Anesthesia and analgesia
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Clinical TrialThe influence of epidural needle bevel orientation on spread of sensory blockade in the laboring parturient.
Both asymmetrical sensory blockade and dural puncture are undesirable outcomes of epidural analgesia. Identifying the epidural space with the needle bevel oriented parallel to the longitudinal axis of the patient's back limits the risk of headache in the event of dural puncture. However, rotating the bevel to direct a catheter cephalad may risk dural puncture. We prospectively studied the effects of needle rotation on the success of labor epidural analgesia and on the incidence of dural puncture. One hundred sixty ASA physical status I or II laboring parturients were randomly assigned to one of four groups. The epidural space was identified with the bevel of an 18-gauge Hustead needle directed to the patient's left. It was then rotated as follows: Group 0 = no rotation, final bevel orientation left (n = 39); Group 90 = rotation 90 degrees clockwise, bevel cephalad (n = 43); Group 180 = rotation 180 degrees clockwise, bevel right (n = 36); Group 270 = rotation 270 degrees clockwise, bevel caudad (n = 42). A single-orifice catheter was inserted 3 cm, and analgesia was induced in a standardized fashion. Dural puncture was evenly distributed among the groups (4.4%). There were more dermatomal segments blocked, fewer one-sided blocks, and more patients comfortable at 30 min with the needle bevel directed cephalad. Using a catheter inserted through a needle oriented in the cephalad direction increases the success of epidural analgesia. ⋯ This prospective study shows that an epidural catheter inserted through a needle oriented in the cephalad direction increases the success of labor analgesia in the parturient. Carefully rotating the needle cephalad does not increase the risk of dural puncture, intravascular catheters, or failed blocks.
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Clinical TrialKetamine attenuates the interleukin-6 response after cardiopulmonary bypass.
Cardiopulmonary bypass (CPB) has been proposed as a model for studying the inflammatory cascade associated with the systemic inflammatory response syndrome. Serum interleukin-6 (IL-6) concentration seems to be a good indicator of activation of the inflammatory cascade and predictor of subsequent organ dysfunction and death. Prolonged increases of circulating IL-6 are associated with morbidity and mortality after cardiac operations. In the present study, we compared the effects of adding ketamine 0.25 mg/kg to general anesthesia on serum IL-6 levels during and after elective coronary artery bypass grafting (CABG). Thirty-one patients undergoing elective CABG were randomized to one of two groups and prospectively studied in a double-blind manner. The patients received either ketamine 0.25 mg/kg or a similar volume of isotonic sodium chloride solution in addition to large-dose fentanyl anesthesia. Blood samples for analysis of serum IL-6 levels were drawn before the operation; after CPB; 4, 24, and 48 h after surgery; and daily for 6 days beginning the third day postoperatively. Ketamine suppressed the serum IL-6 response immediately after CPB and 4, 24, and 48 h postoperatively (P < 0.05). During the first 7 days after surgery, the serum IL-6 levels in the ketamine group were significantly lower than those in the control group (P < 0.05). On Day 8 after surgery, IL-6 levels were no different from baseline values in both groups. A single dose of ketamine 0.25 mg/kg administered before CPB suppresses the increase of serum IL-6 during and after CABG. ⋯ In this randomized, double-blind, prospective study of patients during and after coronary artery bypass surgery, we examined whether small-dose ketamine added to general anesthesia before cardiopulmonary bypass suppresses the increase of the serum interleukin-6 (IL-6) concentration. Serum IL-6 levels correlate with the patient's clinical course during and after coronary artery bypass. Ketamine suppresses the increase of serum IL-6 during and after coronary artery bypass surgery.
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Comparative Study Clinical TrialIntrathecal sufentanil versus epidural lidocaine with epinephrine and sufentanil for early labor analgesia.
Intrathecal sufentanil provides approximately 2 h of excellent labor analgesia with minimal motor blockade. Epidural sufentanil has received less scrutiny but may provide the same benefits as intrathecal sufentanil. In this study, we compared epidural sufentanil 40 microg after a lidocaine with an epinephrine test dose with intrathecal (i.t.) sufentanil 10 microg with respect to onset and duration of analgesia, degree of motor block, side effect profile, and mode of delivery. Seventy ASA physical status I or II parturients in early labor (< or = 4 cm cervical dilation) were randomized to receive either i.t. sufentanil 10 microg with a combined spinal-epidural technique (CSE) or epidural sufentanil 40 microg (e.p.) after epidural catheter placement and testing with 3 mL of 1.5% lidocaine with epinephrine (15 microg). After the administration of analgesia, pain scores and side effects were recorded for each patient at 5, 10, 15, 20, and 30 min, and every 30 min thereafter, by an observer blinded to the technique used. The study period was completed when the patients requested additional analgesia. All patients, except one, achieved adequate analgesia with the initial study dose and satisfactorily completed the study. There were no demographic differences between the two groups. Pain relief was rapid for all patients; pain scores were significantly lower at 5 and 10 min in the i.t. group versus the e.p. group. The mean duration of analgesia was similar between the e.p. group (127 +/- 40 min) and the i.t. group (110 +/- 48 min). No patient experienced any motor block. Side effects were similar between the two groups, except for pruritus-both the incidence and severity were significantly more profound at 5, 10, 15, 20, and 30 min in the i.t. group. There was no difference in time from analgesic to delivery, incidence of operative or assisted delivery, or cervical dilation at the time of redose. For early laboring patients, epidural sufentanil 40 microg after a lidocaine test dose provides analgesia comparable to that of i.t. sufentanil 10 microg with less pruritus. ⋯ We compared the efficacy and side effects of intrathecal sufentanil with epidural sufentanil with a local anesthetic test dose for analgesia during labor. Analgesia was equally good, although the intrathecal group experienced more itching.
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Comparative Study Clinical TrialComparison of desflurane with isoflurane or propofol in spontaneously breathing ambulatory patients.
Desflurane is a potentially useful anesthetic for ambulatory surgery, but it has had limited evaluation in spontaneously breathing patients. After the induction of anesthesia with propofol and laryngeal mask insertion, 90 patients were randomized to receive isoflurane (0.25%-1%), propofol (50-200 microg x kg(-1) x min(-1)), or desflurane (1.4%-6%) for anesthetic maintenance. Respiratory complications were uncommon; only six patients coughed (three who received isoflurane, one who received propofol, and two who received desflurane), and no anesthetic produced significant respiratory depression. Purposeful movement was significantly more common with propofol (19 patients; 63%) compared with isoflurane (7 patients; 23%) or desflurane (2 patients; 6.7%), but no patient had recall. Emergence times were similar in the isoflurane, propofol, and desflurane groups (5.1 +/- 2.3, 5.6 +/- 3.1, and 4.4 +/- 1.4 min, respectively). Later recovery end points and pain and sedation visual analog scale scores did not differ among groups. Overall, 85 patients (94%) were free from postoperative nausea and vomiting. Desflurane produced few respiratory complications in spontaneously breathing ambulatory patients but offered no improvement in emergence or recovery compared with isoflurane. Propofol also did not reduce recovery times or side effects; however, it was more difficult to maintain an adequate depth of anesthesia. We conclude that neither desflurane nor propofol offered any major advantages over the older anesthetic, isoflurane, under the conditions of our study. ⋯ The new inhaled anesthetic desflurane is acceptable in spontaneously breathing outpatients despite its known ability to irritate the airway. The i.v. anesthetic propofol was associated with more patient movement (without awareness) during surgery. Neither anesthetic conferred any clinically significant advantages over the older inhaled drug, isoflurane.
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Clinical TrialShould adult patients drink fluids before discharge from ambulatory surgery?
We studied 726 consenting patients to determine whether withholding oral fluids from adult ambulatory surgical patients before discharge would decrease the incidence of postoperative nausea and vomiting (PONV) and shorten the duration of stay in the ambulatory surgery unit (ASU). Patients were randomly assigned to the drinking or nondrinking group. Both groups received a standard regimen of general anesthesia, fluid replacement, and analgesia. In the ASU, patients in the drinking group were given mandatory oral fluids to drink before discharge. Nausea and pain were assessed by using a visual analog scale 15, 30, 60, 90, 105, 120, 150, and 180 min postoperatively. The time to drink, sit up, void, and ambulate, and the time until discharge were recorded. Patients were interviewed by telephone 24 h postoperatively. There was no significant difference in the frequency of PONV between the drinking and the nondrinking groups either in the hospital or after discharge. Patients in the drinking group required more time to begin ambulating (105 +/- 38 vs 98 +/- 34 min; P < 0.02) and to void (112 +/- 40 vs 105 +/- 37 min; P < 0.01). Patients in the drinking group also stayed in the ASU longer (85 +/- 49 vs 81 +/- 47 min; P < 0.03). Time to postanesthetic discharge was also significantly longer in the drinking group than the nondrinking group (106 +/- 40 vs 98 +/- 36 min; P < 0.015). A similar percentage of patients in both groups were "very satisfied" with their ambulatory surgical care. There was no difference in postoperative complications and need for medical help. Withholding early postoperative oral fluids facilitated earlier ambulation and decreased the stay in the ASU but did not decrease the incidence of PONV. Thus, in this ambulatory surgical population, there does not seem to be justification to require drinking before discharge. ⋯ To answer the question of whether adult outpatients should drink before discharge after minor surgical procedures, 726 patients were randomized to either drink approximately 150 mL of liquid or not to drink. Neither drinking nor nondrinking worsened postoperative nausea or vomiting or prolonged hospital stay. Therefore, patients should be allowed to choose whether they drink before discharge.