Anesthesia and analgesia
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Anesthesia and analgesia · Jan 2001
Clinical TrialAn evaluation of the brachial plexus block at the humeral canal using a neurostimulator (1417 patients): the efficacy, safety, and predictive criteria of failure.
To evaluate the efficacy and safety of the multiple peripheral nerve block technique at the humeral canal (humeral block) with the use of a neurostimulator, we prospectively studied 1417 patients undergoing upper limb surgery with a brachial plexus block at the humeral canal (1468 blocks). The success rate (defined as sensory block [in all nerve distributions] and/or the absence of another anesthetic technique required to allow surgery) was 95%. The threshold of minimal stimulation used to locate each nerve before injecting the anesthetic solution was the unique predictive factor for identified failure. For the median nerve, the threshold was 0.8 mA with a relative risk of failure (RRf: relative risk evaluated by series of Taylor with a 95% confidence interval) = 1.49 (P = 0.04), for the radial nerve the threshold was 0.6 mA (RRf 1.3, P = 0.02), and 0.7 mA for the ulnar nerve (RRf 1.36, P = 0.04). For any equal or higher stimulation level, the risk of failure of the humeral block increased. For the musculocutaneous nerve, we did not observe a significant stimulation threshold for the risk of failure; although beyond 0.7 mA, the RRf was always more than 1.3. Adverse events occurred in 7% of all cases and were usually minor (nausea/vomiting, anxiety, local pain). Our study provides supplementary information on the efficacy and safety of this technique. Stimulation thresholds are clinically identified for the first time as the main factor linked to the failure of a technique using a neurostimulator. We conclude that the humeral block is a reliable peripheral block allowing good success rates results with minor complications, which can be used as an alternative to the axillary block. ⋯ We prospectively evaluated the feasibility and the factors causing failure of a peripheral nerve block technique (humeral block) using neurostimulation in a large number of patients. The importance of the level of stimulation for the success of the block was evaluated for the first time.
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Anesthesia and analgesia · Jan 2001
Comparative Study Clinical TrialA videographic analysis of laryngeal exposure comparing the articulating laryngoscope and external laryngeal manipulation.
Activation of the articulating laryngoscope and external laryngeal manipulation (ELM) improve laryngeal exposure during direct laryngoscopy. We used a head-mounted direct laryngoscopy imaging system and a previously validated scoring system for assessing laryngeal view (the percentage of glottic opening or POGO score) on 33 adult patients undergoing laryngoscopy. On each patient, we videotaped the initial laryngeal exposure (blade not activated), the view with activation of the blade, and the view with operator-directed external laryngeal manipulation. ⋯ We conclude that ELM is superior to articulating laryngoscope blade activation in improving POGO scores during laryngoscopy on adult patients in standard sniffing position. Using recordings from a direct laryngoscopy video system, we compared laryngeal views in 33 patients with a special articulating laryngoscope blade to views achieved by external laryngeal manipulation (pressing on the patient's neck). Laryngeal exposure, which is important for placement of tracheal tubes, was better with external laryngeal manipulation.
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Anesthesia and analgesia · Jan 2001
Awake craniotomy for removal of intracranial tumor: considerations for early discharge.
We retrospectively reviewed the anesthetic management, complications, and discharge time of 241 patients undergoing awake craniotomy for removal of intracranial tumor to determine the feasibility of early discharge. The results were analyzed by using univariate analysis of variance and multiple logistic regression. The median length of stay for inpatients was 4 days. Fifteen patients (6%) were discharged 6 h after surgery and 76 patients (31%) were discharged on the next day. Anesthesia was provided by using local infiltration supplemented with neurolept anesthesia consisting of midazolam, fentanyl, and propofol. There was no significant difference in the total amount of sedation required. Overall, anesthetic complications were minimal. One patient (0.4%) required conversion to general anesthesia and one patient developed a venous air embolus. Fifteen patients (6%) had self-limiting intraoperative seizures that were short-lived. Of the 16 patients scheduled for ambulatory surgery, there was one readmission and one unanticipated admission. It may be feasible to discharge patients on the same or the next day after awake craniotomy for removal of intracranial tumor. However, caution is advised and patient selection must be stringent with regards to the preoperative functional status of the patient, tumor depth, surrounding edema, patient support at home, and ease of access to hospital for readmission. ⋯ It may be feasible to perform awake craniotomies for removal of intracranial tumor as an ambulatory procedure; however, caution is advised. Patient selection must be stringent with respect to the patient's preoperative functional status, tumor depth, surrounding edema, patient support at home, and ease of access to hospital for readmission.
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Anesthesia and analgesia · Jan 2001
Editorial CommentHow can local anesthetic in the wound not help?
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Anesthesia and analgesia · Jan 2001
The effects of peripheral administration of a novel selective antagonist for prostaglandin E receptor subtype EP(1), ONO-8711, in a rat model of postoperative pain.
Mechanically evoked pain, also known as incident pain, induced by coughing or deep breathing after surgery leads to potentially devastating consequences. It is generally thought that the prostaglandin receptor- (especially, the receptor for prostaglandin E(2), EP receptor) mediated sensitization of sensory nerve fibers is a key contributor to the generation of hyperalgesia. We examined whether a peripherally administered novel selective EP(1) antagonist, ONO-8711, would be a potential analgesic for incision-induced mechanical hyperalgesia. We used a rat model of postoperative pain introduced by Brennan et al. (1). Withdrawal thresholds to punctate stimulation and response frequencies to nonpunctate mechanical stimulation were determined by using von Frey filaments applied adjacent to the wound and directly to the incision site of the hind paw, respectively. Mechanical hyperalgesia to punctate and nonpunctate stimuli was observed 2 and 24 h after the incision. ONO-8711 (2, 10, or 50 microg) or saline was administered subcutaneously into the hind paw on the ipsilateral side to the incision. ONO-8711 significantly (P < 0.01) increased the withdrawal thresholds to punctate mechanical stimulation and significantly (P < 0.01) decreased the response frequencies to nonpunctate mechanical stimulation in a dose- and time-dependent manner 2 and 24 h after the incision. We conclude that EP(1) receptor-mediated sensitization of sensory nerve fibers may contribute to the generation of mechanical hyperalgesia produced by incisional surgery, and that the EP(1) receptor antagonist ONO-8711 may be an option for treatment of postoperative pain, especially incident pain. ⋯ The peripheral administration of an antagonist for EP(1) receptor that is a subtype of prostaglandin E receptors can inhibit the mechanical hyperalgesia induced by a surgical incision.