Anesthesia and analgesia
-
Anesthesia and analgesia · Feb 2000
Randomized Controlled Trial Clinical TrialPatient-controlled epidural analgesia during labor: the effects of the increase in bolus and lockout interval.
Most studies use a bolus size of <6 mL of 0.125% bu- pivacaine for patient-controlled epidural analgesia (PCEA) during labor. In this double-blinded, randomized study, we compared the efficacy of a larger bolus injected via a PCEA pump to a conventional PCEA setting. By using a combination of 0.125% bupivacaine with 1:800,000 epinephrine and 0.625 microg/mL sufentanil, the first PCEA setting was typical (4 mL/8 min), whereas the other combined a 12-mL bolus dose and a 25-min lockout interval, i.e., similar maximal hourly dose. Rescue analgesia was provided with 6 mL of 0.25% bupivacaine. Patient satisfaction and pain were scored on verbal and visual analog scales. Data were analyzed from 103 parturients in the 12-mL/25-min group and 100 in the 4-mL/8-min group. In the 12-mL/25-min group, the median pain score on a 0- to 10-cm visual analog scale was lower at 6-cm cervical dilation (1 [range = 0-8] vs 3 [0-8]) and at delivery (1 [0-10] vs 2 [0-10]). Satisfaction was also better (70% vs 38% "excellent" opinions, at 6-cm cervical dilation). Use of the pump (ratio of successful and total demands) was high and similar in both groups. Rescue analgesia was comparable. Doses of analgesics were greater in the 12-mL/25-min group (hourly bupivacaine dose = 13.9 +/- 5.3 [mean+/- SD] vs 9.4 +/- 4.1 mg). No differences were noted between groups for the severity of hypotension, ephedrine requirement, outcome of the delivery, and Apgar scores. ⋯ A patient-controlled epidural analgesia setting that allows a parturient to receive an increased analgesic dose improves satisfaction with patient-controlled epidural analgesia during labor.
-
Anesthesia and analgesia · Feb 2000
Randomized Controlled Trial Clinical TrialPrevention of hypotension by a single 5-mg dose of ephedrine during small-dose spinal anesthesia in prehydrated cesarean delivery patients.
To evaluate the effectiveness of prophylactic ephedrine for the prevention of hypotension associated with spinal anesthesia, 50 parturients undergoing cesarean delivery received either ephedrine 5 mg or saline IV in a double-blinded fashion immediately after the induction of spinal anesthesia. Spinal anesthesia was performed with hyperbaric bupivacaine 6.6 mg combined with sufentanil 3.3 microg as part of a combined spinal-epidural technique. All patients received 1000 mL of lactated Ringer's solution and 500 mL of hydroxyethylstarch 6% before the spinal injection. Additional ephedrine boluses (5 mg) were administered IV when the systolic blood pressure or heart rate decreased by more than 30% from baseline values, when systolic blood pressure became <100 mm Hg, or when patients complained of nausea or feeling faint. The height of the block was equal in the groups; however, more patients in the placebo group were found to develop hypotension (58% vs 25%, P < 0. 05). Only 2 (8%) patients in the ephedrine group developed hypotension with systolic blood pressure values <90 mm Hg, whereas 10 patients (42%) in the saline group experienced hypotension of this severity (P < 0.05). In addition, there was a higher incidence of nausea in the placebo-treated patients. The total amount of ephedrine administered did not differ between groups. These findings suggest that the incidence and severity of hypotension are significantly reduced by the IV administration of a prophylactic dose of 5 mg ephedrine in patients receiving small-dose spinal anesthesia for cesarean delivery. ⋯ Ephedrine is the drug most often used to correct hypotension during spinal anesthesia for cesarean delivery in healthy patients. A single IV dose of 5 mg decreases the occurrence and limits the severity of hypotension in prehydrated subjects receiving a small-dose spinal local anesthetic-opioid combination.
-
Anesthesia and analgesia · Feb 2000
Randomized Controlled Trial Comparative Study Clinical TrialA comparison of the incidence of the oculocardiac and oculorespiratory reflexes during sevoflurane or halothane anesthesia for strabismus surgery in children.
We examined changes in the cardiorespiratory system of small children during surgical correction of strabismus with a laryngeal mask airway and spontaneous respiration with sevoflurane or halothane inhaled anesthesia. Fifty-one children, 1-7 yr old, having outpatient strabismus correction were randomized to sevoflurane (S) or halothane (H) in 66% nitrous oxide at 1.3 minimum alveolar concentration. Children breathed spontaneously through a laryngeal mask airway and were not pretreated with anticholinergics. The oculocardiac reflex (OCR), defined as a 20% decrease in heart rate (HR) from baseline, dysrhythmias, or sinoatrial arrest concomitant with ocular muscle traction occurred less frequently with sevoflurane than with halothane (S 38%, H79%, P = 0.009). The baseline HR was higher with sevoflurane (S 114 +/- 13 bpm, H 101 +/- 15 bpm, P = 0.002). The lowest HR occurred with halothane (S 95 +/- 22 bpm, H 73 +/- 19 bpm, P = 0.001). The incidence of dysrhythmias was higher in the halothane group (S 4%, H 42%, P = 0.004). Reductions in minute ventilation and PETCO(2) accompanied OCRs. Airway irritability was present with halothane only (S 0, H 3). Eleven children, of whom the majority had received halothane, required measures to correct SpO(2) < 95% or PETCO(2) > 60 mm Hg during maintenance anesthesia (S 11%, H 32%). Sevoflurane may be a more suitable anesthetic than halothane for operations involving traction on the ocular muscles with spontaneous respiration in children because of reduced incidence of OCR, airway irritability, and ventilatory disturbances. ⋯ Some children experience a sudden slowing of the heart and impaired breathing when the surgeon pulls on the eye muscles during squint operations under anesthesia. Sevoflurane, a recently developed anesthetic vapor, may reduce this problem when compared with the established vapor halothane.
-
Anesthesia and analgesia · Feb 2000
Randomized Controlled Trial Clinical TrialPropofol/sufentanil anesthesia suppresses the metabolic and endocrine response during, not after, lower abdominal surgery.
We investigated the influence of propofol/sufentanil anesthesia on metabolic and endocrine responses during, and immediately after, lower abdominal surgery. Twenty otherwise healthy patients undergoing abdominal hysterectomy for benign myoma received either continuous infusions of propofol supplemented with sufentanil (0.01 microg. kg(-1). min(-1), n = 10) or enflurane anesthesia (enflurane, n = 10). Plasma concentrations of glucose, lactate, free fatty acids, triglycerides, insulin, glucagon, cortisol, epinephrine, and norepinephrine were measured before, during, and 2 h after surgery. Pre- and postoperative endogenous glucose production (R(a) glucose) was analyzed by an isotope dilution technique by using [6,6-(2)H(2)] glucose. Propofol/sufentanil anesthesia prevented the increase in plasma cortisol and catecholamine concentrations and attenuated the hyperglycemic response during surgery without showing any difference after the operation. Mediated through a higher glucagon/insulin quotient (propofol/sufentanil 15 +/- 7 versus enflurane 8 +/- 4 pg/microU, P < 0.05), the R(a) glucose postoperatively increased more in the propofol/sufentanil than in the enflurane group (propofol/sufentanil 15.6 +/- 2.0 versus enflurane 13.4 +/- 2.2 micromol. kg(-1). min(-1), P < 0.05). ⋯ The concept of stress-free anesthesia using propofol combined with sufentanil is valid only during surgery. The metabolic endocrine stress response 2 h after the operation is more pronounced than after inhaled anesthesia.
-
Anesthesia and analgesia · Feb 2000
Comparative Study Clinical TrialA pilot study of pharyngeal pulse oximetry with the laryngeal mask airway: a comparison with finger oximetry and arterial saturation measurements in healthy anesthetized patients.
We compared pharyngeal SpO(2) by using the laryngeal mask airway (LMA) to finger SpO(2) and oxygen saturation from arterial blood samples (SaO(2)). We studied 20 hemodynamically stable, well oxygenated, anesthetized patients (ASA physical status I-III, aged 18-80 yr). A single-use pediatric pulse oximeter was attached to the back plate of a size 5 LMA. Pharyngeal and finger SpO(2) (dominant index finger) and SaO(2) (nondominant radial artery) were measured with the cuff volume at 0-40 mL in the neutral position. The intracuff pressure was then set at 60 cm H(2)O in the neutral position, and readings were taken with the head-neck flexed, extended, and rotated. SaO(2) was the same as pharyngeal SpO(2) at 20 and 30 mL cuff volume, but higher than pharyngeal SpO(2) at all other cuff volumes and head-neck positions (P < 0.04). SaO(2) was always higher than finger SpO(2) (P < 0.01). Pharyngeal SpO(2) was higher than finger SpO(2) at cuff volumes 10-40 mL and in the flexed and rotated head-neck positions (all: P < 0.007), but was lower at 0 cuff volume (P < 0.0001) and similar in the extended head-neck position. There was an increase in pharyngeal SpO(2) between 0 and 10 mL cuff volume (P < 0.0001), but no changes thereafter. Pharyngeal SpO(2) was similar in the flexed, rotated and extended head-neck positions. Pharyngeal SpO(2) agrees more closely with SaO(2) (mean difference < 0.7%) than finger SpO(2) (mean difference > 1.1%) at 10-40 mL cuff volume and in head-neck flexion. The standard error of limits was identical (0.09) for both finger SpO(2) and pharyngeal SpO(2) if data at 0 cuff volume are excluded. We conclude that pharyngeal SpO(2) with the LMA is feasible and generally provides more accurate readings than finger SpO(2) in hemodynamically stable, well oxygenated, anesthetized patients. ⋯ Pharyngeal oximetry with the laryngeal mask airway is feasible and generally provides more accurate readings than finger oximetry in hemodynamically stable, well oxygenated, anesthetized patients.