Anesthesia and analgesia
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Anesthesia and analgesia · Apr 2004
Randomized Controlled Trial Clinical TrialIntrathecal sufentanil and fetal heart rate abnormalities: a double-blind, double placebo-controlled trial comparing two forms of combined spinal epidural analgesia with epidural analgesia in labor.
Combined spinal epidural analgesia (CSE) for labor pain relief has become increasingly popular. However, the effect of intrathecal sufentanil on the incidence of uterine hyperactivity and fetal heart rate (FHR) abnormalities remains controversial. We hypothesized that the use of intrathecal sufentanil in a dose of 7.5 microg is more likely to induce a nonreassuring FHR tracing than a small dose of spinal sufentanil combined with bupivacaine or epidural analgesia. Three-hundred parturients were randomized into three groups. In the first group, epidural analgesia was initiated with 12.5 mg of bupivacaine, 12.5 microg of epinephrine, and 7.5 microg of sufentanil in a volume of 10 mL (EPD group). In Group 2, initial intrathecal analgesia consisted of 2.5 mg of bupivacaine, 2.5 microg of epinephrine, and 1.5 microg of sufentanil (BSE group); in Group 3, spinal analgesia consisted of 7.5 microg of sufentanil (SUF group). Analgesia was maintained in all groups with patient-controlled epidural analgesia using bupivacaine 0.125%, 1.25 microg/mL of epinephrine, and 0.75 microg/mL of sufentanil (bolus, 4 mL; lockout, 15 min). Cardiotocography was monitored continuously 15 min before analgesia and for 60 min after the start of analgesia. The quality of analgesia, labor, and neonatal outcome and side effects were recorded. Twenty-four percent of patients in the SUF group developed FHR abnormalities (bradycardia or late decelerations) during the first hour after initiation of analgesia compared with 12% in the BSE group and 11% in the EPD group. Uterine hyperactivity occurred in 12% of parturients in the SUF group but in only 2% in the other groups. Onset of analgesia was more rapid in both CSE groups as compared with the EPD group. However, 29% of patients in the BSE group developed severe hypotension, requiring IV ephedrine (29% in the BSE group versus 7% and 12% in the EPD and SUF groups, respectively). All these differences reached statistical significance. The present data corroborate previous recommendations of caution when performing CSE using a large dose (7.5 microg or more) of spinal sufentanil because of the risk of uterine hyperactivity and FHR abnormalities. ⋯ Combined spinal epidural analgesia (CSE) produces pain relief during labor. Fetal heart rate changes after CSE using intrathecal sufentanil have been reported. We performed a randomized, blinded trial confirming that fetal heart rate changes are more frequent after CSE using 7.5 micro g of intrathecal sufentanil as compared with other forms of neuraxial labor analgesia.
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Anesthesia and analgesia · Apr 2004
Randomized Controlled Trial Clinical TrialThe efficacy of continuous fascia iliaca compartment block for pain management in burn patients undergoing skin grafting procedures.
Postoperative pain from split skin donor sites is often more intense than the pain at the grafted site. In this prospective, randomized, double-blind study we assessed the efficacy of a continuous fascia iliaca compartment block (FICB) in reducing the pain at the thigh donor site. Twenty patients, with a total burn surface area of 16% +/- 13% (mean +/- SD) were randomized 1:1 to receive either ropivacaine 0.2% or saline 0.9%. All patients received a general anesthesic followed by preincision continuous FICB with 40 mL of the randomized solution, then an infusion of 10 mL/h of either ropivacaine or saline until the first dressing change (72 h later). Postoperative analgesia consisted of propacetamol 2g/6h, IV patient-controlled analgesia of morphine chlorhydrate (2 mg/mL), and morphine hydrochlorate 0.5 mg/kg PO once 60 min before first dressing change. The visual analog scale (VAS) scores were compared using the Mann-Whitney U-test preoperatively, 24 and 48 h postoperatively, and during the first dressing change. The cumulative morphine consumption was compared with repeated-measures analysis of variance followed by Scheffé's method if indicated. Patients with continuous FICB had significantly reduced postoperative morphine consumption at all time points (23 +/- 20 versus 88 +/- 29 mg after 72 h, study versus control groups, respectively; P < 0.05). In both groups, VAS scores remained low but were only significantly lower for patients with continuous FICB during the first dressing change (3 [1] versus 7 [3]; median [interquartile range]; P < 0.05). We conclude that continuous FICB is an efficient method for diminishing pain at the thigh donor site. (250 words) ⋯ Postoperative pain at the split skin donor sites is often more intense than the pain at the grafted site. This prospective, randomized, double-blind study assessed the efficacy of a continuous fascia iliaca compartment block in reducing the pain at the thigh donor site.
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Anesthesia and analgesia · Apr 2004
Randomized Controlled Trial Clinical TrialPreoperative ketamine improves postoperative analgesia after gynecologic laparoscopic surgery.
In this study, we evaluated the preemptive effect of a small dose of ketamine on postoperative wound pain. In a randomized, double-blinded, controlled trial, we compared the analgesic requirement in patients receiving preincision ketamine with ketamine after skin closure or placebo after gynecologic laparoscopic surgery. One-hundred-thirty-five patients were randomly assigned to receive preincision or postoperative ketamine 0.15 mg/kg or saline IV. Anesthetic technique was standardized. Patients were interviewed regularly up to 4 wk after surgery. Pain score, morphine consumption, side effects, and quality of recovery score were recorded. Patients receiving preincision ketamine had a lower pain score in the first 6 h after operation compared with the postoperative (P = 0.001) or placebo groups (P < 0.001). The mean (95% confidence intervals) time to first request for analgesia in the preincision group, 1.8 h (1.4-2.1), was longer than the postoperative group, 1.2 h (0.9-1.5; P < 0.001), or the placebo group, 0.7 h (0.4-0.9; P < 0.001). The mean +/- SD morphine consumption in the preincision group, 1.5 +/- 2.0 mg, was less than that in the postoperative group, 2.9 +/- 3.1 mg (P = 0.04) and the placebo group, 3.4 +/- 2.7 mg (P = 0.003). There was no significant difference among groups with respect to hemodynamic variables or side effects. No patient complained of hallucinations or nightmares. We conclude that a small dose of ketamine is not only safe, but it also provides preemptive analgesia in patients undergoing gynecologic laparoscopic surgery. ⋯ In women undergoing laparoscopic gynecologic surgery, a small preoperative dose of ketamine (0.15 mg/kg) produced preemptive analgesia. There were no significant hemodynamic and psychological side effects with this dose.
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Anesthesia and analgesia · Apr 2004
Randomized Controlled Trial Comparative Study Clinical TrialAnalgesic effects of intraarticular sufentanil and sufentanil plus methylprednisolone after arthroscopic knee surgery.
We studied the effect of intraarticular saline, sufentanil, or sufentanil plus methylprednisolone after knee arthroscopic meniscectomy. In a double-blind randomized study, 60 patients undergoing knee arthroscopic meniscectomy were allocated to groups receiving intraarticular saline, intraarticular sufentanil 10 microg, or sufentanil 10 microg plus methylprednisolone 40 mg at the end of arthroscopy during general anesthesia. Postoperatively, pain levels at rest and during movement (i.e., active flexion of the knee) were measured by a visual analog scale and were significantly decreased in the sufentanil and sufentanil plus methylprednisolone groups compared with the control group. Moreover, we found that there was a significant reduction in intraarticular sufentanil and sufentanil plus methylprednisolone in the postoperative consumption of analgesics. We also found that the use of intraarticular sufentanil or sufentanil plus methylprednisolone after knee arthroscopic meniscectomy decreases the amount of supplementary analgesic needed for pain relief during the early postoperative period. In addition, we detected that sufentanil provided prolonged pain relief up to 24 h when compared with control, whereas when we combined sufentanil plus methylprednisolone, we found that it further reduced pain and use of analgesics when compared with sufentanil. ⋯ The combined use of intraarticular sufentanil (10 microg) and methylprednisolone (40 mg) in arthroscopic meniscectomy surgery reduced both postoperative pain scores and the use of additional analgesics.
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Anesthesia and analgesia · Apr 2004
Randomized Controlled Trial Clinical TrialInotropes improve right heart function in patients undergoing aortic valve replacement for aortic stenosis.
The administration of inotropes after aortic valve replacement (AVR) for aortic stenosis (AS) is controversial. Issues include the risk of left ventricular (LV) systolic outflow obstruction (LVOTO) and the proper treatment of diastolic dysfunction for patients in whom LV systolic function is often preserved and subsequently improved. In this study, we assessed the hemodynamic benefits of inotropes for patients undergoing AVR for AS. Thirty-four patients were prospectively randomized to one of three groups: epinephrine, milrinone, or placebo. Hemodynamic and echocardiographic data were obtained before and immediately after cardiopulmonary bypass (CPB). Data were also obtained before and after increases in ventricular preload to assess the effects of inotropes on diastolic function. The use of inotropes was associated with significantly larger increases in right ventricular (RV) (placebo, 0.5%; epinephrine, +9%; milrinone, +8%; P < 0.01) and LV (placebo, +7%; epinephrine, +18%; milrinone, +20%; P = 0.07) ejection fractions (EF) and cardiac output after CPB. Changes in cardiac output and index were more strongly correlated with changes in RVEF (r = 0.56, P < 0.01; r = 0.47, P < 0.01, respectively) than with LVEF (r = 0.22, r = 0.08). Of all patients receiving epinephrine or milrinone, only one (1 of 22) had a decrease in RVEF, whereas 6 of 12 patients receiving placebo had a reduction in RVEF from pre-CPB to post-CPB. Correspondingly, for LVEF, 1 of 22 patients receiving inotropes had a decrease in LVEF, whereas 3 of 12 placebo patients had a reduction in LVEF from pre-CPB to post-CPB. No patient had evidence of LVOTO. Inotropes improved hemodynamics after AVR for AS. This was attributable more to improved RV function than to changes in LV function. Although there were no changes in diastolic function, it is possible that this study did not allow significant timing to observe benefits of inotropes on diastolic function in this setting. ⋯ Compared with placebo, both epinephrine and milrinone similarly improved biventricular performance after aortic valve replacement, with a greater impact on right ventricular function. Choice of either inotropic drug should be driven by blood pressure and hemodynamic goals in this setting.