Anesthesia and analgesia
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Anesthesia and analgesia · Feb 2002
Randomized Controlled Trial Clinical TrialAre lactated Ringer's solution and normal saline solution equal with regard to coagulation?
Crystalloids represent an attractive strategy to alleviate intravascular volume deficits. Crystalloid hemodilution was associated with hypercoagulability in in vitro and in vivo studies. The influence of different crystalloids on coagulation in the surgical patient is not well studied. In a prospective, randomized study in patients undergoing major abdominal surgery, we used either lactated Ringer's solution (RL) (n = 21) or 0.9% saline solution (SS) (n = 21) exclusively for intravascular volume replacement over 48 h to maintain central venous pressure between 8 and 12 mm Hg. Activated thrombelastography (TEG) using different activators (intrinsic TEG, extrinsic TEG, heparinase TEG, aprotinin TEG) was used to measure coagulation time, clot formation time, and maximum clot firmness. Measurements were performed after induction of anesthesia (T0), immediately after surgery (T1), 5 h after surgery (T2), and on the morning of the first (T3) and second (T4) postoperative days. RL 18,750 +/- 1890 mL and 17,990 +/- 1790 mL of SS were infused during the study period. Acidosis was seen only in the SS-treated group. Blood loss was not different between the groups. Fibrinogen and antithrombin III decreased similarly at T1 and T2 in both groups, most likely because of hemodilution. Differences in TEG data from normal baseline were seen only immediately after surgery and 5 h thereafter, indicating mild hypercoagulability in the intrinsic TEG (RL, from 147 +/- 130 s to 130 +/- 11 s; SS, from 146 +/- 12 s to 131 +/- 12 s). There were no differences in coagulation between RL- and SS-treated patients. We conclude that in major abdominal surgery intravascular volume replacement with crystalloids resulted in only moderate and abbreviated changes in coagulation. No differences in activated TEG and blood loss were seen between an RL- and an SS-based intravascular volume replacement regimen. ⋯ In 42 patients undergoing major abdominal surgery, either lactated Ringer's solution or 0.9% saline solution were exclusively used for volume therapy for 48 h. Activated thrombelastography revealed some mild hypercoagulability after surgery. No differences in coagulation were seen between the two intravascular volume replacement strategies.
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Anesthesia and analgesia · Feb 2002
Randomized Controlled Trial Comparative Study Clinical TrialSmall-dose selective spinal anesthesia for short-duration outpatient laparoscopy: recovery characteristics compared with desflurane anesthesia.
We conducted a randomized controlled trial to compare the recovery characteristics of selective spinal anesthesia (SSA) and desflurane anesthesia (DES) in outpatient gynecological laparoscopy. Twenty ASA physical status I patients undergoing gynecological laparoscopy were randomized to receive either SSA with lidocaine 10 mg + sufentanil 10 microg or general anesthesia with DES and N(2)O. Intraoperative conditions, recovery times, postanesthesia recovery scores, and postoperative outcomes were recorded. Intraoperative conditions were comparable in both groups. All patients in the SSA group were awake and oriented at the end of surgery, whereas patients in the DES group required 7 +/- 2 min for extubation and orientation. SSA patients had a significantly shorter time to straight leg raising (3 +/- 1 min versus 9 +/- 4 min; P < 0.0001) and to ambulation (3 +/- 0.9 min versus 59 +/- 16 min; P < 0.0001) compared with the DES group. SSA patients had significantly less postoperative pain than DES patients (P < 0.05). We concluded that SSA was an effective alternative to DES for outpatient gynecological laparoscopy. ⋯ This study compared the use of a desflurane general anesthetic to a small-dose spinal anesthetic in ambulatory gynecological laparoscopy. Using the spinal technique, patients can walk from the operating room table to a stretcher on completion of surgery. Their recovery time was similar to that of the desflurane group.
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Anesthesia and analgesia · Feb 2002
Clinical Trial Controlled Clinical TrialEpidural infusion pressure in degenerative spinal disease before and after epidural steroid therapy.
The analgesic mechanism of epidural steroids in reducing pain associated with degenerative spinal disease (DSD) is poorly understood. We report increased inline epidural infusion pressure in patients with DSD and assess whether this phenomenon is affected by administration of an epidural steroid injection. We collected data during epidural placement for routine surgery or epidural steroid therapy. Using a 17-gauge Tuohy needle, with patients in the right lateral decubitus position, loss of resistance to 2 mL of saline identified the epidural space. Two minutes later the needle was attached to saline-filled tubing connected to a pressure transducer (Baxter PX 260 pressure monitoring kit with Truwave TM disposable pressure transducer). In the first part of the study, 4 successive boluses of 3 mL of local anesthetic were administered at a rate of 6 mL/min to 15 patients (age 47 +/- 6 yrs) with radicular back pain and magnetic resonance imaging (MRI) or computed tomography (CT) evidence of DSD, and to 8 control patients with no history of back pain (age 44 +/- 5 yr) while inline epidural infusion pressure was measured. In the second part of the study 44 patients with low back pain and MRI or CT evidence of DSD presenting to the pain clinic were infused with 8 mL of 0.125% bupivacaine and 40 mg of methylprednisolone (20 mg/mL) at a rate of 6 mL/min while inline epidural infusion pressure was measure and recorded. This was repeated 3 wk later. Initially, DSD patients had significantly increased infusion pressures over normals, which most likely reflects outflow resistance or obstruction. A significant decrease in inline epidural infusion pressure was observed after epidural steroid treatment. This change in pressure may indicate efficacy from epidural steroid injection. ⋯ During injection into the epidural space we observed increased resistance in patients with degenerative spinal disease. This resistance was significantly less when measured 3 wk after an epidural steroid injection. This change in pressure may indicate efficacy from epidural steroid injection.
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Anesthesia and analgesia · Feb 2002
Randomized Controlled Trial Clinical TrialActive warming during cesarean delivery.
We tested the hypothesis that 15 min of forced-air prewarming, combined with intraoperative warming, prevents hypothermia and shivering in patients undergoing elective cesarean delivery. We simultaneously tested the hypothesis that maintaining maternal normothermia increases newborn temperature, umbilical vein pH, and Apgar scores. Thirty patients undergoing elective cesarean delivery were randomly assigned to forced-air warming or to passive insulation. Warming started 15 min before the induction of epidural anesthesia. Core temperature was measured at the tympanic membrane, and shivering was graded by visual inspection. Patients evaluated their thermal sensation with visual analog scales. Rectal temperature and umbilical pH were measured in the infants after birth. Results were compared with unpaired, two-tailed Student's t-tests and chi(2) tests. Core temperatures after 2 h of anesthesia were greater in the actively warmed (37.1 degrees C +/- 0.4 degrees C) than in the unwarmed (36.0 degrees C +/- 0.5 degrees C; P < 0.01) patients. Shivering was observed in 2 of 15 warmed and 9 of 15 unwarmed mothers (P < 0.05). Babies of warmed mothers had significantly greater core temperatures (37.1 degrees C +/- 0.5 degrees C vs 36.2 degrees C +/- 0.6 degrees C) and umbilical vein pH (7.32 +/- 0.07 vs 7.24 +/- 0.07). ⋯ Perioperative forced-air warming of women undergoing cesarean delivery with epidural anesthesia prevents maternal and fetal hypothermia, reduces maternal shivering, and improves umbilical vein pH.
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Anesthesia and analgesia · Feb 2002
Autoantibodies associated with volatile anesthetic hepatitis found in the sera of a large cohort of pediatric anesthesiologists.
Anesthetic-induced hepatitis is thought to have an immune-mediated basis, in part because many patients who develop hepatitis have serum autoantibodies that react with specific hepatic proteins. The present study shows that pediatric anesthesiologists also have these serum autoantibodies. Moreover, levels of these autoantibodies are higher than those of general anesthesiologists. We collected sera from 105 pediatric and 53 general anesthesiologists (including 3 nurse anesthetists), 20 halothane hepatitis patients, and 20 control individuals who were never exposed to inhaled anesthetics. Serum cytochrome P450 2E1 (P450 2E1) and 58-kd hepatic endoplasmic reticulum protein (ERp58) autoantibodies were measured by enzyme-linked immunosorbent assays. Positive values were 2 SD above median control values. Two multiple regression models were constructed. Pediatric anesthesiologists, like halothane hepatitis patients, had higher serum autoantibody levels of ERp58 and P450 2E1 than general anesthesiologists and controls, which was possibly because of their increased occupational exposures to anesthetics. Female anesthesiologists had higher levels of ERp58 autoantibodies than male anesthesiologists, whereas female pediatric anesthesiologists had higher levels of P450 2E1 autoantibodies than all other anesthesiologists. One female pediatric anesthesiologist had symptoms of hepatic injury. Because most anesthesiologists do not develop volatile anesthetic-induced hepatic injury, the findings suggest that pathogenic ERp58 and P450 2E1 autoantibodies may not directly cause volatile anesthetic hepatitis. Female anesthesiologists have high levels of these autoantibodies; however, the majority of these individuals do not develop hepatitis, suggesting that autoantibodies may not have a pathological role in volatile anesthetic-induced hepatitis. ⋯ Environmental exposure of anesthesiology personnel to certain inhaled anesthetics can induce the formation of autoantibodies that have been associated with anesthetic hepatitis. Female anesthesiologists have high levels of these autoantibodies; however, the majority of these individuals do not develop hepatitis, suggesting that autoantibodies may not have a pathological role in volatile anesthetic-induced hepatitis.