Anesthesia and analgesia
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Anesthesia and analgesia · Jun 2001
Case ReportsTunneled epidural catheters for prolonged analgesia in pediatric patients.
We conducted this retrospective study to document the efficacy and safety, and demonstrate the spectrum of indications for subcutaneously tunneled epidural catheters in the management of prolonged pain in pediatric patients. The charts of 25 patients with prolonged pain that was unresponsive to conventional opioid therapy (10: end stage malignancy, 8: extensive abdominal surgery, 7: trauma, etc.) and who received thoracic, lumbar, or caudal tunneled epidural catheters between 1995 and 1999 were reviewed for efficacy and catheter-related complications (infection or bleeding at the insertion site, toxicity related to local anesthetics, tachyphylaxis and respiratory depression). Tunneled epidural catheters were effective in providing extended analgesia in all subjects. In 14 patients with chronic pain, cumulative 48-h enteral and parenteral opioid requirements were reduced or eliminated after catheter insertion. Catheters remained in place for a median of 11 days (range, 4--240 days) until there was no further need for parenteral analgesia (n = 15), death because of the underlying disease (n = 6), accidental removal (n = 2), or possible infection (n = 2). No serious local or systemic complications (meningitis, epidural abscess, systemic infection, epidural hematoma, or spinal cord injury; seizures, local anesthetic toxicity) occurred related to this technique. Five patients were discharged from the hospital with the catheter for home analgesic therapy. The use of a percutaneously inserted, subcutaneously tunneled epidural catheter is safe, effective, and provides pain relief in situations in which conventional analgesic therapy either fails or is impractical. The technique is one that may be of great value to children suffering from pain. ⋯ Children and adolescents with pain may safely have a spinal catheter placed for a period of time without undo risk of infection or other complications. Spinal catheters provide excellent pain relief, often eliminating the need for riskier medications for painful events such as wound cleansing and dressing changes.
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Anesthesia and analgesia · Jun 2001
Comparative Study Clinical TrialGender does not influence epsilon-aminocaproic acid concentrations in adults undergoing cardiopulmonary bypass.
Epsilon-aminocaproic acid (epsilon-ACA) is administered to cardiac surgery patients to reduce blood transfusions. Highly water-soluble drugs, such as epsilon-ACA, often have larger distribution volumes in males than in females. We hypothesized that epsilon-ACA concentrations using this dosing scheme would differ by gender because of differences in body composition and weight-adjusted volumes of distribution. ⋯ The area under the epsilon-ACA arterial concentration versus time curves was compared by using analysis of variance. Measured epsilon-ACA concentrations were smaller than predicted by the published model, but the area under the concentration versus time curves was not significantly different between men and women. Combining the present concentration data with that previously published, our updated two-compartment model included the following estimated population pharmacokinetic values: V(1) (11.8 L pre-CPB, 14.9 L during and after CPB), V(2) (12.0 L pre-CPB, 15.0 L during and after CPB), Cl(1) (0.125 L/min pre-CPB, 0.037 L/min during CPB, 0.156 L/min after CPB), Cl(2) (0.155 L/min pre-CPB, 0.013 L/min during CPB, 0.193 L/min after CPB).
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Anesthesia and analgesia · Jun 2001
Randomized Controlled Trial Clinical TrialIntensity of labor pain and cesarean delivery.
Some authors have suggested that the intensity of labor pain may be related to labor dystocia. We performed a secondary analysis of a previously published randomized investigation of the effects of epidural analgesia during labor compared with patient-controlled IV meperidine on cesarean delivery. Two-hundred-fifty-nine women who received patient-controlled IV meperidine were identified for analysis. ⋯ Pain scores were significantly higher in women requiring 50 mg/h of meperidine (8.7 vs 8.0, P = 0.05), and their labors tended to be longer (9 vs 5 h, P = 0.09). More cesarean deliveries for obstructed labor were performed in women requiring >50 mg/h of meperidine (14% vs 1.4%, P = 0.001). Neonatal outcomes were similar in the two groups.
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Anesthesia and analgesia · Jun 2001
Clinical TrialThe association of high jugular bulb venous oxygen saturation with cognitive decline after hypothermic cardiopulmonary bypass.
This study was conducted to investigate whether jugular bulb venous oxygen saturation (SjVO(2)) predicted cognitive decline after cardiac surgery with hypothermic cardiopulmonary bypass (CPB). We studied 35 patients undergoing cardiac surgery. After the induction of anesthesia, a 5.5F fiberoptic oximetry catheter was retrogradely inserted into the jugular bulb, and SjVO(2) and other cerebral oxygenation variables were analyzed before, during, and after CPB. At each point, an oxyhemoglobin dissociation curve was drawn, and the P(50) value of jugular bulb venous blood was calculated by computer analysis. Cognitive function was assessed with the revised version of Hasegawa's Dementia Scale and the Benton Revised Visual Retention Test before and early after the operation. In 15 patients (the Decline group), cognitive function was declined after surgery, whereas it remained unchanged in 20 patients (the Normal group). SjVO(2) was significantly higher and cerebral oxygen extraction was significantly lower before and during CPB in the Decline group than in the Normal group (P < 0.05). The oxygen pressure at an oxygen saturation of 50% was significantly lower before and after CPB in the Decline group than in the Normal group (P < 0.05). Logistic regression analysis showed that high SjVO(2) was a predictor of cognitive decline after cardiac surgery. We conclude that high SjVO(2) was associated with cognitive decline after cardiac surgery with hypothermic CPB. ⋯ Jugular bulb venous oxygen desaturation has been suggested as a predictor of cognitive decline after cardiac surgery. However, the clinical value of jugular bulb venous oxygen saturation (SjVO(2)) may be limited during hypothermic cardiopulmonary bypass (CPB) when oxygen affinity to hemoglobin is increased. This study shows that high SjVO(2) before and during hypothermic CPB is a predictor of subsequent cognitive decline.
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Anesthesia and analgesia · Jun 2001
Comparative Study Clinical TrialNoninvasive monitoring of carbon dioxide during mechanical ventilation in older children: end-tidal versus transcutaneous techniques.
We prospectively compared the accuracy of end-tidal CO(2) (ETCO(2)) and transcutaneous CO(2) (TCCO(2)) monitoring in older pediatric patients (4 yr or older) receiving mechanical ventilation for respiratory failure. ETCO(2) and TCCO(2) were simultaneously monitored and compared with arterial CO(2) (PaCO(2)) values when arterial blood gas analysis was performed. Eighty-two sample sets were compared. The ETCO(2) to PaCO(2) difference was 6.4 +/- 6.3 mm Hg, whereas the TCCO(2) to PaCO(2) difference was 2.6 +/- 2.0 mm Hg (P < 0.0001). The absolute difference of ETCO(2) and PaCO(2) was 5 or less in 47 of 82 measurements, whereas the absolute TCCO(2) to PaCO(2) difference was 5 or less in 76 of 82 measurements (P < 0.00001). Regression analysis of ETCO(2) and PaCO(2) values revealed a correlation coefficient of 0.5418 and an r value of 0.8745. Regression analysis of TCCO(2) and PaCO(2) values revealed a correlation coefficient of 1.0160 and an r value of 0.9693. Bland-Altman analysis revealed a bias of -5.68 with a precision of +/-6.93 when comparing ETCO(2) with PaCO(2) and a bias of 0.02 with a precision of +/-3.27 when comparing TCCO(2) and PaCO(2) (P < 0.00001). TCCO(2) monitoring provided an accurate estimation of PaCO(2) over a wide range of CO(2) values and was superior to ETCO(2) monitoring in older pediatric patients with respiratory failure. TCCO(2) monitoring may be considered as a useful adjunct to monitoring of ventilation in this patient population. ⋯ The authors report on the accuracy of noninvasive, transcutaneous CO(2) monitoring during mechanical ventilation in children 4 yr or older. Application of this technique should be useful by decreasing the need for repeated, costly, and sometimes painful arterial blood gas analysis, and the continuity of assessment should facilitate proactive, rather than reactive, ventilator manipulations.