Anesthesia and analgesia
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Anesthesia and analgesia · Oct 2001
Randomized Controlled Trial Comparative Study Clinical TrialNormal saline versus lactated Ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study.
Metabolic acidosis and changes in serum osmolarity are consequences of 0.9% normal saline (NS) solution administration. We sought to determine if these physiologic changes influence patient outcome. Patients undergoing aortic reconstructive surgery were enrolled and were randomly assigned to receive lactated Ringer's (LR) solution (n = 33) or NS (n = 33) in a double-blinded fashion. Anesthetic and fluid management were standardized. Multiple measures of outcome were monitored. The NS patients developed a hyperchloremic acidosis and received more bicarbonate therapy (30 +/- 62 mL in the NS group versus 4 +/- 16 mL in the LR group; mean +/- SD), which was given if the base deficit was greater than -5 mEq/L. The NS patients also received a larger volume of platelet transfusion (478 +/- 302 mL in the NS group versus 223 +/- 24 mL in the LR group; mean +/- SD). When all blood products were summed, the NS group received significantly more blood products (P = 0.02). There were no differences in duration of mechanical ventilation, intensive care unit stay, hospital stay, and incidence of complications. When NS was used as the primary intraoperative solution, significantly more acidosis was seen on completion of surgery. This acidosis resulted in no apparent change in outcome but required larger amounts of bicarbonate to achieve predetermined measurements of base deficit and was associated with the use of larger amounts of blood products. These changes should be considered when choosing fluids for surgical procedures involving extensive blood loss and requiring extensive fluid administration. ⋯ Predominant use of 0.9% saline solution in major surgery has little impact on outcome as assessed by duration of mechanical ventilation, intensive care unit stay, hospital stay, and postoperative complications, but it does appear to be associated with increased perioperative blood loss.
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Anesthesia and analgesia · Oct 2001
Randomized Controlled Trial Clinical TrialThe influence of a bupivacaine and fentanyl epidural infusion after epidural fentanyl in patients allowed to ambulate in early labor.
Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. This study was designed to determine the influence of an epidural infusion of bupivacaine plus fentanyl administered after initiation of epidural labor analgesia with fentanyl. Specifically, we evaluated whether there is an increase in motor block or an increased time to request for further analgesic medication. Fifty-one laboring primigravid women at <5 cm cervical dilation who requested epidural analgesia were enrolled. After a 3-mL epidural test dose of 1.5% lidocaine with epinephrine (5 microg/mL), patients received fentanyl 100 microg via the epidural catheter. They then randomly received either an infusion (10 mL/h) of 0.0625% bupivacaine with fentanyl (3 microg/mL) or an infusion of preservative-free saline. After the administration of the initial analgesic, pain scores and side effects were recorded for each patient at 10, 20, and 30 min, every 30 min thereafter, and at the time of request for additional analgesic medication, by an observer blinded to the technique used. There were no demographic differences between the two groups. The mean duration of analgesia (time from initial dose to request for additional analgesia) was increased in the group that received a continuous infusion of bupivacaine and fentanyl compared with the Saline group (198 +/- 86 vs 145 +/- 50 min; P < 0.009). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block. Fourteen patients chose to ambulate in the Saline group, and 12 patients chose to ambulate in the Infusion group. In early laboring patients, a continuous infusion of 0.0625% bupivacaine infusion with fentanyl (3 microg/mL) prolonged the duration until top-up was required, after epidural fentanyl 100 microg after a lidocaine and epinephrine test dose, and did not cause any clinically detectable motor block. ⋯ A 0.0625% bupivacaine and fentanyl (3 microg/mL) infusion, when added to epidural fentanyl (100 microg), prolongs the analgesic duration without increasing motor block in women in early labor.
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Anesthesia and analgesia · Oct 2001
Randomized Controlled Trial Clinical TrialThe placement of the epidural catheter at the predicted site by electrical stimulation test.
More accurate segmental and sagittal positioning of the epidural catheter tip is required for the success of continuous epidural analgesia, spinal cord monitoring, and percutaneous epidural spinal cord stimulation. We examined the usefulness of an electrical stimulation test for verifying the proper placement of the epidural catheter tip at the predicted site in the posterior epidural space by using a locally developed epidural catheter with electrodes at its tip. The test included the observation of segmental bilateral muscle twitches and the patient's report of feeling in the region stimulated by moving the epidural catheter electrode back and forth and changing the direction of the bevel of the Tuohy needle. The success rate of midline placement at the required spinal segment was significantly more frequent (99%; P < 0.001) in the group (n = 289) receiving the electrical stimulation test compared with the group (n = 277) not receiving the test (success rate 57%). The results indicate the usefulness of this method. We concluded that the electrical stimulation test is effective for verifying the proper placement of the catheter electrode tip. ⋯ Ideally the epidural catheter tip should be positioned in the posterior epidural space near the midline. We concluded that the electrical stimulation test is effective for verifying the proper placement of the catheter electrode tip.
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Anesthesia and analgesia · Oct 2001
Clinical TrialThe continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects.
We investigated the incidence of bacterial and vascular or neurological complications resulting from femoral nerve catheters used for postoperative analgesia. Patients requiring continuous femoral blockade were consecutively included. Using surgical aseptic procedure, 211 femoral nerve catheters were placed (short-beveled insulated needle, peripheral nerve stimulator). After 48 h, each catheter was removed and semiquantitative bacteriological cultures were performed on each distal catheter tip. Postoperative analgesia and antibiotics were standardized. All complications during the insertion of the catheters and postoperatively (after 48 h and 6 wk) were noted. Few initial complications with no immediate or delayed complications were noted (20 difficult insertions, 3 impossible injections, 3 ineffective catheters, and 12 vascular punctures). After 48 h, 208 catheters were analyzed; 57% had positive bacterial colonization (with a single organism in 53%). The most frequent organisms were Staphylococcus epidermidis (71%), Enterococcus (10%), and Klebsiella (4%). Neither cellulitis nor abscess occurred. Three transitory bacteremias likely related to the catheter occurred. After 6 wk, no septic complications were noted. One femoral paresthesia, partially recovered 1 yr later, was noted. We conclude that the risk of bacterial complications is small with femoral nerve catheters, although the rate of colonization is frequent. ⋯ In this prospective study, continuous femoral nerve catheters were effective for postoperative analgesia but had a frequent rate of bacterial catheter colonization. We found no serious infections after short-term (2-day) infusion. Side effects were few, but one nerve injury occurred.
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Anesthesia and analgesia · Oct 2001
Clinical TrialJugular bulb oxyhemoglobin desaturation, S100beta, and neurologic and cognitive outcomes after coronary artery surgery.
We reported that a decline in cognitive performance 3 mo after coronary artery bypass grafting surgery is associated with palpable aortic atheroma, but not postoperative jugular bulb oxyhemoglobin saturation (SjO2) <50%. However, the effect of SjO2 on clinical neurologic findings is not known. S100beta is a possible surrogate biochemical marker of brain injury, and we report here the scored clinical neurologic findings in 98 patients from our previous study in relation to SjO2, cognitive performance, aortic atheroma, and S100beta. Patients underwent a scored neurologic examination and cognitive assessment the day before and 3 mo after coronary artery bypass grafting surgery. Intraoperatively, intermittent blood sampling was performed, and postoperatively, the area under the curve describing SjO2 <50% in relation to time was calculated from continuous jugular bulb reflectance oximetry. Palpation was used to assess the ascending aorta for the presence of atheroma. The jugular bulb concentration of S100beta was measured 6 h after completion of surgery. The neurologic score 3 mo after surgery did not correlate with either intra- or postoperative SjO2 (r = 0.111, P = 0.278; and r = -0.074, P = 0.467, respectively). The main determinant of neurologic score at 3 mo was the preoperative neurologic score (r(2) = 0.63, P < 0.001), whereas palpable atheroma of the ascending aorta made a small but significant contribution (r(2) = 0.034, P = 0.004). Neurologic and cognitive scores correlated before surgery (r = 0.226, P = 0.022) and at 3 mo after surgery (r = 0.348, P < 0.001). A preoperative neurologic deficit of two or more had a small but significant negative effect on cognitive performance at 3 mo (standardized beta = -0.097, P = 0.018). There was a significant univariate correlation between S100beta and the 3-mo neurologic score (r = -0.232, P < 0.05), but not a multivariate correlation (beta = -0.090, P = 0.156). ⋯ Intraoperative jugular bulb oxyhemoglobin saturation (SjO2) and postoperative SjO2 <50% do not have an important influence on long-term neurologic outcome after coronary artery bypass graft surgery. Subtle preoperative neurology is associated with long-term cognitive decline, and aortic atheroma is a risk factor for both cognitive and neurologic decline.