Anesthesia and analgesia
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Anesthesia and analgesia · Apr 2000
Randomized Controlled Trial Comparative Study Clinical TrialA comparison of intrathecal analgesia with fentanyl or sufentanil after total hip replacement.
We designed this study to compare the postoperative analgesic effects of intrathecal fentanyl and sufentanil, the end points being onset, quality, and duration of action. A total of 42 geriatric patients, scheduled for elective total hip replacement under continuous spinal anesthesia, were randomized in two double-blinded groups as soon as they experienced a pain score higher than 3 of 10 on the visual analog scale in the recovery room. Either 7.5 microg sufentanil or 40 microg fentanyl in 2 mL normal saline were intrathecally administered. Pain scores, rescue analgesia (ketorolac and morphine), and adverse effects (respiratory depression, postoperative nausea and vomiting, and itching) were recorded for 24 h after surgery. In both groups, comparing sufentanil to fentanyl, the time to a pain score <3 (9 +/- 9 vs 11 +/- 8 min), the time to the lowest pain score (18 +/- 6 vs 20 +/- 15 min), and the time to the first systemic analgesic intervention for a pain score >3 (241 +/- 102 vs 214 +/- 120 min) were comparable as were the analgesic requirements during the first 24 h. We conclude that, after total hip replacement, both lipid soluble opioids produce excellent analgesia with comparable onset, duration of action, and low incidence of minor adverse effects. ⋯ We compared the postoperative analgesic properties of 40 microg intrathecal fentanyl and 7.5 microg sufentanil after total hip replacement. Both opioids provided satisfactory analgesia, with comparable onset (11 +/- 8 vs 9 +/- 9 min) and duration of action (214 +/- 120 vs 241 +/- 102 min), as well as low incidence of minor side effects.
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Anesthesia and analgesia · Apr 2000
Meta AnalysisPrevention of pain on injection with propofol: a quantitative systematic review.
The best intervention to prevent pain on injection with propofol is unknown. We conducted a systematic literature search (Medline, Embase, Cochrane Library, bibliographies, hand searching, any language, up to September 1999) for full reports of randomized comparisons of analgesic interventions with placebo to prevent that pain. We analyzed data from 6264 patients (mostly adults) of 56 reports. On average, 70% of the patients reported pain on injection. Fifteen drugs, 12 physical measurements, and combinations were tested. With IV lidocaine 40 mg, given with a tourniquet 30 to 120 s before the injection of propofol, the number of patients needed to be treated (NNT) to prevent pain in one who would have had pain had they received placebo was 1.6. The closest to this came meperidine 40 mg with tourniquet (NNT 1.9) and metoclopramide 10 mg with tourniquet (NNT 2.2). With lidocaine mixed with propofol, the best NNT was 2.4; with IV alfentanil or fentanyl, it was 3 to 4. IV lidocaine before the injection of propofol was less analgesic. Temperature had no significant effect. There was a lack of data for all other interventions to allow meaningful conclusions. The diameter of venous catheters and speed of injection had no impact on pain. ⋯ IV lidocaine (0.5 mg/kg) should be given with a rubber tourniquet on the forearm, 30 to 120 s before the injection of propofol; lidocaine will prevent pain in approximately 60% of the patients treated in this manner.
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Anesthesia and analgesia · Apr 2000
Randomized Controlled Trial Clinical TrialThe use of a ketamine-propofol combination during monitored anesthesia care.
Supplemental analgesics are commonly used to enhance analgesia and improve patient comfort during procedures performed under local anesthesia and sedation. Because the use of ketamine as an analgesic adjunct to propofol sedation has not been well established, we evaluated its impact on analgesia, sedation, and recovery after ambulatory surgery. One hundred female outpatients undergoing breast biopsy procedures under local anesthesia participated in this randomized, double-blinded, placebo-controlled study. After premedication with midazolam, 2 mg IV, patients received an infusion of a solution containing propofol (9.4 mg/mL) in combination with either placebo (saline) (Group 1) or ketamine, 0.94 mg/mL (Group 2), 1.88 mg/mL (Group 3), or 2.83 mg/mL (Group 4). The sedative infusion rate was varied to maintain a deep level of sedation (Observer Assessment of Alertness/Sedation score 4) and normal respiratory and hemodynamic functions. Sufentanil, 2.5 microg IV, "rescue" boluses were used as needed to treat patients' responses (if any) to local anesthetic infiltration or surgical stimulation. Ketamine produced a dose-dependent reduction in the "rescue" opioid requirements. However, there was an increase in postoperative nausea and vomiting, psychomimetic side effects, and delay in discharge times with the largest ketamine dosage (Group 4). The adjunctive use of ketamine during propofol sedation provides significant analgesia and minimizes the need for supplemental opioids. The combination of propofol (9.4 mg/mL)/ketamine (0.94-1.88 mg/mL) provides effective sedation/analgesia during monitored anesthesia care. ⋯ Ketamine, when used in subhypnotic dosages, may be an useful adjuvant to propofol sedation.
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Anesthesia and analgesia · Apr 2000
Randomized Controlled Trial Clinical TrialThe hemodynamic and adrenergic effects of perioperative dexmedetomidine infusion after vascular surgery.
We tested dexmedetomidine, an alpha(2) agonist that decreases heart rate, blood pressure, and plasma norepinephrine concentration, for its ability to attenuate stress responses during emergence from anesthesia after major vascular operations. Patients scheduled for vascular surgery received either dexmedetomidine (n = 22) or placebo (n = 19) IV beginning 20 min before the induction of anesthesia and continuing until 48 h after the end of surgery. All patients received standardized anesthesia. Heart rate and arterial blood pressure were kept within predetermined limits by varying anesthetic level and using vasoactive medications. Heart rate, arterial blood pressure, and inhaled anesthetic concentration were monitored continuously; additional measurements included plasma and urine catecholamines. During emergence from anesthesia, heart rate was slower with dexmedetomidine (73 +/- 11 bpm) than placebo (83 +/- 20 bpm) (P = 0.006), and the percentage of time the heart rate was within the predetermined hemodynamic limits was more frequent with dexmedetomidine (P < 0.05). Plasma norepinephrine levels increased only in the placebo group and were significantly lower for the dexmedetomidine group during the immediate postoperative period (P = 0.0002). We conclude that dexmedetomidine attenuates increases in heart rate and plasma norepinephrine concentrations during emergence from anesthesia. ⋯ The alpha(2) agonist, dexmedetomidine, attenuates increases in heart rate and plasma norepinephrine concentrations during emergence from anesthesia in vascular surgery patients.