Anesthesia and analgesia
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Anesthesia and analgesia · Nov 2002
Randomized Controlled Trial Clinical TrialCaudal anesthesia in children: effect of volume versus concentration of bupivacaine on blocking spermatic cord traction response during orchidopexy.
In this study we compared the intensity and level of caudal blockade when two different volumes and concentrations of a fixed dose of bupivacaine were used. Fifty children, 1-6 yr old, undergoing unilateral orchidopexy received a caudal block with a fixed 2 mg/kg dose of bupivacaine immediately after the induction. Group 1 (n = 23) received 0.8 mL/kg of 0.25% bupivacaine, whereas Group 2 (n = 27) received 1.0 mL/kg of 0.2% bupivacaine. Epinephrine 1:400,000 and 0.1 mL of sodium bicarbonate per 10 mL of local anesthetic solution were added. There were no statistically significant differences between the two groups in their anesthesia, surgery, recovery, and discharge times. Fifteen patients (65.2%) in Group 1 required an increase in inspired halothane concentration to block hemodynamic and/or ventilatory response during spermatic cord traction, as compared with 8 patients (29.6%) in Group 2 (P = 0.022). In the recovery room, four (17.4%) patients in Group 1 required rescue treatment with fentanyl, versus two (7.4%) in Group 2 (P = 0.372). In children undergoing orchidopexy, a caudal block with a larger volume of dilute bupivacaine is more effective than a smaller volume of the standard 0.25% solution in blocking the peritoneal response during spermatic cord traction, with no change in the quality of postoperative analgesia. ⋯ In children undergoing orchidopexy, a caudal block with a larger volume of dilute bupivacaine is more effective than a smaller volume of the more concentrated solution in blocking the peritoneal response during spermatic cord traction, with no change in the quality of postoperative analgesia.
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Anesthesia and analgesia · Nov 2002
Randomized Controlled Trial Comparative Study Clinical TrialNasotracheal intubation: a simple and effective technique to reduce nasopharyngeal trauma and tube contamination.
Our hypothesis was that nasopharyngeal passage of an endotracheal tube can be facilitated by a nasopharyngeal airway (Wendl tube) acting as a "pathfinder." Accordingly, we performed a randomized, controlled trial with blinded assessment of nasopharyngeal bleeding and contamination of the tip of the endotracheal tube. After the induction of anesthesia, a Wendl tube (28 Ch) was inserted into the more patent nostril. In the control group (n = 30), the Wendl tube was retrieved before nasopharyngeal passage was attempted with an endotracheal tube (inner diameter, 7.0 mm). In the intervention group (n = 30), the Wendl tube was kept in position and only its adjustable flange was removed. Then, we inserted the tip of the endotracheal tube into the trailing end of the Wendl tube. Subsequently, the endotracheal tube was advanced under visual control to the oropharynx guided by the Wendl tube. After the endotracheal tube was positioned in the oropharynx, the Wendl tube was removed and intubation completed. Six hours after surgery, we determined the patients' nasal pain. The "pathfinder" technique reduced the incidence (P < 0.001) and severity (P = 0.001) of bleeding, decreased tube contamination with blood and mucus (P < 0.001), and diminished postoperative nasal pain (P = 0.036). ⋯ Nasopharyngeal passage of an endotracheal tube can be facilitated by a flexible Wendl tube (nasopharyngeal airway) covering and guiding the rigid tube tip. This technique is helpful in reducing the incidence and severity of nosebleeds and in minimizing contamination of the tip of the endotracheal tube with blood and mucus.
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Anesthesia and analgesia · Nov 2002
Randomized Controlled Trial Comparative Study Clinical TrialA randomized, double-blinded comparison of thoracic epidural ropivacaine, ropivacaine/fentanyl, or bupivacaine/fentanyl for postthoracotomy analgesia.
Epidural ropivacaine has not been compared with bupivacaine for postthoracotomy analgesia. Eighty patients undergoing elective lung surgery were randomized in a double-blinded manner to receive one of three solutions for high thoracic epidural analgesia. A continuous epidural infusion of 0.1 mL. kg(-1). h(-1) of either 0.2% ropivacaine, 0.15% ropivacaine/fentanyl 5 micro g/mL, or 0.1% bupivacaine/fentanyl 5 micro g/mL was started at admission to the intensive care unit. We assessed pain scores (rest and spirometry), IV morphine consumption, spirometry, hand grip strength, PaCO(2), heart rate, blood pressure, respiratory rate, and side effects (sedation, nausea, vomiting, and pruritus) for 48 h. Thoracic epidural ropivacaine/fentanyl provided adequate pain relief similar to bupivacaine/fentanyl during the first 2 postoperative days after posterolateral thoracotomy. The use of plain 0.2% ropivacaine was associated with worse pain control during spirometry, larger consumption of IV morphine, and increased incidence of postoperative nausea and vomiting. Morphine requirements were larger in the ropivacaine group, with no differences between bupivacaine/fentanyl and ropivacaine/fentanyl groups. Patients in the ropivacaine group experienced more pain and performed worse in spirometry than patients who received epidural fentanyl. There was no significant difference in motor block. We conclude that epidural ropivacaine/fentanyl offers no clinical advantage compared with bupivacaine/fentanyl for postthoracotomy analgesia. ⋯ Thoracic epidural ropivacaine/fentanyl provided adequate pain relief and similar analgesia to bupivacaine/fentanyl during the first 2 postoperative days after posterolateral thoracotomy. Plain 0.2% ropivacaine was associated with worse pain control and an increased incidence of postoperative nausea and vomiting. We conclude that epidural ropivacaine/fentanyl offers no clinical advantage compared with bupivacaine/fentanyl for postthoracotomy analgesia.
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Anesthesia and analgesia · Nov 2002
Randomized Controlled Trial Comparative Study Clinical TrialOndansetron and dolasetron provide equivalent postoperative vomiting control after ambulatory tonsillectomy in dexamethasone-pretreated children.
In this prospective, randomized, double-blinded, placebo-controlled study, we compared the incidence of emesis and 48-h recovery profiles after a single dose of preoperative ondansetron versus dolasetron in dexamethasone-pretreated children undergoing ambulatory tonsillectomy. One-hundred-forty-nine children, 2-12 yr old, ASA physical status I and II, completed the study. All children received standardized perioperative care, including premedication, surgical and anesthetic techniques, IV fluids, analgesics, and rescue antiemetic medications. Patients were randomized to receive ondansetron 0.15 mg/kg, maximum 4 mg (Group 1); dolasetron 0.5 mg/kg, maximum 25 mg (Group 2); or saline placebo (Group 3) IV before the initiation of surgery. In addition, all patients received dexamethasone 1 mg/kg (maximum 25 mg). Rescue antiemetics were administered for two or more episodes of retching/vomiting. The incidence of retching/vomiting before home discharge did not differ between the ondansetron and dolasetron groups and was significantly less frequent compared with the placebo group (10%, Group 1; 8%, Group 2; 30%, Group 3). Similar results were obtained at 24-48 h after discharge (6%, Groups 1 and 2; 18%, Group 3). The need for rescue antiemetics administered after the second retching/vomiting episode was significantly less in Groups 1 (4%) and 2 (6%) compared with Group 3 (22%) before home discharge. The complete response rate, defined as no retching/vomiting and no antiemetic for 48 h, was significantly increased in Groups 1 (76%) and 2 (74%) compared with Group 3 (44%). The antiemetic efficacy of prophylactic ondansetron and dolasetron was comparable in dexamethasone-pretreated children undergoing ambulatory tonsillectomy. ⋯ The efficacy of a single dose of prophylactic ondansetron versus dolasetron in conjunction with dexamethasone was studied on posttonsillectomy retching/vomiting and 48-h recovery in children 2-12 yr old. Compared with placebo, ondansetron and dolasetron produced comparable reductions in the incidence of retching/vomiting and the need for rescue antiemetics.
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Anesthesia and analgesia · Nov 2002
Randomized Controlled Trial Clinical TrialThe effect of the addition of epinephrine on early systemic absorption of epidural ropivacaine in humans.
The addition of epinephrine to ropivacaine has not been recommended because ropivacaine has intrinsic vasoconstrictor properties. However, few pharmacokinetic data are available on the addition of epinephrine to epidural ropivacaine in humans. In this prospective, double-blinded study, we randomized patients having elective abdominal hysterectomy to receive epidural ropivacaine 1.5 mg/kg, diluted in 15 mL, either with (epinephrine group, n = 12) or without (plain group, n = 12) epinephrine 5 microg/mL and then measured arterial and venous plasma concentrations of ropivacaine at intervals up to 180 min. We found that arterial and venous plasma ropivacaine concentrations were smaller in the epinephrine group compared with the plain group in the first 60 min after the drug administration (P < 0.01). Mean (+/- SD) maximum total plasma ropivacaine concentration was smaller in the epinephrine group (arterial, 0.92 +/- 0.32 microg/mL; venous, 0.82 +/- 0.33 microg/mL) compared with the plain group (1.31 +/- 0.39 microg/mL and 1.31 +/- 0.50 microg/mL, respectively; P = 0.01). Time to maximum total plasma ropivacaine concentration was not significantly different between groups (mean +/- SD; arterial, 16 +/- 2 min; venous, 23 +/- 2 min in the epinephrine group versus 9 +/- 2 min and 12 +/- 3 min, respectively, in the plain group; P = 0.08). Arterial plasma ropivacaine concentrations were larger than venous concentrations during the first hour (P < 0.01); the arterio-venous difference decreased exponentially, and the rate and magnitude of this decrease was unaffected by epinephrine. We conclude that the addition of epinephrine 5 microg/mL to ropivacaine reduced the early systemic plasma concentrations of ropivacaine after epidural injection and may be useful for decreasing the risk of toxicity from systemic absorption of epidural ropivacaine. ⋯ The addition of epinephrine 5 microg/mL to epidural ropivacaine reduced the systemic arterial and venous plasma concentrations of ropivacaine in the first hour and the maximum plasma concentration of ropivacaine. Epinephrine may be a useful additive for reducing the risk of systemic toxicity when large doses of ropivacaine are given epidurally.