Anesthesia and analgesia
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Anesthesia and analgesia · Aug 2001
Predictors of breakthrough pain during labor epidural analgesia.
Parturients who receive labor epidural analgesia may experience breakthrough pain that requires supplemental medications. We investigated the factors associated with breakthrough pain. This prospective observational study included 1963 parturients who received epidural analgesia. Subjects were categorized into two groups on the basis of the number of episodes of breakthrough pain: the Recurrent Breakthrough Pain (RBP) group experienced three or more episodes. Univariate and multivariate regression analyses were used to evaluate factors associated with the RBP group. By multivariate analysis, nulliparity, heavier fetal weight, and epidural catheter placement at an earlier cervical dilation were found to be independently associated with the RBP group. These factors may predict which parturients' analgesia may be complicated by breakthrough pain. Parturients who received a combined spinal/epidural technique were less likely to be associated with the RBP group. The combined spinal/epidural technique may be superior to conventional epidural anesthesia, because breakthrough pain occurred less often. It is interesting to note that the characteristics that are associated with the RBP group are similar to those that have been associated with increased severity of maternal pain. ⋯ Nulliparity, heavier fetal weight, and epidural catheter placement at an early cervical dilation are predictors of breakthrough pain during epidural labor analgesia. The combined spinal/epidural technique may be associated with a decreased incidence of breakthrough pain.
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Anesthesia and analgesia · Aug 2001
A new, safety-oriented, integrated drug administration and automated anesthesia record system.
Medication errors are an important cause of patient morbidity and mortality and excessive costs, including in anesthesia. Conventional methods of injectable drug administration in anesthesia make little use of technology to support manual checking and are idiosyncratic and relatively error prone. Similarly, conventional anesthesia records are handwritten, time-consuming to make, and often unreliable. There are automated record systems, but they do not provide support for checking drugs. Therefore, by using a multifaceted approach based on established principles of systems design and human factors psychology, we have developed a system that includes trays that promote a well-organized anesthetic workspace, color- and bar-coded labeling of syringes, and automatic visual and auditory verification of the syringe labels by computer just before each drug administration. In addition, documentation of drugs administered and a traditional anesthetic case record are generated automatically. The system has been successfully deployed for 25 mo and has been used by 35 anesthesiologists in 1148 diverse cases, including cardiopulmonary bypass procedures, heart and lung transplants, and orthopedic and otorhinolaryngologic operations. It is in daily use in a tertiary teaching center and in a private hospital. ⋯ Traditional methods of drug administration and record keeping in anesthesia are relatively error prone. By using sound principles of systems design and human factors psychology, we have designed and deployed a system with the aim of improving patient safety by facilitating correct drug administration and accurate anesthesia record making.
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Anesthesia and analgesia · Aug 2001
Randomized Controlled Trial Clinical TrialMore epidural than intravenous sufentanil is required to provide comparable postoperative pain relief.
The extent to which epidurally administered sufentanil acts directly on spinal opioid receptors remains controversial. We tested the hypothesis that small-dose boluses of sufentanil, given epidurally or IV, provide comparable analgesia at similar plasma sufentanil concentrations. The lipophilicity of sufentanil makes it likely to be absorbed into fat surrounding the epidural space. We therefore also tested the hypothesis that more epidural than IV sufentanil is required to produce comparable analgesia. Analgesia and plasma sufentanil concentrations were evaluated in 20 postoperative patients randomly assigned to patient-controlled epidural or IV sufentanil. Pain was evaluated with visual analog scales by blinded observers. Sufentanil doses and plasma concentrations were measured. Analgesia was similar with epidural and IV sufentanil administration. Plasma sufentanil concentrations were virtually identical in the two groups. However, significantly larger sufentanil doses were required with epidural administration: 238 +/- 50 microg vs 160 +/- 32 microg (P < 0.01). The primary mechanism by which small-dose boluses of epidurally-administered sufentanil produce analgesia seems to be systemic absorption of the drug with subsequent recirculation to the supraspinal opioid receptors. This study demonstrates that the cumulative dose of sufentanil, when administered as a small epidural bolus, is approximately 50% more than that administered IV to provide comparable analgesia. This indicates that the bioavailability of epidurally-administered sufentanil is reduced and suggests that a large proportion of the drug may be absorbed into the epidural fat. ⋯ More epidural than IV sufentanil was required to provide comparable postoperative pain relief and similar plasma sufentanil concentrations. These data suggest that when sufentanil is administered in small-dose boluses, much of the drug is absorbed into the epidural fat and that the primary mechanism by which epidurally administered sufentanil produces analgesia is via systemic absorption.
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Anesthesia and analgesia · Aug 2001
Randomized Controlled Trial Clinical TrialPropofol in an emulsion of long- and medium-chain triglycerides: the effect on pain.
In a test of two formulations of propofol for induction, patients experienced less pain with the formulation in Intralipid (Propofol-Lipuro 1%) than with Diprivan 1%.
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Anesthesia and analgesia · Aug 2001
Randomized Controlled Trial Clinical TrialThe use of remifentanil to facilitate the insertion of the laryngeal mask airway.
Propofol is often used as an IV induction drug for anesthesia and the insertion of a laryngeal mask airway (LMA). As a sole anesthetic, it may be associated with undesirable airway responses such as coughing and gagging. We conducted a randomized, double-blinded study to compare the conditions during insertion of the LMA in 120 patients who received normal saline (Group P), remifentanil 0.25 microg/kg (Group R1), or remifentanil 0.5 microg/kg (Group R2) before the induction of anesthesia with IV propofol. The addition of remifentanil significantly improved the conditions of insertion; in Group R1, 82.5% (33 of 40 patients), and in Group R2, 85.0% (34 of 40 patients) had excellent insertion conditions as compared with the Control group P, 32.5% (13 of 40 patients). Patients in Group P were apneic for a mean (SD) time of 85 (38) s, 186 (75) s in group R1, and 284 (130) s in group R2. There was a lesser decrease in mean arterial blood pressure in group R1. We conclude that remifentanil 0.25 microg/kg, when administered after IV propofol 2.5 mg/kg, provides excellent conditions for insertion of the LMA with minimal hemodynamic disturbances. ⋯ Small-dose remifentanil can provide excellent conditions for laryngeal mask airway insertion with minimal hemodynamic disturbances.