Canadian journal of anaesthesia = Journal canadien d'anesthésie
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Randomized Controlled Trial Clinical Trial
Can immediate opioid requirements in the post-anaesthesia care unit be used to determine analgesic requirements on the ward?
The aim of this prospective study was to evaluate the efficacy of two dosage regimens of (i.m.) morphine calculated from an initial (i.v.) titrated dose in the early postoperative period. Seventy ASA I-III patients who underwent general anaesthesia (GA) (n = 58), regional anaesthesia (RA) (n = 10) or GA+RA (n = 2) for orthopaedic (n = 54), urological (n = 11) or abdominal surgery (n = 5) received i.v. titrated morphine in the post-anaesthesia care unit (PACU). Titration consisted of 3 mg morphine i.v. every ten minutes until patients had a visual analogue pain scale (VAS) < 3, without marked sedation. ⋯ Only 16 patients were excluded from the rest of the study. Only 16 patients had a VAS > 3 at least once during the study period and only three needed rescue analgesia which was available on request. We conclude that a systematic i.m. morphine regimen adapted from an initial i.v. titration in the PACU provides efficacious and relatively inexpensive postoperative analgesia, applicable to a great majority of patients.
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Randomized Controlled Trial Comparative Study Clinical Trial
Premedication for ambulatory surgery in preschool children: a comparison of oral midazolam and rectal thiopentone.
Seventy five ASA 1 and 2 children, aged between six months and five years were randomized to receive oral midazolam 0.5 mg.kg-1, rectal thiopentone 35 mg.kg-1 or no premedication to compare the safety and efficacy of, and parental attitudes to, both premedicants. Cardio-respiratory variables were from the time of premedication to awakening from anaesthesia. In addition, anxiety and sedation scores and patients' acceptance of both premedicant and mask at induction, were all recorded using four-point rating scales. ⋯ Parental preoperative satisfaction rating was higher for thiopentone, but not midazolam, than no premedication (P < 0.05). When asked their premedication preferences for subsequent general anaesthetics, a higher proportion of parents whose children were not premedicated requested an alternative regimen (P < 0.01). In conclusion the study found that premedication with rectal thiopentone provided superior induction characteristics to oral midazolam, but with a longer recovery period.
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This article reviews the process by which new drugs are introduced into anaesthetic practice with particular emphasis on pharmaceutical development and government regulation. After a brief overview of the drug development process, new trends in drug development are discussed including implementation of pharmacokinetic, pharmacodynamic and toxicokinetic studies in both preclinical and human phases of drug evaluation. ⋯ The processes of drug development and regulation require much effort and cooperation between clinicians, pharmaceutical manufacturers and government regulators to achieve a common goal; the development and utilization of safe and effective drugs. A fundamental understanding of these processes may further facilitate optimal drug utilization and the active involvement of anaesthetists in the drug development process.
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Case Reports
Laparoscopic extraperitoneal inguinal hernia repair complicated by subcutaneous emphysema.
The case of a healthy 59-yr-old man who underwent elective laparoscopic extraperitoneal inguinal hernia repair and general anaesthesia is presented. After one hour of surgery, a sudden increase in the FETCO2 from 5.0% to 9.4% in relation to a massive subcutaneous emphysema, but without any haemodynamic instability, was noticed. The acute rise of FETCO2 was the first sign of an abnormal event. ⋯ Subcutaneous emphysema and hypercarbia are potential complications of laparoscopic surgery, but are more likely to occur in extraperitoneal surgery, since insufflated CO2 can diffuse easily into the surrounding tissues. High insufflation pressures will increase chances of this occurring and was the most likely cause of this complication. This case encouraged us to make recommendations for the management of laparoscopic extraperitoneal surgery which included: monitoring of CO2 insufflation pressure, routine examination and palpation of chest wall, use of N2O with caution, adjusting ventilation to physiological FETCO2 and excluding other causes of subcutaneous emphysema and hypercarbia.
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This study was undertaken to examine the variation of the arterial to end-tidal PCO2 (Pa-PETCO2) difference during prolonged neurosurgical anaesthesia. Hyperventilation is often used to reduce intracranial pressure in neurosurgical patients. Continuous end-tidal CO2 monitoring is used as a guide between arterial CO2 measurements. ⋯ The mean slope for all patients was then computed. There were no changes in the Pa-PETCO2 difference with time (P > 0.05) suggesting a constant relationship between the arterial and end-tidal PCO2 measurements over time. We conclude that end-tidal PCO2 can be used as a reliable guide to estimate arterial PCO2 during neurosurgical procedures of greater than four hours duration once the Pa-PETCO2 difference has been established.