Anesthesiology
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Multicenter Study Clinical Trial
Anesthetic management for obstetric hysterectomy: a multi-institutional study.
A prospectively designed review of all obstetric hysterectomies performed in five university hospitals between November 1, 1984 and October 31, 1987 has been performed. There were 41,107 deliveries and 46 obstetric hysterectomies, an incidence of 0.11%. Twenty-five hysterectomies were elective and 21 were emergent. ⋯ Abnormal placentation now represents a major indication for emergency obstetric hysterectomy. Furthermore, significant hemorrhage is more likely with emergency obstetric hysterectomy than with elective hysterectomy. Finally, elective cesarean hysterectomy is not a contraindication to performance of continuous epidural anesthesia.
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Randomized Controlled Trial Comparative Study Clinical Trial
A comparison of morphine, meperidine, and oxymorphone as utilized in patient-controlled analgesia following cesarean delivery.
Seventy-five patients (n = 75) undergoing elective cesarean delivery during epidural anesthesia were randomly assigned to receive one of three opioid analgesics via patient-controlled analgesia (PCA) when they first complained of pain in the recovery room. Following administration of an analgesic loading dose, patients were allowed to self-administer morphine 1.8 mg, meperidine 18 mg, or oxymorphone 0.3 mg iv every 8 min as required. Data collected during the 24-h observation period included visual analog scale (VAS) pain scores at rest and during movement, VAS patient satisfaction scores, total drug administered, the ratio of attempts/injections, and the incidence of nausea/vomiting, sedation, and pruritus. ⋯ Oxymorphone was associated with the highest incidence of nausea and vomiting (P less than 0.05), whereas increased sedation and pruritus were noted with morphine. Patient satisfaction with drug effect demonstrated significant negative correlations with resting pain scores and degree of sedation. Whereas morphine is a more commonly utilized PCA analgesic, the excellent analgesia, low incidence of sedation, and high patient satisfaction provided by meperidine and oxymorphone suggested useful alternatives.
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Comparative Study
Manual evaluation of residual curarization using double burst stimulation: a comparison with train-of-four.
Double burst stimulation (DBS) is a new mode of stimulation developed to reveal residual neuromuscular blockade under clinical conditions. The stimulus consists of two short bursts of 50 Hz tetanic stimulation, separated by 750 ms, and the response to the stimulation is two short muscle contractions. Fade in the response results from neuromuscular blockade as with train-of-four stimulation (TOF). ⋯ Fade frequencies were statistically significantly higher with DBS than with TOF, regardless of the TOF ratio level. Absence of fade with TOF implied a 48% chance of considerable residual relaxation as compared with 9% when fade was absent with DBS. The results demonstrate that DBS is more sensitive than TOF in the manual detection of residual neuromuscular blockade.
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The authors evaluated the efficacy and incidence of side effects from blockade of the femoral nerve with 0.5% bupivacaine in 14 children with fracture of the middle third of the femoral shaft. In nine of these children, a pharmacokinetic analysis was also performed. The onset of analgesia occurred in 8.0 +/- 3.5 minutes after blockade of the femoral nerve. ⋯ The maximum bupivacaine plasma concentration was 0.89 +/- 0.37 microgram/ml, obtained 24.4 +/- 12.6 min after the end of the injection. The femoral nerve blockade with bupivacaine provides prompt, effective, and prolonged analgesia in children suffering from fractures of the femoral shaft, allowing transport, radiographic examination, and application of traction in optimal conditions. Although the sample size was small, the side effects appeared to be rare.
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To determine the influence of a patient's position on the incidence of dysrhythmias during pulmonary artery catheterization, 34 adult patients scheduled for elective coronary artery bypass graft surgery and pulmonary artery catheterization were studied. All introducers were inserted via the right internal jugular vein using the Seldinger technique with the patient in the Trendelenburg position. For each patient, the pulmonary artery catheter was advanced twice: once while the patient was in the Trendelenburg (T) position with a 5-10 degrees head-down tilt and another with a 5 degrees head-up and right lateral tilt (R) position. ⋯ In 11 of the 13 patients, the dysrhythmia classification changed from malignant in the Trendelenburg position to benign or absent in the right lateral tilt position. Although the incidence of dysrhythmias was similar in both groups, the Trendelenburg position was associated with a significantly higher incidence of malignant dysrhythmias than the right tilt position (P less than 0.05). The authors conclude that the head-up and right lateral tilt position appears superior to the Trendelenburg position for passage of the pulmonary artery catheter in the awake patient scheduled for elective coronary bypass surgery.