Anesthesia and analgesia
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Anesthesia and analgesia · Oct 1999
Randomized Controlled Trial Clinical TrialMulti-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized, double-blinded, placebo-controlled study.
Pain is the dominant complaint after laparoscopic cholecystectomy. No study has examined the combined effects of a somato-visceral blockade during laparoscopic cholecystectomy. Therefore, we investigated the effects of a somato-visceral local anesthetic blockade on pain and nausea in patients undergoing elective laparoscopic cholecystectomy. In addition, all patients received multi-modal prophylactic analgesic treatment. Fifty-eight patients were randomized to receive a total of 286 mg (66 mL) ropivacaine or 66 mL saline via periportal and intraperitoneal infiltration. During the first 3 postoperative h, the use of morphine and antiemetics was registered, and pain and nausea were rated hourly. Daily pain intensity, pain localization, and supplemental analgesic consumption were registered the first postoperative week. Ropivacaine reduced overall pain the first two hours and incisional pain for the first three postoperative hours (P < 0.01) but had no apparent effects on intraabdominal or shoulder pain. During the first 3 postoperative h, morphine requirements were lower (P < 0.05), and nausea was reduced in the ropivacaine group (P < 0.05). Throughout the first postoperative week, incisional pain dominated over other pain localizations in both groups (P < 0.01). We conclude that the somato-visceral local anesthetic blockade reduced overall pain during the first 2 postoperative h, and nausea, morphine requirements, and incisional pain were reduced during the first 3 postoperative h in patients receiving prophylactic multi-modal analgesic treatment. ⋯ A combination of incisional and intraabdominal local anesthetic treatment reduced incisional pain but had no effect on deep intraabdominal pain or shoulder pain in patients receiving multimodal prophylactic analgesia after laparoscopic cholecystectomy. Incisional pain dominated during the first postoperative week. Incisional infiltration of local anesthetics is recommended in patients undergoing laparoscopic cholecystectomy.
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Anesthesia and analgesia · Oct 1999
Randomized Controlled Trial Clinical TrialHemodynamic responses induced by dopamine and dobutamine in anesthetized patients premedicated with clonidine.
To test the hypothesis that the pharmacological effects of dopamine (DOA) and dobutamine (DOB) are altered when there is inhibition of the release of norepinephrine from nerve endings, we examined the hemodynamic responses to DOA and DOB in anesthetized patients premedicated with oral clonidine. Seventy adult patients were assigned to one of two groups (oral premedication with clonidine 5 microg/kg or no premedication). After the induction of general anesthesia, heart rate and systemic blood pressure (BP) were measured for 10 min after each of five IV infusions (3 and 5 microg x kg(-1) x min(-1) of DOA; 0.5, 1, and 3 microg x kg(-1) x min(-1) of DOB) in a randomized, double-blind manner. In patients given clonidine, the mean BP increases induced by DOA 5 microg x kg(-1) x min(-1) were significantly attenuated (P < 0.01), whereas the mean BP increases induced by DOB-0.5, 1, or 3 microg x kg(-l) x min(-1) were significantly enhanced (P < 0.01 or 0.05). The heart rate responses to DOA and DOB did not differ between patients with or without clonidine. Premedication with clonidine alters the effects on BP to both DOA and DOB. When small doses of DOA or DOB are used in clonidine-premedicated patients, differences of pharmacological profiles need to be considered for perioperative management. ⋯ Our randomized, double-blind study suggests that premedication with clonidine may enhance the effect on blood pressure response to a small dose of dobutamine (direct-acting) and attenuate that to a small dose of dopamine (mixed direct-and indirect-acting) in patients anesthetized with fentanyl and nitrous oxide.
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Anesthesia and analgesia · Oct 1999
ReviewDesign of appointment systems for preanesthesia evaluation clinics to minimize patient waiting times: a review of computer simulation and patient survey studies.
Anesthesiologists can use the science of clinic scheduling to design appointment systems for preanesthesia evaluation clinics. The principal reasons reported for inappropriately [or arguably unethically] long patient waiting times are provider tardiness, lack of patient punctuality, patient no-shows, and improperly designed appointment systems. However, the fundamental reason why anesthesia clinics have such long patient waiting times is because of their relatively long mean (and consequently standard deviation) of consultation times. ⋯ Substantial provider idle time should be expected. Appropriate values for breaks, appointment intervals, and percentage no-shows should be determined by computer simulation, using parameters appropriate for each provider and anesthesia clinic. Finally, traditional efforts at making waiting for a consultation tolerable should be made.
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Anesthesia and analgesia · Oct 1999
Comparative StudyPerioperative- and long-term mortality rates after major vascular surgery: the relationship to preoperative testing in the medicare population.
Debate continues regarding the value of cardiovascular testing and coronary revascularization before major vascular surgery. Whereas recent guidelines have advocated selective preoperative testing, several authors have suggested that it is no longer necessary in an era of low perioperative cardiac morbidity and mortality. We used data from a random sample of Medicare beneficiaries to determine the mortality rate after vascular surgery, based on the use of preoperative cardiac testing. A 5% nationally random sample of the aged Medicare population for the final 6 mo of 1991 and first 11 mo of 1992 was used to identify a cohort of patients who underwent elective infrainguinal or abdominal aortic reconstructive surgery. Use within the first 6 mo of 1991 was reviewed to determine if preoperative noninvasive cardiovascular imaging or coronary revascularization was performed. Thirty-day (perioperative) and 1-yr mortalities were assessed. Perioperative mortality was significantly increased for aortic surgery (209 of 2865 or 7.3%), compared with infrainguinal surgery (232 of 4030 or 5.8%); however, 1-yr mortality was significantly increased for infrainguinal surgery (16.3% vs 11.3%, P < 0.05). Stress testing, with or without coronary revascularization, was associated with improved short-and long-term survival in aortic surgery. The use of stress testing with coronary revascularization was not associated with reduced perioperative mortality after infrainguinal surgery. Stress testing alone was associated with reduced long-term mortality in patients undergoing infrainguinal revascularization. ⋯ Analysis of the Medicare Claims database suggests that vascular surgery is associated with substantial perioperative and long-term mortality. The reduced long-term mortality in patients who had previously undergone preoperative testing and coronary revascularization reinforces the need for a prospective evaluation of these practices.
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Anesthesia and analgesia · Oct 1999
Comparative StudyThe long-term effect of epidural administration of butamben suspension on nerve injury-induced allodynia in rats.
Although local anesthetics can, in some situations, alleviate neuropathic pain, currently available preparations are short-acting and nonselective, producing, for example, motor dysfunction. Clinical studies report that a novel suspension preparation of butamben has the advantage of a prolonged duration of action, and it can be used epidurally, without impairment of motor function. In this behavioral study, we investigated the effect of the epidural administration of a 5% butamben suspension on nerve injury-induced allodynia. Behavioral studies were performed using an established animal model of neuropathic pain, which involves a partial ligation of the sciatic nerve. Nociceptive thresholds to mechanical stimulation were determined by the paw withdrawal method. The allodynia to mechanical stimulation induced by partial nerve ligation was significantly attenuated by daily injections, for 5 days, of 10 microL of butamben suspension. The analgesia lasted at least 7 days after the final injection. Daily injections of 10 microL of vehicle, for 5 days, had no significant effect on allodynia. During the period of daily injections, both the butamben and vehicle treated rats had temporary impairment of motor coordination compared with untreated controls. Motor function recovered after the final injection. Neither daily injections of butamben for 2 or 3 days, nor smaller volumes for 5 days (2.5-5 microL), had a long-lasting effect. We conclude that repeated epidural administration of butamben suspension for several days provides long-lasting analgesia in rats with nerve injury-induced allodynia to mechanical stimulation. ⋯ In this animal behavioral study, using rats with nerve injury-induced pain, we examined the possible long-term analgesic effects of epidural administration of a suspension of the local anesthetic, butamben. We found that multiple doses for several days were required to provide a prolonged analgesia.