Anesthesia and analgesia
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Anesthesia and analgesia · Jan 2002
Ambulatory discharge after long-acting peripheral nerve blockade: 2382 blocks with ropivacaine.
Discharging patients with a long-acting peripheral nerve block remains controversial. Concerns about accidental injury of the limb or surgical site because of an insensate extremity are common despite a lack of data on the subject. We report a study examining the efficacy and complications of discharge after long-acting block. This prospective study included 1791 patients receiving an upper or lower extremity nerve block with 0.5% ropivacaine and discharged the day of surgery. Efficacy (conversion to general anesthesia and opioid use), persistent motor or sensory weakness, complications, satisfaction, and unscheduled health care visits were assessed in the postanesthesia care unit (PACU) and at 24 h and 7 days postoperatively using a detailed questionnaire. There were 2382 blocks placed: 1119 upper extremity blocks and 1263 lower extremity blocks. Efficacy was demonstrated by a small conversion to general anesthesia (1%-6%) and a lack of patients requiring opioids in the PACU (89%-92%). A large percentage of patients continued to use opioids at 7 days (17%-22%). Despite the requirement for opioids, satisfaction with the anesthesia experience was high at 24 h and 7 days (Liekert scale [1-5] mean at 24 h, 4.88 +/- 0.44; mean at 7 days, 4.77 +/- 0.69) and most (98%) would choose the same anesthetic again. Thirty-seven patients (1.6%) were identified with symptoms or complaints at 7 days. After review, 6 of them (0.25%) had a persistent paresthesia that may have been related to the block or discharge. We conclude that long-acting peripheral nerve blockade may be safely used in the ambulatory setting with a high degree of efficacy, safety, and satisfaction. This technique is associated with an infrequent incidence of neurologic complications and injuries. Given the frequent incidence of persistent pain at 7 days, prolongation of the analgesia would be beneficial. ⋯ This study demonstrates that long-acting peripheral nerve blockade may be safely used in the ambulatory setting with a high degree of efficacy and satisfaction. This technique is associated with an infrequent incidence of neurologic complications and injuries despite discharge with an insensate extremity. The frequent incidence of pain at 7 days suggests that longer-acting local anesthetics are still needed.
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Anesthesia and analgesia · Jan 2002
Randomized Controlled Trial Clinical TrialAlkalinization of intracuff lidocaine improves endotracheal tube-induced emergence phenomena.
We sought to evaluate the effect of filling an endotracheal tube cuff with 40 mg lidocaine alone (Group L) or alkalinized lidocaine (Group LB) in comparison to an Air Control group (Group C) on adverse emergence phenomena in a randomized controlled study (n = 25 in each group). The incidence of sore throat was decreased for Group LB in comparison to Group L during the 24 postextubation hours. The difference between Group L and Group C remained significant in the two postextubation hours only. Plasma lidocaine levels increased when lidocaine was alkalinized (C(max) were 62.5 +/- 34.0 ng/mL and 3.2 +/- 1.0 ng/mL for Groups LB and L, respectively). Cough and restlessness before tracheal extubation were decreased in Group LB compared with Group L and in Group L compared with Group C. Nausea, postoperative vomiting, dysphonia, and hoarseness were increased after extubation in Group C compared with the liquid groups, and a better tolerance was recorded with Group LB compared with Group L. The increase of arterial blood pressure and cardiac frequencies during the extubation period was less in the liquid groups than in the control group and less in Group LB compared with Group L. We concluded that use of intracuff alkalinized lidocaine is an effective adjunct to endotracheal intubation. ⋯ Use of 40 mg of alkalinized lidocaine, rather than lidocaine or air, to fill the endotracheal tube cuff reduces the incidence of sore throat in the postoperative period. This approach also decreases hemodynamic effects, restlessness, dysphonia, and hoarseness.
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Anesthesia and analgesia · Jan 2002
The use of a human patient simulator in the evaluation of and development of a remedial prescription for an anesthesiologist with lapsed medical skills.
The New York State Society of Anesthesiologists' Committee on Continuing Medical Education and Remediation has been charged by the Office of Professional Medical Conduct of the New York State Department of Health to develop a remediation program for individuals ordered into retraining. We describe the development of an anesthesiology-specific evaluation to identify areas of deficiency to both determine a candidate's suitability, as well as to facilitate the creation of an appropriate prescription for retraining. ⋯ Specifically, the use of simulation allowed the exploration of a candidate's preparation, approach to clinical situations, technical abilities, response to clinical problems, ability to problem solve, and accuracy of medical record keeping. Human patient simulation should be considered a valuable tool in the process of evaluating physicians with lapsed medical skills.
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Opening of the first door of pulse photometry gave us pulse oximeter. The next door opens to multiwavelength pulse photometry. It will give us a high performance pulse oximeter, providing a wide variety of clinical information simultaneously. This next generation of pulse photometry should further improve bedside monitoring and patient care.
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Anesthesia and analgesia · Jan 2002
Randomized Controlled Trial Clinical TrialEsmolol and anesthetic requirement for loss of responsiveness during propofol anesthesia.
The administration of esmolol decreases the propofol blood concentration, preventing movement after skin incision during propofol/morphine/nitrous oxide anesthesia. However, interaction with esmolol has not been tested when propofol is infused alone. Accordingly, we tested the hypothesis that esmolol decreases the propofol blood concentration, preventing response to command (CP50-awake) when propofol is infused alone in healthy patients presenting for minor surgery. With approval and consent, we studied 30 healthy patients, who were randomized to esmolol bolus (1 mg/kg) and then infusion (250 microg x kg(-1) x min(-1)) or placebo. Five minutes later, a target-controlled infusion of propofol was commenced. Ten minutes later, responsiveness was assessed by a blinded observer. Oxygen saturation, heart rate, and noninvasive arterial blood pressure were recorded every 2 min. Arterial blood samples were taken at 5 and 10 min of propofol infusion for propofol assay. Results were analyzed with a generalized linear regression model: P <0.05 was considered statistically significant. The probability of response to command decreased with increasing propofol blood concentration (CP50-awake = 3.42 microg/mL). Esmolol did not alter the relative risk of response to command. We conclude that the previously observed effect of esmolol on propofol CP50 was not caused by an interaction between these two drugs. ⋯ There is no evidence to suggest that esmolol, an ultra-short-acting cardioselective beta-blocker, affects anesthetic requirement for loss of responsiveness during propofol anesthesia.