Anesthesia and analgesia
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Anesthesia and analgesia · Jun 2004
Multiple casualty terror events: the anesthesiologist's perspective.
In a 28-mo period 14 multiple-casualty terror events occurred in Jerusalem, challenging the Department of Anesthesiology and Critical Care Medicine of the city's sole Level 1 trauma center. We performed a retrospective review of the response of the department to evaluate staff activities, resource use (emergency department, operating rooms, and intensive care unit [ICU]), and patient flow. A total of 1062 people were injured in the 14 multi-casualty terror incidents. The emergency department treated 355 victims; 108 of them were hospitalized, and 58 underwent surgery during the first 8 h. Only two surgeries were performed during the first hour, and the average time to the first surgery was 124 min. Fifty-one patients were admitted to the ICU an average of 5.5 h after the terror event. After a terrorist act, multiple, simultaneous efforts were required of the anesthesiology department, including taking part in the initial resuscitation in the emergency department, anesthetizing victims for surgery and angiographies, and caring for them in the recovery room and ICU. Therefore, anesthesiology departments are greatly impacted by such events and must plan for them to maximize the use of available personnel and to have the appropriate equipment and supplies available. ⋯ Anesthesiologists provide essential care to patients injured in terror events, from the initial resuscitation through therapeutic/diagnostic procedures and surgeries. Operational issues faced by a department of anesthesiology during the initial 8 h after terrorist actions were examined. Multiple, and often parallel, efforts were required of the department.
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Anesthesia and analgesia · Jun 2004
Case ReportsThe use of dexmedetomidine to facilitate opioid and benzodiazepine detoxification in an infant.
Prolonged use of opioids and benzodiazepines for the care of critically ill infants and children can generate physical dependence. We present a case of an 8-mo-old infant with Hunter's syndrome who was maintained on very large doses of fentanyl and midazolam and who could not be weaned from these drugs by conventional taper. We used dexmedetomidine, an alpha(2)-adrenergic agonist, to facilitate opioid and benzodiazepine withdrawal. A processed electroencephalogram (Bispectral Index) was used to guide the titration of dexmedetomidine in this neurologically impaired infant. This is the first report of this drug being used in an infant to manage chemical dependence withdrawal. ⋯ Dexmedetomidine was used to facilitate opioid and benzodiazepine withdrawal in an 8-mo-old infant. A processed electroencephalogram (Bispectral Index) was used to guide the titration of dexmedetomidine in this neurologically impaired infant. This is the first report of dexmedetomidine use in an infant to manage chemical dependence withdrawal.
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Anesthesia and analgesia · Jun 2004
The effect of propofol on cytotoxicity and apoptosis of lipopolysaccharide-treated mononuclear cells and lymphocytes.
IV anesthetics may inhibit proper immune responses and further compromise an already depressed defense system. To assess the possible role of propofol on human immune function in sepsis, we studied cytotoxicity, and apoptosis of mononuclear cells (MNCs). Peripheral blood MNCs were preincubated in 1 microg/mL of lipopolysaccharide (LPS) and then reincubated in different concentrations of propofol (1 microg/mL, 5 microg/mL, 10 microg/mL, or 50 microg/mL). To determine cytotoxicity, lactate dehydrogenase release was assayed by mixing MNCs (4 x 10(5)/100 microL) with K-562 tumor cells as target cells (1 x 10(4)/100 microL)(E: T ratio of 40:1). Apoptosis was determined by measuring the annexin positive cells using flow cytometry. Cytotoxicity and apoptosis of LPS-treated MNCs were unchanged by clinically acceptable concentrations of propofol (1 microg/mL, 5 microg/mL, and 10 microg/mL). However, significant differences were observed in cytotoxicity (P = 0.004) and apoptosis (P = 0.002) with propofol 50 microg/mL. By gating MNCs, we found that lymphocyte apoptosis was significantly increased at 50 microg/mL of propofol, but monocytes were unaffected (P = 0.02). In terms of cytotoxicity and apoptosis, propofol allowed MNCs to retain their cytotoxicity in septic conditions by protecting immune cells from apoptosis. ⋯ Propofol at acceptable therapeutic concentrations, and under experimentally contrived septic conditions, did not affect the cytotoxic activity of mononuclear cells or the apoptosis level of mononuclear cells, lymphocytes, and monocytes from peripheral blood.
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Anesthesia and analgesia · Jun 2004
Simultaneous determination of neuromuscular blockade at the adducting and abducting laryngeal muscles using phonomyography.
Phonomyography (PMG) is a new method for measuring neuromuscular blockade (NMB) at the larynx. In this study, we used PMG to compare NMB at the posterior cricoarytenoid (PCA) and the lateral cricoarytenoid muscle (LCA) in humans. Twelve patients were included in this study. Endotracheal intubation was performed without aid of neuromuscular blocking drugs. One small condenser microphone was inserted beside the vocal cords into the muscular process at the base of the arytenoid cartilage to record acoustic responses of the LCA (vocal cord adduction), and a second microphone was placed behind the larynx to measure NMB of the PCA (vocal cord abduction). Stimulation of the recurrent laryngeal nerve was performed using superficial electrodes placed at the neck (midline between jugular notch and cricoid cartilage) using train-of-four (TOF) stimulation every 12 s. After supramaximal stimulation, mivacurium 0.1 mg/kg was injected and onset, peak effect, and offset of NMB measured and compared using t-test (P < 0.05). The data are presented as mean (SD). Peak effect, onset time, and early recovery to 25% of control twitch height were not significantly different between PCA and LCA at 86% (13) versus 78% (16), 2.3 min (0.45) versus 2.3 min (1.0), and 9.55 min (3.05) versus 8.5 min (4.7), respectively. However, recovery to 75%, 90% of control twitch height, and recovery to a TOF ratio of 0.8 were significantly longer at the PCA than at the LCA at 14 min (4) versus 11 min (5), 17 min (5) versus 11.8 min (5.6), and 17.5 min (5.6) versus 12.3 min (5.5), respectively. The authors conclude that recovery of NMB at the PCA takes longer than at the LCA in humans after mivacurium. ⋯ After neuromuscular blockade in humans, the recovery of the ability to open the vocal cords takes longer than the ability to close the vocal cords.