Anesthesia and analgesia
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Anesthesia and analgesia · Aug 1999
Randomized Controlled Trial Clinical TrialPostoperative analgesia with no motor block by continuous epidural infusion of ropivacaine 0.1% and sufentanil after total hip replacement.
We assessed the analgesic efficacy of postoperative epidural ropivacaine 0.1% with and without sufentanil 1 microgram/mL in this prospective, randomized, single-blinded study of 30 ASA physical status I-III patients undergoing elective total hip replacement. Lumbar epidural block using 0.75% ropivacaine was combined with either propofol sedation or general anesthesia for surgery. After surgery, the epidural infusion was commenced. Fifteen patients in each group received either an epidural infusion of 0.1% ropivacaine with 1 microgram/mL sufentanil (R + S) or 0.1% ropivacaine without sufentanil (R) at a rate of 5-9 mL/h. All patients had access to i.v. piritramide via a patient-controlled analgesia device. The R + S group consumed six times less piritramide over a 48-h infusion period than the R group (median 12.7 vs 73.0 mg; P < 0.001). Motor block was negligible for the study duration in both groups. Patient satisfaction was excellent. The incidence of adverse events, such as nausea, was similar. We conclude that a continuous epidural infusion of 0.1% ropivacaine with 1 microgram/mL sufentanil is more effective than ropivacaine alone in treating pain after elective hip replacement without motor block. ⋯ This is the first randomized study comparing the efficacy of the epidural combination of ropivacaine 0.1% and sufentanil 1 microgram/mL versus plain ropivacaine 0.1% in treating pain after hip replacement. We found that ropivacaine 0.1% and sufentanil 1 microgram/mL led to a sixfold reduction in opioid requirements after total hip replacement by producing a negligible motor block.
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Anesthesia and analgesia · Aug 1999
Randomized Controlled Trial Comparative Study Clinical TrialSevoflurane speeds recovery of baroreflex control of heart rate after minor surgical procedures compared with isoflurane.
Volatile anesthetics attenuate arterial baroreflex functions, whereas noxious stimuli may modify baroreflex-induced circulatory responses during anesthesia. We designed the present study to compare baroreflex control of heart rate during sevoflurane and isoflurane anesthesia in young healthy surgical patients. Baroreflex sensitivity was assessed in 24 patients randomized to receive either sevoflurane (n = 12) or isoflurane (n = 12) for general anesthesia. After an 8- to 10-h fast and no premedication, measurements of RR intervals obtained from electrocardiography and systolic blood pressure (SBP) measured through a radial artery catheter were made at conscious baseline (Awake), during end-tidal sevoflurane 2% or isoflurane 1.2% plus 67% nitrous oxide before incision (Anesth), during surgery at end-tidal sevoflurane 2% or isoflurane 1.2% plus 67% nitrous oxide (Surg), and 20 min after tracheal extubation (Recov). Baroreflex responses were triggered by bolus i.v. injections of phenylephrine (100-150 micrograms) and nitroprusside (100-150 micrograms) to increase and decrease SBP by 15-30 mm Hg, respectively. The linear portions of the baroreflex curves relating RR intervals and SBP were determined to obtain baroreflex sensitivities. Baroreflex sensitivities to both pressor and depressor tests were significantly depressed during Anesth and Surg periods compared with Awake values in both anesthetic techniques. The pressor test sensitivity during the Recov period returned to the Awake value after sevoflurane (12.9 +/- 3.7 vs 11.0 +/- 8.7 ms/mm Hg [mean +/- SD]) but was still depressed after isoflurane anesthesia (13.9 +/- 8.0 vs 4.8 +/- 3.2 ms/mm Hg; P < 0.05). The depressor test sensitivities during the Recov period remained depressed after both anesthetic techniques. We conclude that both sevoflurane and isoflurane depress arterial baroreflex function during anesthesia and surgery, but the pressor test sensitivity was restored more quickly after sevoflurane than after isoflurane anesthesia. ⋯ Arterial baroreflex function is an important neural control system for maintaining cardiovascular stability. We found that baroreflex control of heart rate due to hypertensive perturbation returned to the preanesthetic level more quickly after sevoflurane than after isoflurane anesthesia.
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Anesthesia and analgesia · Aug 1999
Randomized Controlled Trial Clinical TrialThe effect of hematocrit on cerebral blood flow velocity in neonates and infants undergoing deep hypothermic cardiopulmonary bypass.
Varying degrees of hemodilution are used during deep hypothermic cardiopulmonary bypass. However, the optimal hematocrit (Hct) level to ensure adequate oxygen delivery without impairing microcirculatory flow is not known. In this prospective, randomized study, cerebral blood flow velocity in the middle cerebral artery was measured using transcranial Doppler sonography in 35 neonates and infants undergoing surgery with deep hypothermic cardiopulmonary bypass. Patients were randomized to low Hct (aiming for 20%) or high Hct (aiming for 30%) during cooling on cardiopulmonary bypass (CPB). Systolic (V(s)), mean (Vm), and diastolic (Vd) cerebral blood flow velocity, as well as pulsatility index (PI = [V(s) - Vd]/Vm) and resistance index (RI = [V(s) - Vd]/V(s)) were recorded at six time points: postinduction, at cannulation, after 10 min cooling on CPB, rewarmed to 35 degrees C on CPB, immediately off CPB, and at skin closure. Vm was significantly lower in the high Hct group compared with that in the low Hct group during cooling (P < 0.01). Postinduction, the high Hct group demonstrated significantly lower Vd immediately off CPB (P < 0.01) and significantly lower Vm and V(s) at skin closure (P < 0.001). We conclude that there is an inverse relation between hematocrit and cerebral blood flow velocity during deep hypothermic cardiopulmonary bypass in neonates and infants. ⋯ There is an inverse relation between hematocrit and cerebral blood flow velocity during deep hypothermic cardiopulmonary bypass in neonates and infants. Further studies correlating Hct and cerebral blood flow velocity with cerebral metabolic rate and neurologic outcome are necessary to determine the optimal Hct during deep hypothermic cardiopulmonary bypass.
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Anticipated technical difficulty is one factor that can influence the anesthesiologist's decision to perform neuraxial (spinal or epidural) blockade. Problems during the procedure may be associated with patient dissatisfaction, neurologic sequelae, or hematoma. We designed this study of 595 neuraxial blocks to determine whether any patient characteristics would be useful in predicting a difficult neuraxial block. Before the procedure, the following data were noted: demographic data, body habitus (normal, thin, muscular, obese), spinal landmarks (good = easily palpable spinous processes, poor = difficult to palpate spinous processes, none = unable to positively identify spinous processes), and spinal anatomy (assessed by inspection and examination as normal or deformed). We noted the technique, approach, needle type, needle gauge, etc. We also recorded whether the procedure was completed at the first (first-level success) or second spinal level and the total number of new skin punctures (attempts) necessary to complete the procedure. Of all the factors considered, the quality of landmarks best correlated with technical difficulty as measured by both first-level success and number of attempts. Abnormal spinal anatomy correlated with difficulty as measured by number of attempts. Body habitus also correlated with difficulty, but only as measured by number of attempts. There was no association between either measure of difficulty and any of the following: age, sex, spinal versus epidural, approach, needle type, needle gauge, or training level of the provider. Thoracic epidurals were less difficult than lumbar epidurals by both measures of difficulty. We conclude that body habitus does not seem to be the best predictor of technical difficulty. An examination of the patient's back for the quality of landmarks and obvious anatomical deformity better predicts the ease or difficulty of neuraxial block. Other factors seem to have little or no influence on the difficulty of neuraxial block procedures. ⋯ We studied a number of factors, including equipment, technique, and patient characteristics, that may indicate the ease or difficulty of performing neuraxial (spinal and epidural) blocks. Of these factors, only patient characteristics had significant predictive value. We found that an examination of the patient's back for the quality of landmarks and obvious anatomical deformity better predicts the ease or difficulty of neuraxial block than does body habitus.
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Anesthesia and analgesia · Aug 1999
Effects of one minimum alveolar anesthetic concentration sevoflurane on cerebral metabolism, blood flow, and CO2 reactivity in cardiac patients.
We investigated the cerebral hemodynamic effects of 1 minimum alveolar anesthetic concentration (MAC) sevoflurane anesthesia in nine male patients scheduled for elective coronary bypass grafting. For measurement of cerebral blood flow (CBF), a modified Kety-Schmidt saturation technique was used with argon as an inert tracer gas. Measurements of CBF were performed before the induction of anesthesia and 30 min after induction under normocapnic, hypocapnic, and hypercapnic conditions. Compared with the awake state under normocapnic conditions, sevoflurane reduced the mean cerebral metabolic rate of oxygen by 47% and the mean cerebral metabolic rate of glucose by 39%. Concomitantly, CBF was reduced by 38%, although mean arterial pressure was kept constant. Significant changes in jugular venous oxygen saturation were absent. Hypocapnia and hypercapnia caused a 51% decrease and a 58% increase in CBF, respectively. These changes in CBF caused by variation of Paco2 indicate that cerebrovascular CO2 reactivity persists during 1 MAC sevoflurane anesthesia. ⋯ We used a modified Kety-Schmidt saturation technique to investigate the effects of 1 minimum alveolar anesthetic concentration (MAC) sevoflurane on cerebral blood flow, metabolism, and CO2 reactivity in cardiac patients. We found that the global cerebral blood flow and global cerebral metabolic rate of oxygen remained coupled and that cerebrovascular CO2 reactivity is not impaired by the administration of 1 MAC sevoflurane.