receptor antagonist, were demonstrated previously. We assessed the use of postoperative patient-controlled epidural analgesia (PCEA) or IV patient-controlled analgesia (PCA) in patients undergoing surgery for bone malignancy under standardized combined general and epidural anesthesia with or without DM. Patients (n = 120) were randomly allocated to receive PCEA (ropivacaine 3.2 mg plus fentanyl 8 microg/dose) or IV-PCA (morphine 2 mg/dose) postoperatively, starting at subjective visual analog scale pain intensity >or=4 of 10 for up to 96 h. Placebo or DM 90 mg orally (30 patients/group/set) was given in a double-blinded manner before surgery and for 2 days afterwards. Diclofenac 75 mg IM was available as a rescue drug. DM patients used PCA and rated their pain >50% less than their placebo counterparts in each set, especially during the first 2 postoperative days (P < 0.01). Hourly and overall maximal pain intensity among PCEA patients was approximately 50% less than in the IV-PCA set (P < 0.01). Diclofenac was used 42% less (P < 0.01) by the PCA-DM patients compared with their placebo counterparts. Seven PCEA-DM and 11 IV-PCA-DM individuals reported having side effects compared with 44 in the PCEA-placebo and the IV-PCA-placebo groups (P < 0.01). Time to first ambulation was similar with both analgesia techniques but shorter among the DM-treated patients compared with the placebo recipients (1.5 +/- 0.8 versus 2.1 +/- 1.1 days, P = 0.02). Thus, DM afforded better pain control and reduced the demand for analgesics, augmented the PCEA effect versus IV-PCA, and was associated with minimal untoward effects in each analgesia set. DM patients ambulated earlier than placebo recipients. ⋯ Patients undergoing bone-malignancy surgery under combined general and epidural anesthesia received randomly patient-controlled epidural analgesia (PCEA) or IV patient-controlled analgesia (PCA) postoperatively and dextromethorphan (DM) 90 mg or placebo double-blindly for 3 days (n = 30/group/set). The DM effect was recorded with minimal untoward effects: it afforded better pain control and reduced the demand for analgesics compared with the placebo, especially when associated with PCEA. DM patients ambulated earlier than placebo recipients.
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Anesthesia and analgesia · Mar 2004
Randomized Controlled Trial Clinical TrialAdding dexmedetomidine to lidocaine for intravenous regional anesthesia.
Dexmedetomidine is approximately 8 times more selective toward the alpha-2-adrenoceptors than clonidine. It decreases anesthetic requirements by up to 90% and induces analgesia in patients. We designed this study to evaluate the effect of dexmedetomidine when added to lidocaine in IV regional anesthesia (IVRA). We investigated onset and duration of sensory and motor blocks, the quality of the anesthesia, intraoperative-postoperative hemodynamic variables, and intraoperative-postoperative pain and sedation. Thirty patients undergoing hand surgery were randomly assigned to 2 groups to receive IVRA. They received 40 mL of 0.5% lidocaine and either 1 mL of isotonic saline (group L, n = 15) or 0.5 microg/kg dexmedetomidine (group LD, n = 15). Sensory and motor block onset and recovery times and anesthesia quality were noted. Before and after the tourniquet application at 5, 10, 15, 20, and 40 min, hemodynamic variables, tourniquet pain and sedation, and analgesic use were recorded. After the tourniquet deflation, at 30 min, and 2, 4, 6, 12, and 24 h, hemodynamic variables, pain and sedation values, time to first analgesic requirement, analgesic use, and side effects were noted. Shortened sensory and motor block onset times, prolonged sensory and motor block recovery times, prolonged tolerance for the tourniquet, and improved quality of anesthesia were found in group LD. Visual analog scale scores were significantly less in group LD in the intraoperative period and 30 min, and 2, 4, and 6 h after tourniquet release. Intra-postoperative analgesic requirements were significantly less in group LD. Time to first analgesic requirements was significantly longer in group LD in the postoperative period. We conclude that the addition of 0.5 microg/kg dexmedetomidine to lidocaine for IVRA improves quality of anesthesia and perioperative analgesia without causing side effects. ⋯ This study was designed to evaluate the effect of dexmedetomidine when added to lidocaine for IV regional anesthesia. This is the first clinical study demonstrating that the addition of 0.5 microg/kg dexmedetomidine to lidocaine for IV regional anesthesia improves quality of anesthesia and intraoperative-postoperative analgesia without causing side effects.
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Anesthesia and analgesia · Mar 2004
Randomized Controlled Trial Comparative Study Clinical TrialThe pharmacodynamic effects of a lower-lipid emulsion of propofol: a comparison with the standard propofol emulsion.
Using a randomized, double-blind protocol design, we compared a new lower-lipid emulsion of propofol (Ampofol) containing propofol 1%, soybean oil 5%, and egg lecithin 0.6% with the most commonly used formulation of propofol (Diprivan) with respect to onset of action and recovery profiles, as well as intraoperative efficacy, when administered for induction and maintenance of general anesthesia as part of a "balanced" anesthetic technique in 63 healthy outpatients. Anesthesia was induced with sufentanil 0.1 microg/kg (or fentanyl 1 microg/kg) and propofol 2 mg/kg IV and maintained with a variable-rate propofol infusion, 120-200 microg x kg(-1) x min(-1). Onset times to loss of the eyelash reflex and dropping a syringe were recorded. Severity of pain on injection, speed of induction, intraoperative hemodynamic variables, and electroencephalographic bispectral index values were assessed. Recovery times to opening eyes and orientation were noted. The results demonstrated that there were no significant differences between Ampofol and Diprivan with respect to onset times, speed of induction, anesthetic dose requirements, bispectral index values, hemodynamic variables, recovery variables, or patient satisfaction. However, the incidence of pain on injection was more frequent in the Ampofol group (26% versus 6%, P < 0.05). We conclude that Ampofol is equipotent to Diprivan with respect to its anesthetic properties but was associated with a more frequent incidence of mild pain on injection. ⋯ The pharmacodynamic profile of a lower-lipid containing emulsion of propofol (Ampofol) was compared with Diprivan when administered for induction and maintenance of general anesthesia. This preliminary study demonstrated that the two formulations of propofol were equivalent with respect to their induction and maintenance properties. However, Ampofol was associated with a more frequent incidence of pain on injection.
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Anesthesia and analgesia · Mar 2004
Randomized Controlled Trial Comparative Study Clinical TrialCombined spinal-epidural anesthesia using epidural volume extension leads to faster motor recovery after elective cesarean delivery: a prospective, randomized, double-blind study.
Epidural volume extension (EVE) via a combined spinal-epidural (CSE) technique is the enhancement of a small-dose intrathecal block by epidural saline boluses. In this prospective, randomized, double-blind study, we compared the EVE technique with single-shot spinal anesthesia with respect to its sensory and motor block profile and hemodynamic stability. Sixty-two parturients (n = 31 in each group) undergoing elective cesarean deliveries were administered either spinal anesthesia with hyperbaric 0.5% bupivacaine 9 mg and fentanyl 10 microg or CSE comprising intrathecal hyperbaric 0.5% bupivacaine 5 mg with fentanyl 10 microg, followed by 0.9% saline 6.0 mL through the epidural catheter 5 min thereafter. In each group, the lowest systolic blood pressure (SBP), sensory block level to loss of pain from pinprick, and modified Bromage scores were recorded at 2.5-min intervals. The visual analog pain score (VAS), peak sensory block height, highest modified Bromage motor score, time for sensory regression to the tenth thoracic dermatome (T10), and motor block recovery were compared between groups. Both groups were comparable in demographic data, VAS scores, peak sensory block height, time for sensory regression to T10, and lowest SBP recorded. Patients in the EVE group demonstrated significantly faster motor recovery to modified Bromage 0 (73 +/- 33 min versus 136 +/- 32 min, P < 0.05). ⋯ When compared with conventional, single-shot spinal anesthesia, epidural volume extension of a small-dose spinal block provides satisfactory anesthesia for cesarean delivery with only 55% of the bupivacaine dose required and is associated with faster motor recovery of the lower limbs.
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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.