Anesthesiology
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This study tested the hypothesis that the threshold for thermoregulatory vasoconstriction is lowered as isoflurane concentration increases, but the intensity of vasoconstriction, once triggered, is well preserved during isoflurane anesthesia. The thermoregulatory threshold was prospectively defined as the central temperature at which vasoconstriction occurred, and significant vasoconstriction was defined as a skin-surface temperature gradient (forearm-fingertip) greater than or equal to 4 degrees C. The threshold for thermoregulatory vasoconstriction and the intensity of vasoconstriction, measured as maximum skin-temperature gradient, was determined in six unpremedicated patients electively donating a kidney during isoflurane anesthesia, and in four healthy, awake volunteers. ⋯ The threshold for thermoregulatory cutaneous vasoconstriction was inversely correlated with anesthetic dose, the thermoregulatory threshold decreasing approximately 3 degrees C/% isoflurane concentration. There were no statistically significant differences between maximum skin-surface temperature gradients in awake volunteers and patients given isoflurane, or between any of the groups when patients from previous studies given halothane or nitrous oxide/fentanyl anesthesia were included in the comparison. These data indicate that the intensity of vasoconstriction, once triggered, is similar during several different types of anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)
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Adverse outcomes associated with respiratory events constitute the single largest class of injury in the American Society of Anesthesiology Closed Claims Study (522 of 1541 cases; 34%). Death or brain damage occurred in 85% of cases. The median cost of settlement or jury award was +200,000. ⋯ The esophageal intubation group was notable for a recurring diagnostic failure: in 48% of cases where auscultation of breath sounds was performed and documented, this test led to the erroneous conclusion that the endotracheal tube was correctly located in the trachea. Claims for difficult tracheal intubation were distinguished by a comparatively small proportion of cases (36%) in which the outcome was considered preventable with better monitoring. A better understanding of respiratory risks may require investigative protocols that initiate data collection immediately upon the recognition of a critical incident or adverse outcome.
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The authors tested the hypothesis that during epidural anesthesia: 1) shivering-like tremor is primarily normal thermoregulatory shivering; 2) hypothermia does not produce a subjective sensation of cold; and 3) injectate temperature does not influence tremor intensity. An epidural catheter was inserted into ten healthy, nonpregnant volunteers randomly assigned to skin-surface warming below the T10 dermatome (warmed group) or no extra warming (unwarmed group). Each volunteer was given two 30-ml epidural injections of 1% lidocaine (16.0 +/- 4.7 degrees C and 40.6 +/- 0.7 degrees C at the catheter tip), in random order separated by at least 3 h. ⋯ Integrated EMG intensity did not differ significantly following epidural injection of warm and cold lidocaine: tremor started when tympanic membrane temperature decreased about 0.5 degrees C and continued until central temperature returned to within 0.5 degrees C of control. Tremor always was preceded by hypothermia and vasoconstriction in the arms. Thermal comfort increased in both groups after epidural injection, with maximal comfort occurring at the lowest tympanic temperatures.(ABSTRACT TRUNCATED AT 250 WORDS)
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In order to evaluate reversal time from very intense neuromuscular blockade caused by a continuous infusion of atracurium, the time course of neostigmine induced reversal from different levels of neuromuscular blockade was evaluated using the post-tetanic count (PTC) and the train-of-four (TOF) in 30 patients anesthetized with nitrous oxide, fentanyl, and thiopental. Reversal time (time from administration of neostigmine at different PTC levels to a TOF ratio of 0.7) was found to depend upon the degree of blockade at the time of reversal. ⋯ Total recovery time (spontaneous recovery plus reversal time) was not shortened by an early injection of neostigmine. It is concluded that neostigmine administration during intense neuromuscular blockade following atracurium infusion does not shorten total recovery time and offers no clinical advantages.