Anesthesia and analgesia
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Clinical TrialTranexamic acid and aprotinin reduce postoperative bleeding and transfusions during primary coronary revascularization.
We evaluated the blood conservation effects of tranexamic acid (TA) or aprotinin administered before and during cardiopulmonary bypass (CPB) in a prospective, randomized, double-blind study of 150 adult patients undergoing primary coronary artery bypass grafting surgery. Patients received either TA (2 g) or large-dose aprotinin (7 million KIU). Thirty additional untreated patients otherwise managed in a similar fashion were included from a recently completed study for comparison of outcomes. Demographic, medical, surgical, laboratory, mediastinal chest tube drainage (MCTD), transfusion, and outcome data were collected. Allogeneic blood product administration was tightly controlled. The demographic, medical, and surgical characteristics did not significantly differ between the two therapy groups. The median postoperative MCTD loss in the TA group did not significantly differ from that in the aprotinin-treated group (708 vs 600 mL). The percentage of patients that received no allogeneic blood products was 25% for the TA group and 27% for the aprotinin group (P = not significant). The median number of allogeneic blood products administered to the TA group (0 U) did not significantly differ from that administered to the aprotinin group (0 U). The percentage of patients with excessive MCTD (>1000 mL/24 h) did not significantly differ between groups (19% and 17%, respectively). In comparison, the control group had a significantly greater (P < 0.05) median MCTD (1020 mL), median allogeneic blood product exposure (4.5 U), and incidence of excessive MCTD (66%) and transfusion therapy (66%). These data help to support the use of pharmacologic methods to improve clinically relevant indicators of blood conservation for primary CPB procedures. Furthermore, the data show that TA is equivalent to aprotinin for blood conservation in patients at risk of excessive post-CPB bleeding and transfusion therapy. ⋯ In a randomized, blind trial, we evaluated the effects of tranexamic acid or aprotinin on blood conservation after primary cardiopulmonary bypass surgery. Both drugs were equally effective in reducing blood loss, the incidence of transfusion, and the amount of blood products transfused compared with placebon.
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Clinical TrialAnalgesic effect of bupivacaine on extraperitoneal laparoscopic hernia repair.
Local anesthetics decrease postoperative pain when placed at the surgical site. Patients benefit from laparoscopic extraperitoneal hernia repair because this allows earlier mobilization than the more classical open surgical approach. The purpose of this study was to determine the pain-sparing efficacy of local anesthetics placed in the preperitoneal fascial plane during extraperitoneal laparoscopic inguinal hernia surgery. Forty-two outpatients were included in a double-blind, randomized, placebo-controlled, institutional review board-approved study. At the conclusion of a standardized general anesthetic, 21 patients received 60 mL of 0.125% bupivacaine into the preperitoneal fascial plane before incisional closure, whereas the other 21 patients received 60 mL of the isotonic sodium chloride solution placebo. Postoperative pain was assessed 1, 4, 8, 24, and 72 h postoperatively. In addition, postoperative fentanyl and outpatient acetaminophen 500 mg/hydrocodone 5 mg requirements were recorded. All hernia repairs were performed by the same surgeon. Appropriate statistical analyses were used. There were no significant differences between the bupivacaine and isotonic sodium chloride solution groups with regard to postoperative pain scores, length of postanesthesia care unit stay, or analgesic requirements. Furthermore, neither unilateral versus bilateral repair nor operative time affected the measured parameters. The addition of 60 mL of 0.125% bupivacaine into the preperitoneal fascial plane during extraperitoneal laparoscopic hernia repair did not significantly alter pain scores, supplementary analgesic requirements, or recovery room length of stay. ⋯ The placement of 60 mL of 0.125% bupivacaine into the preperitoneal fascial plane during extraperitoneal laparoscopic hernia repair did not significantly alter pain scores, supplementary analgesic requirements, or recovery room length of stay.
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Clinical TrialIncidence and time course of cardiovascular side effects during spinal anesthesia after prophylactic administration of intravenous fluids or vasoconstrictors.
We studied the time course of arterial hypotension and/or bradycardia requiring treatment during spinal anesthesia and compared the efficacy of i.v. fluid or vasoconstrictor administration for the prevention of these side effects. Patients (n = 1066) were randomly allocated to either a volume group (lactated Ringer's solution 15 mL/kg within 15 min before spinal anesthesia), a dihydroergotamine group (10 microg/kg i.m. 15 min before anesthesia), or a placebo group. All patients breathed O2-enriched air during spinal anesthesia (4 mL of plain 0.5% bupivacaine). With the placebo, there were side effects (mean incidence 22.9%) for up to 45 min after the start of anesthesia. Dihydroergotamine reduced the incidence of side effects, preferentially the late ones, more (mean incidence 11.8%) than fluid administration (mean incidence 16.9%), which was effective only during the first 15 min of anesthesia. Both heart rate and arterial pressure decreased within 15 min before the manifestation of symptoms. In a subgroup of patients, the incidence of side effects (8%) was greatly reduced by the intraoperative application of both sedatives and opioids. We conclude that cardiovascular side effects may occur at any time during spinal anesthesia. Fluid administration reduced the incidence of early events, but dihydroergotamine the late events. ⋯ Cardiovascular side effects requiring treatment occurred at any time during spinal anesthesia in our placebo-controlled study, regardless of the prophylactic regimen (fluid infusions versus dihydroergotamine).
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Anesthesia and analgesia · Aug 1998
Randomized Controlled Trial Clinical TrialThe efficacy of intrathecal neostigmine, intrathecal morphine, and their combination for post-cesarean section analgesia.
We designed this study to evaluate the postoperative analgesic efficacy and safety of intrathecal (i.t.) neostigmine, i.t. morphine, and their combination in patients undergoing cesarean section under spinal anesthesia. Seventy-nine term parturients were randomly divided into four groups to receive isotonic sodium chloride solution 0.2 mL, neostigmine 25 microg, morphine 100 microg, or the combination of i.t. neostigmine 12.5 microg and morphine 50 microg with i.t. 0.5% hyperbaric bupivacaine 12 mg. There were no significant differences among the four groups with regard to spinal anesthesia, maternal blood pressure and heart rate, or fetal status. Postoperative analgesia was provided by i.v. patient-controlled analgesia (PCA) using fentanyl and ketorolac. Compared with the saline group, the time to first PCA use was significantly longer in the neostigmine group (P < 0.001), with lower 24-h analgesic consumption (P < 0.001). Nausea and vomiting were the most common side effects of i.t. neostigmine (73.7%). Analgesic effectiveness was similar between the neostigmine and morphine groups. Compared with the neostigmine group, the combination group had significantly prolonged analgesic effect and reduced 24-h PCA consumption (P < 0.05) with less severity of nausea and vomiting (P = 0.058). Compared with the morphine group, the combination group tended to have prolonged times to first PCA use (P = 0.054) with a lower incidence of pruritus (P < 0.03). ⋯ Intrathecal (i.t.) neostigmine 25 microg produced postoperative analgesia for cesarean section similar to that of i.t. morphine 100 microg, but with a high incidence of nausea and vomiting. The combination of i.t. neostigmine 12.5 microg and i.t. morphine 50 microg may produce better postoperative analgesia with fewer side effects than i.t. neostigmine 25 microg or i.t. morphine 100 microg alone.
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Anesthesia and analgesia · Aug 1998
A molecular description of how noble gases and nitrogen bind to a model site of anesthetic action.
How some noble and diatomic gases produce anesthesia remains unknown. Although these gases have apparently minimal capacities to interact with a putative anesthetic site, xenon is a clinical anesthetic, and argon, krypton, and nitrogen produce anesthesia at hyperbaric pressures. In contrast, neon, helium, and hydrogen do not cause anesthesia at partial pressures up to their convulsant thresholds. We propose that anesthetic sites influenced by noble or diatomic gases produce binding energies composed of London dispersion and charge-induced dipole energies that are sufficient to overcome the concurrent unfavorable decrease in entropy that occurs when a gas molecule occupies the site. To test this hypothesis, we used the x-ray diffraction model of the binding site for Xe in metmyoglobin. This site offers a positively charged moiety of histidine 93 that is 3.8 A from Xe. We simulated placement of He, Ne, Ar, Kr, Xe, H2, and N2 sequentially at this binding site and calculated the binding energies, as well as the repulsive entropy contribution. We used free energies obtained from tonometry experiments to validate the calculated binding energies. We used partial pressures of gases that prevent response to a noxious stimulus (minimum alveolar anesthetic concentration [MAC]) as the anesthetic endpoint. The calculated binding energies correlated with binding energies derived from the in vivo (ln) data (RTln[MAC], where R is the gas constant and T is absolute temperature) with a slope near 1.0, indicating a parallel between the Xe binding site in metmyoglobin and the anesthetic site of action of noble and diatomic gases. Nonimmobilizing gases (Ne, He, and H2) could be distinguished by an unfavorable balance between binding energies and the repulsive entropy contribution. These gases also differed in their inability to displace water from the cavity. ⋯ The Xe binding site in metmyoglobin is a good model for the anesthetic sites of action of noble and diatomic gases. The additional binding energy provided by induction of a dipole in the gas by a charge at the binding site enhanced binding.