Anesthesia and analgesia
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Anesthesia and analgesia · Aug 2000
Randomized Controlled Trial Clinical TrialFentanyl improves analgesia but prolongs the onset of axillary brachial plexus block by peripheral mechanism.
We evaluated the effects of fentanyl added to lidocaine for axillary brachial plexus block in 66 adult patients scheduled for elective hand and forearm surgery. In this double-blinded study, all patients received 40 mL of 1.5% lidocaine with 1:200,000 epinephrine, injected into the brachial plexus sheath using the axillary perivascular technique, and they were randomized into three groups. Group 1 was given lidocaine containing 2 mL of normal saline plus 2 mL of normal saline IV. Patients in Group 2 received lidocaine containing 100 microg fentanyl plus 2 mL of normal saline IV. Group 3 patients received lidocaine containing 2 mL of normal saline plus 100 microg fentanyl IV. Sensory and motor blockade were evaluated by using a pinprick technique and by measuring the gripping force, respectively. The success rate of sensory blockade for radial and musculocutaneous nerves and the duration of the sensory blockade significantly increased in Group 2 (323 +/- 96 min) as compared with Group 1 (250 +/- 79 min). However, onset time of analgesia was prolonged in every nerve distribution by adding fentanyl to brachial plexus block. IV fentanyl had no effect on the success rate, onset, or duration of blockade. We conclude that the addition of fentanyl to lidocaine causes an improved success rate of sensory blockade but a delayed onset of analgesia, although this may be accounted for by the decreased pH caused by the fentanyl. ⋯ It is still unclear whether the addition of a peripheral opioid is useful for nerve blockade in humans. Peripheral application of fentanyl to lidocaine for axillary brachial plexus blockade in this study provided an improved success rate of sensory blockade and prolonged duration.
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Anesthesia and analgesia · Aug 2000
Randomized Controlled Trial Clinical TrialIs succinylcholine after pretreatment with d-tubocurarine and lidocaine contraindicated for outpatient anesthesia?
Because succinylcholine has obvious advantages for facilitating endotracheal intubation in the ambulatory setting (e.g., low cost, fast onset, and no need for reversal of neuromuscular block), it is important to determine whether this muscle relaxant is indeed associated with an increased incidence of postoperative myalgias, compared with alternative but more expensive nondepolarizing muscle relaxants. We studied 119 outpatients undergoing endoscopic nasal sinus surgery or septoplasty. The anesthetic technique consisted of propofol/lidocaine for induction, followed by isoflurane/nitrous oxide/oxygen for maintenance. Oral tracheal intubation was performed by using a fiberscope. Patients were randomly assigned to one of two muscle relaxant groups. Group 1 patients received d-tubocurarine 3 mg followed by succinylcholine 1.5 mg/kg. Group 2 patients received mivacurium 0.2 mg/kg. After recovery from anesthesia, patients were asked whether they had any muscle pain and/or stiffness. Pain was categorized by location and quantified by using a verbal scale (from 0 to 10). Analgesic usage and myalgias limiting ambulation were recorded. After discharge from the ambulatory surgery unit, patients were contacted by telephone on Postoperative Day 1. If patients complained of myalgias, they were contacted by telephone on Days 2 and 3. Only one patient (in the mivacurium-treated group) reported myalgia as a limiting factor in ambulation or resumption of normal activity. There were no differences between groups with respect to the incidence (21% in the succinylcholine-treated group and 18% in the mivacurium-treated group), location, or severity of myalgia. In conclusion, succinylcholine (preceded by pretreatment with d-tubocurarine and lidocaine) is not associated with an increased incidence of myalgias, compared with mivacurium, when used to facilitate tracheal intubation in patients undergoing ambulatory nasal surgery. ⋯ The results of this study show that the frequency of muscle pains after surgery in outpatients is approximately 20%, regardless of whether succinylcholine (after precurarization) or mivacurium is used to assist in insertion of the breathing tube.
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Anesthesia and analgesia · Aug 2000
Randomized Controlled Trial Clinical TrialPropofol without muscle relaxants for conventional or fiberoptic nasotracheal intubation: a dose-finding study.
Endotracheal intubation has been performed during the administration of propofol anesthesia without neuromuscular blockade. In this study, we determined the propofol dose required for conventional nasotracheal or for fiberoptic nasotracheal intubation of all patients. Thirty-two patients undergoing maxillofacial surgery were randomly assigned to the conventional (n = 16) or to the fiberoptic (n = 16) intubation group. In both groups, anesthesia was induced by using IV fentanyl and IV titrated propofol according to clinical need (spontaneous respiration rate, verbal response). An endotracheal tube was placed nasally in the pharynx and the vocal cords visualized by using a fiberscope inserted via the tube. In the conventional group, the larynx was visualized additionally with a laryngoscope blade (Miller). In both groups propofol was titrated until the vocal cords opened. Patients were tracheally intubated, and the propofol dose was recorded. In all patients, the trachea could be intubated without the use of muscle relaxants. Considerable interindividual differences of dose requirements were observed. The amount of propofol required in the conventional group was significantly (P < 0.0001) larger (median +/- SD: 2.74 +/- 1.59 mg/kg; range 1.95-7.07 mg/kg) than in the fiberoptic group (1.37 +/- 0.59 mg/kg; 0.72-2.86 mg/kg). Hemodynamics remained stable in all patients. Postintubational hoarseness occurred in three patients of each group. Fiberoptic nasal intubation without a muscle relaxant can be facilitated with significantly smaller and more predictable dosages of propofol than conventional nasal endotracheal intubation. The possibility of titrating the propofol dose under assisted ventilation until the vocal cords open during fiberoptic nasotracheal intubation and the better predictability of the required dose favors the fiberoptic approach. ⋯ In this study, contrary to all preceding studies using predefined doses of propofol and opioids, we determined the minimal required propofol dose in combination with fentanyl for conventional or fiberoptic nasotracheal intubation without muscle relaxants.
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Anesthesia and analgesia · Aug 2000
Case ReportsVecuronium-induced neuromuscular blockade in a patient with cerebral palsy and hemiplegia.
We evaluated vecuronium-induced neuromuscular block in both arms of a patient with cerebral palsy and hemiplegia. A remarkable resistance to vecuronium was observed in the hemiplegia side compared with cerebral palsy side. Complete recovery from neuromuscular block should be assessed in the cerebral palsy side that shows a delayed recovery.
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Anesthesia and analgesia · Aug 2000
The efficacy and safety of epidural infusions of levobupivacaine with and without clonidine for postoperative pain relief in patients undergoing total hip replacement.
We assessed the efficacy and tolerability of epidural infusions of levobupivacaine, levobupivacaine plus clonidine, and clonidine for postoperative analgesia in 86 patients undergoing total hip replacement. For each group, an epidural cannula was inserted before surgery and 15 mL of 0.75% plain levobupivacaine was administered. Three hours later, an epidural infusion (6 mL/h) of levobupivacaine 0.125% (L), levobupivacaine 0.125% plus clonidine 8.3 microg/mL (LC) or clonidine alone (8.3 microg/mL) (C) was initiated. Morphine consumption was recorded for the following 24 h as were visual analog pain scores and the degree of sensory and motor blockade. The mean (median) morphine consumption was lowest in the combination group (LC),14 (7) mg; higher in the clonidine group (C), 23 (21) mg; and highest in the levobupivacaine group (L), 37 (36) mg (P = 0.022). The median times until the first request for analgesia which were 2. 9, 5.9, and 12.5 h for Groups L, C, and LC, respectively (P < or = 0. 01). There were no statistical differences among the groups regarding the maximum degree of postoperative motor blockade. On average, the systolic blood pressure in the two clonidine groups was slightly lower than in those from the levobupivacaine group. We conclude that the epidural administration of a combination of levobupivacaine plus clonidine is well tolerated and gives better analgesia than either drug used alone. ⋯ In patients undergoing total hip replacement, the addition of the alpha(2)-adrenergic agonist clonidine to epidural infusions of levobupivacaine significantly improved postoperative analgesia.