Anesthesiology
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Randomized Controlled Trial Comparative Study Clinical Trial
Does epidural administration of butorphanol offer any clinical advantage over the intravenous route? A double-blind, placebo-controlled trial.
The differential effects of intravenous versus epidural administration of short-acting, lipid-soluble opioids is controversial. This study was undertaken to compare these two routes of administration using the mixed agonist-antagonist opioid, butorphanol. Forty-five women undergoing elective cesarean delivery at term under epidural lidocaine anesthesia were randomized to receive a single bolus of either epidural or intravenous butorphanol 2 mg or saline control for postoperative analgesia. ⋯ Analgesia was quantitated using a visual analogue scale and subsequent PCA morphine requirements. The interval from study drug injection until first request for PCA use was equivalent for the intravenous and epidural groups (89 +/- 9 and 83 +/- 8 min, respectively) and significantly longer than in control group (39 +/- 4 min, P less than 0.001, intravenous and epidural vs. control). Analgesia was equivalent in the intravenous and epidural groups at all observation points, and pain scores were significantly lower than control for the first 120 min after study drug injection.(ABSTRACT TRUNCATED AT 250 WORDS)
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Epidural or intrathecal infusions of morphine and bupivacaine mixtures are presently used for the treatment of "refractory" cancer pain even though the neurotoxic potential of such mixtures is unknown. The pathologic findings of the spinal column, the meninges, the nerve roots, and the spinal cord, and the clinical neurologic deficits were recorded in 15 patients (5 men and 10 women), aged 26-83 (median 68) yr, treated for 4-274 (median 81) days with intrathecal infusions of morphine (with preservatives [sodium metabisulfite and sodium edetate]) and bupivacaine mixtures, given through open, subcutaneously tunneled nylon catheters. Six patients had been subjected to radiation therapy (20-96 Gy), applied over the spinal column, and four had been treated with antineoplastics believed to be neurotoxic. ⋯ The neuropathologic findings were not related to the duration or cumulative doses of the intrathecal treatment. No new neurologic deficits that could be attributed to the intrathecal administration of the opiate-bupivacaine mixtures were recorded. The neuropathologic and clinical neurologic findings in cancer patients treated with intrathecal morphine-bupivacaine mixtures appeared similar to those in animals and humans reported with either intrathecal morphine or bupivacaine alone.
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Claims against anesthesiologists for eye injuries were analyzed as part of the ASA Closed Claims Project. Eye injury occurred in 3% of all claims in the database (71 of 2,046). The payment frequency for eye injury claims was higher than that for non-eye injury claims (70% vs. 56%; P less than or equal to 0.05). ⋯ The median payment for claim involving movement was 10 times greater than for non-movement claims ($90,000 vs. $9,000; P less than or equal to 0.01). Anesthesiologist reviewers deemed the care rendered in the general anesthesia "movement" claims as meeting standards in only 19% of claims. From the perspective of patient safety, as well as risk management, these data suggest two specific needs: research directed at better understanding of the etiology of corneal abrasion and clinical strategies designed to assure patient immobility during ophthalmic surgery.
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Comparative Study
Intraoperative echocardiography for evaluation of congenital heart defects in infants and children.
To determine the accuracy, utility, and limitations of intraoperative transesophageal echocardiography (TEE) in infants and children, we performed prebypass and postbypass TEE in 90 children undergoing surgical repair of congenital heart lesions, comparing the results to those obtained using intraoperative epicardial echocardiography and pre- and postoperative precordial echocardiography. Patients ranged in age from 4 days to 21 yr (mean 4.1 yr) and in weight from 3 to 68 kg (mean 15.4 kg). Prebypass, we obtained high-quality, two-dimensional TEE images in 86 patients, with correction of the preoperative precordial diagnosis in 3 and confirmation of the preoperative diagnosis in the rest. ⋯ Regurgitant lesions (n = 30) were identified and their severity evaluated in all patients by both TEE and epicardial imaging. Obstructive lesions (n = 33), excluding those involving the right ventricular outflow tract, were well defined by both echocardiographic approaches. Postbypass, we obtained high-quality, two-dimensional, color and Doppler TEE images in 86 patients and epicardial images in 78 patients.(ABSTRACT TRUNCATED AT 250 WORDS)