Anesthesia and analgesia
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Anesthesia and analgesia · May 1999
Randomized Controlled Trial Multicenter Study Clinical TrialHextend, a physiologically balanced plasma expander for large volume use in major surgery: a randomized phase III clinical trial. Hextend Study Group.
Hextend (BioTime, Inc., Berkeley, CA) is a new plasma volume expander containing 6% hetastarch, balanced electrolytes, a lactate buffer, and physiological levels of glucose. In preclinical studies, its use in shock models was associated with an improvement in outcome compared with alternatives, such as albumin or 6% hetastarch in saline. In a prospective, randomized, two-center study (n = 120), we compared the efficacy and safety of Hextend versus 6% hetastarch in saline (HES) for the treatment of hypovolemia during major surgery. Patients at one center had a blood sample drawn at the beginning and the end of surgery for thromboelastographic (TEG) analysis. Hextend was as effective as HES for the treatment of hypovolemia. Patients received an average of 1596 mL of Hextend: 42% received >20 mL/kg up to a total of 5000 mL. No patient received albumin. Hextend-treated patients required less intraoperative calcium (4 vs 220 mg; P < 0.05). In a subset analysis of patients receiving red blood cell transfusions (n = 56; 47%), Hextend-treated patients had a lower mean estimated blood loss (956 mL less; P = 0.02) and were less likely to receive calcium supplementation (P = 0.04). Patients receiving HES demonstrated significant prolongation of time to onset of clot formation (based on TEG) not seen in the Hextend patients (P < 0.05). No Hextend patient experienced a related serious adverse event, and there was no difference in the total number of adverse events between the two groups. The results of this study demonstrate that Hextend, with its novel buffered, balanced electrolyte formulation, is as effective as 6% hetastarch in saline for the treatment of hypovolemia and may be a safe alternative even when used in volumes up to 5 L. ⋯ Hextend (BioTime, Inc., Berkeley, CA) is a new plasma volume expander containing 6% hetastarch, balanced electrolytes, a lactate buffer, and a physiological level of glucose. It is as effective as 6% hetastarch in saline for the treatment of hypovolemia but has a more favorable side effects profile in volumes of up to 5 L compared with 6% hetastarch in saline.
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Anesthesia and analgesia · May 1999
Randomized Controlled Trial Clinical TrialClonidine administered as an axillary block does not affect postoperative pain when given as the sole analgesic.
Used as the sole analgesic, clonidine produces analgesia after epidural, intrathecal, and intraarticular administration. We conducted this double-blinded study to determine whether clonidine has analgesic effects when administered into the brachial plexus sheath. At the conclusion of hand or forearm surgery, performed under axillary brachial plexus block, 45 patients were randomly divided into three groups of 15 each to receive, through an axillary catheter, 15 mL of saline (Group Saline), clonidine 150 microg in 15 mL of saline (Group Clonidine), or bupivacaine 15 mL (Group Bupivacaine). The analgesic effects of the three solutions were evaluated for 6 h. Times to onset of pain and to first analgesic request were longer, and the total dose of pain medication was smaller in Group Bupivacaine compared with the other groups. Visual analog scores were significantly lower in Group Bupivacaine. There was no significant difference in time to onset of pain, time to first analgesic request, total dose of pain medication, and visual analog scores between Group Saline and Group Clonidine at any time. We conclude that the administration of clonidine 150 microg into the brachial plexus sheath does not prolong the onset of postoperative pain. ⋯ Used as the sole analgesic, clonidine produces analgesia after epidural, intrathecal, and intraarticular administration. It also prolongs the analgesic effect of brachial plexus block when mixed with local anesthetics. In this study, the administration of clonidine 150 microg alone into the brachial plexus sheath did not produce postoperative analgesia.
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Anesthesia and analgesia · May 1999
The relationship of cognitive, personality, and academic measures to anesthesiology resident clinical performance.
Cognitive skills (including vigilance), personality factors, and standardized academic test performance may be associated with clinical competence in anesthesiology to varying degrees. Sixty-seven anesthesiology residents in training at one center between 1993 and 1995 were administered the modified Vigil (For Thought, Ltd., Nashua, NH), the Paced Auditory Serial Addition Test, the California Personality Inventory, the State-Trait Anxiety Inventory, and five standardized academic performance tests. The clinical performance of anesthesiology residents was rated on a quarterly basis by a clinical competence committee. A growth curve model indicated that there was significant variability in clinical competence at the start of residency and a statistically significant improvement over time, and that the relative ranking of the residents remained stable over the course of training. Of 46 potential variables, 7 were associated (P < 0.10) with poor clinical performance; these were subjected to a multivariate test (Mantel-Haenszel). Cognitive variables predicting poor clinical performance were difficulty performing a rapid mental arithmetic test requiring divided attention and commission errors during complex visual target detection. Personality variables predicting poor clinical performance were introversion and flexibility. A predictive academic variable was poor anesthesia knowledge as measured by using two different tests during the first month of training. There were varying levels of independence among these variables. ⋯ Early academic test performance and certain cognitive and personality tests were associated with the clinical performance of anesthesiology residents. The predictive value of these findings should be confirmed in a prospective, multicenter study.
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Anesthesia and analgesia · May 1999
Treatment of intraoperative refractory hypotension with terlipressin in patients chronically treated with an antagonist of the renin-angiotensin system.
The goal of the present study was to determine whether terlipressin, an agonist of the vasopressin system, could counteract perioperative hypotension refractory to common vasopressor therapy and to analyze its circulatory effects. We enrolled 51 consecutive vascular surgical patients chronically treated with angiotensin-converting enzyme inhibitors or antagonists of the receptor of angiotensin II, who received a standardized opioid-propofol anesthetic. Of these 51 patients, 32 had at least one episode of hypotension, which responded to epinephrine or phenylephrine. In 10 other patients, systolic arterial pressure (SAP) did not remain above 100 mm Hg for 1 min, despite three bolus doses of ephedrine or phenylephrine. In these patients, we injected a bolus of 1 mg of terlipressin, repeated twice if necessary. Hemodynamic and echocardiographic variables were recorded every 30 s over 6 min. In eight patients, arterial pressure was restored with one injection of terlipressin; in two other patients, three injections were necessary. One minute after the last injection of terlipressin, the SAP increased from 88+/-3 to 100+/-4 mm Hg and reached 117+/-5 mm Hg (P = 0.001) 3 min after the injection and remained stable around this value. This increase in SAP was associated with significant changes in left ventricular end-diastolic area (17.9+/-2 vs 20.2+/-2.2 cm2; P = 0.003), end-systolic area (8.1+/-1.3 vs 9.6+/-1.5 cm2; P = 0.004), end-systolic wall stress (45+/-8 vs 66+/-12; P = 0.001), and heart rate (60+/-4 vs 55+/-3 bpm; P = 0.001). Fractional area change and velocity of fiber shortening did not change significantly. No additional injection of vasopressor was required during the perioperative period. No change in ST segment was observed after the injection. ⋯ Terlipressin is effective to rapidly correct refractory hypotension in patients chronically treated with antagonists of the renin-angiotensin system without impairing left ventricular function.
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Anesthesia and analgesia · May 1999
Randomized Controlled Trial Clinical TrialThe effect of intravenous ketoprofen on postoperative epidural sufentanil analgesia in children.
We compared the effect of IV ketoprofen and placebo as an adjuvant to epidural sufentanil analgesia after major surgery. We used a prospective, randomized, double-blinded, placebo-controlled, parallel-group study design in 54 children aged 1-15 yr who received a standardized anesthetic. Either IV ketoprofen or saline was administered in addition to an epidural sufentanil infusion, which was adjusted as required clinically. The study drug infusions were discontinued when pain scores were <3 on 0-10 scale for 6 h at a sufentanil infusion rate of 0.03 microg x kg(-1) x h(-1). Children in the ketoprofen group had a better analgesic effect, as shown by decreased need for sufentanil (mean [10th-90th percentiles] 8.3 [3.1-15.1] microg/kg vs 12.5 [6.2-18.9] microg/kg; P = 0.002) and earlier possibility to discontinuation of the epidural sufentanil (11 [46%] vs 3 [13%]; P = 0.014) before the end of the 72-h study period. In the ketoprofen group, median (range) pain scores were lower during activity at 24 h (2 [0-5] vs 5 [0-7]; P = 0.01) and at 72 h (0 [0-3] vs 2 [0-6]; P = 0.033), and fewer children had inadequate pain relief during activity at 24 h (0 vs 5; P = 0.037). Children who received ketoprofen required fewer infusion rate adjustments (12 [4-20] vs 17 [6-42]; P = 0.016). In the ketoprofen group, the incidence of desaturation (1 [4%] vs 6 [26%]; P = 0.035) and fever (3 [12%] vs 11 [48%]; P = 0.008) was less than that in the placebo group. We conclude that ketoprofen improved postoperative pain in children. ⋯ We compared the effect of the IV nonsteroidal antiinflammatory drug ketoprofen versus placebo as adjuvants to epidural opioid analgesia with sufentanil. The continuous IV nonsteroidal antiinflammatory drug improved pain after major surgery in children receiving an epidural opioid. Although ketoprofen reduced epidural sufentanil requirements, the incidence of opioid-related adverse effects was not changed.