Anesthesia and analgesia
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Anesthesia and analgesia · Jan 2002
Randomized Controlled Trial Clinical TrialThe effects of three different analgesia techniques on long-term postthoracotomy pain.
In this clinical, randomized, prospective study, we compared the effects of three different analgesia techniques (thoracic epidural analgesia [TEA] with and without preoperative initiation and IV patient-controlled analgesia [IV-PCA]) on postthoracotomy pain in 69 patients. In two groups, a thoracic epidural catheter was inserted preoperatively. Group Pre-TEA had bupivacaine and morphine solution preoperatively and intraoperatively. Postoperative analgesia was maintained with epidural PCA with a similar solution. Group Post-TEA, with no intraoperative medication, had the same postoperative analgesia as Group Pre-TEA plus the bolus dose. Group IV-PCA received only IV-PCA with morphine for postoperative analgesia. Pain was evaluated every 4 h during the first 48 h at rest, cough, and movement. Pre-TEA was associated with decreased pain compared with the other groups. Six months later, the patients were asked about their pain. The incidence and the intensity of pain were most frequent in Group IV-PCA (78%) and were the least in Group Pre-TEA (45%) (Group Pre-TEA versus Group IV-PCA, P = 0.0233; Group Pre-TEA versus Group IV-PCA, P = 0.014). Patients having pain on the second postoperative day had 83% chronic pain. TEA with preoperative initiation is a preferable method in preventing acute and long-term thoracotomy pain. ⋯ Preoperatively initiated thoracic epidural analgesia has the most satisfying results in controlling postthoracotomy pain in the acute and long-term period, and it is associated with a decreased incidence (and intensity) of chronic pain compared with postoperative (epidural or IV) analgesia. Chronic pain has an incidence of 62%.
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Anesthesia and analgesia · Jan 2002
Randomized Controlled Trial Clinical TrialThe influence of nicardipine-, nitroglycerin-, and prostaglandin E(1)-induced hypotension on cerebral pressure autoregulation in adult patients during propofol-fentanyl anesthesia.
We investigated the influence of drug-induced hypotension at a mean arterial pressure (MAP) of 60-70 mm Hg on cerebral pressure autoregulation in 45 adult patients during propofol-fentanyl anesthesia. Time-averaged mean blood flow velocity in the right middle cerebral artery (Vmca) was continuously measured at a PaCO(2) of 39-40 mm Hg by using transcranial Doppler ultrasonography. Hypotension was induced and maintained with a continuous infusion of nicardipine, nitroglycerin, or prostaglandin E(1). Cerebral autoregulation was tested by a slow continuous infusion of phenylephrine to induce an increase in MAP of 20-30 mm Hg. From the simultaneously recorded data of Vmca and MAP, cerebral vascular resistance (CVR) was calculated as MAP/Vmca. Furthermore, the index of autoregulation (IOR) was calculated as DeltaCVR/DeltaMAP, where DeltaCVR = change in CVR and DeltaMAP = change in MAP. The test was performed twice for each condition on each patient: baseline and hypotension. The IOR during baseline was similar among the groups. During nitroglycerin- and prostaglandin E(1)-induced hypotension, IOR was not different from baseline. In contrast, during nicardipine-induced hypotension, IOR significantly decreased compared with baseline (0.37 +/- 0.08 versus 0.83 +/- 0.07, P < 0.01). In conclusion, nicardipine, but not nitroglycerin or prostaglandin E(1), significantly attenuates cerebral pressure autoregulation during propofol-fentanyl anesthesia. ⋯ Vasodilators may influence cerebral autoregulation by changing cerebral vascular tone. Nicardipine, but not nitroglycerin or prostaglandin E(1), attenuated cerebral pressure autoregulation in normal adult patients during propofol-fentanyl anesthesia.
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Anesthesia and analgesia · Jan 2002
Randomized Controlled Trial Clinical TrialRopivacaine 0.075% and bupivacaine 0.075% with fentanyl 2 microg/mL are equivalent for labor epidural analgesia.
Fifty percent effective dose estimates for ropivacaine and bupivacaine suggest that ropivacaine is 40% less potent than bupivacaine to initiate labor analgesia. At clinically used concentrations, however, the drugs seem indistinguishable for initiating and maintaining labor analgesia. We designed this study to evaluate a concentration near the reported 50% effective dose values for ropivacaine and bupivacaine in an attempt to detect differences between the drugs during routine clinical use. Fifty-nine nulliparous women in labor were randomized to receive 0.075% ropivacaine or bupivacaine, each with fentanyl 2 microg/mL. After epidural placement and the administration of a lidocaine/epinephrine test dose, 20 mL of study solution was administered and a patient-controlled epidural infusion was initiated with the following settings: 6 mL/h basal rate, 5 mL bolus, 10 min lockout, and 30 mL/h limit. Breakthrough pain was treated with 10-mL boluses of study solution. By using a study design to detect a 40% difference in hourly drug use between groups, we found no statistically significant differences in the amount of local anesthetic used, verbal pain scores, sensory levels, motor blockade, labor duration, mode of delivery, side effects, or patient satisfaction. We conclude that 0.075% ropivacaine and bupivacaine, with fentanyl, are equally effective for labor analgesia using the patient-controlled epidural analgesia technique. ⋯ At small concentrations, ropivacaine and bupivacaine when combined with fentanyl are equally effective for labor analgesia. Patients self-administered similar volumes of 0.075% ropivacaine or bupivacaine solutions containing fentanyl (2 microg/mL) suggesting that at this concentration, and with the addition of fentanyl, ropivacaine and bupivacaine can be used interchangeably.
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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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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.