Anesthesia and analgesia
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Anesthesia and analgesia · Dec 2003
Randomized Controlled Trial Clinical TrialPreincisional treatment to prevent pain after ambulatory hernia surgery.
We designed this study as a randomized comparison of postoperative pain after inguinal hernia repair in patients treated with triple preincisional analgesic therapy versus standard care. Triple therapy consisted of a nonsteroidal antiinflammatory, a local anesthetic field block, and an N-methyl-D-aspartate inhibitor before incision. The treatment group (n = 17) received rofecoxib, 50 mg PO, a field block with 0.25% bupivacaine/0.5% lidocaine, and ketamine 0.2 mg/kg IV before incision; controls (n = 17) received a placebo PO before surgery. The anesthetic protocol was standardized. Postoperative pain was treated by fentanyl IV and oxycodone 5 mg/acetaminophen 325 mg PO as required for pain. Pain scores (0-10) and analgesic were recorded for the first 7 days after surgery. Pain scores were 47% lower in the treatment group before discharge (3.1 +/- 0.6 versus 5.9 +/- 0.6, P = 0.0026) (mean +/- SE) and 18% less in the first 24 h after discharge (5.6 +/- 0.4 versus 6.8 +/- 0.5, P = 0.05); oral analgesic use was 34% less in the treatment group (4.6 +/- 0.8 doses versus 7.1 +/- 0.7 doses, P = 0.02) in the first 24 h after surgery. We conclude that triple preincisional therapy diminishes pain and analgesic use after outpatient hernia repair, and encourage further evaluation of this technique. ⋯ Outpatients undergoing inguinal hernia repair under general anesthesia report moderate-to-severe pain after surgery. Triple preincisional therapy that included rofecoxib, 50 mg PO, ketamine, 0.2 mg/kg IV, and local anesthetic field block reduced pain scores and analgesic use in the first 24 h after discharge.
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Anesthesia and analgesia · Dec 2003
Randomized Controlled Trial Clinical TrialThe effects of desflurane and propofol on portosystemic pressure in patients with portal hypertension.
Physicians perform hepatic venous pressure measurements to guide medical therapy aimed at reducing portal hypertension. These measurements are frequently performed during general anesthesia. Since most general anesthetic drugs reduce liver blood flow, it is likely that hepatic venous pressures will be altered. We therefore examined the effects of two frequently used anesthetic drugs on hepatic venous pressure in a prospective randomized study to determine if pressure measurements taken during general anesthesia were similar to awake values. We studied 21 patients with hepatitis C, excluding patients with hepatofugal flow and portal vein thrombosis. All patients had free and wedged hepatic venous pressures measured awake with sedation and after anesthesia with either propofol or desflurane. Desflurane significantly increased free hepatic venous pressure (11.9 +/- 4.4 to 23.5 +/- 4.1 mm Hg; P < 0.05) and decreased hepatic venous pressure gradient (21.6 +/- 7.4 to 14.7 +/- 5.2 mm Hg; P < 0.05), whereas propofol did not change these variables. We conclude that desflurane, but not propofol, alters hepatic venous pressure measurements from the awake state, significantly increasing free hepatic venous pressure and decreasing the hepatic venous pressure gradient, an indirect measure of portosystemic pressure. Changes in the hepatic venous pressure gradient must be interpreted with caution during desflurane general anesthesia. ⋯ Desflurane reduces the blood pressure difference between the portal and systemic circulations. This can cause errors in assessment of the success of medical therapy of portal hypertension. Propofol has less effect on the difference between the portal and systemic circulation.
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Anesthesia and analgesia · Dec 2003
Randomized Controlled Trial Clinical TrialRapid water and slow sodium excretion of acetated Ringer's solution dehydrates cells.
Acetated Ringer's solution is a slightly hypotonic infusion fluid (osmolality 270 mosmol/kg) that has inspired the belief that the fluid causes a shift of water volume to the intracellular space. We assessed the role of the kidney in modifying this volume shift by infusing 25 mL/kg of Ringer's acetate solution (mean, 1565 mL) over a time period of 15, 30, 45, and 80 min on different occasions in 5 healthy female volunteers. Regardless of the rate of administration, the excreted urine contained only half as much sodium (mean, 67 mmol/L) as the infused fluid. As there was only a slight increase of 0.9 mmol/L in the serum sodium level, mass balance calculations indicated that 274 mL of water had shifted from the intracellular to the extracellular space 30 min after the infusions ended (P < 0.001). This fluid shift was also maintained over the subsequent 90 min. In conclusion, infusion of Ringer's acetate solution does not promote cellular swelling as a result of the excretion of urine that is low in sodium. A slight dehydration of fluid from the intracellular space still persisted when our measurements ended 2 h after completing the infusion. ⋯ The kidney promotes slight cellular dehydration after infusion of Ringer's acetate solution by rapid excretion of water, whereas natriuresis occurs more slowly. In volunteers, this translocation amounted to 18% of the infused fluid volume and persisted for at least 2 h.
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Anesthesia and analgesia · Dec 2003
Case ReportsTransnasal placement of biplane transesophageal echocardiography probe intraoperatively in an adolescent with congenital heart disease.
Intraoperative transesophageal echocardiography (TEE) is frequently used in children with congenital heart disease (CHD). Although transnasal TEE is being used in various settings in the adult population, there are no descriptions of its use intraoperatively in patients with CHD. This report describes the successful use of transnasal TEE after multiple unsuccessful transoral attempts in an adolescent male undergoing subaortic stenosis repair. ⋯ Transnasal transesophageal echocardiography (TEE) is being used in various settings in the adult population. The author describes its use intraoperatively in an adolescent undergoing surgery for congenital heart disease after unsuccessful transoral attempts.
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Anesthesia and analgesia · Dec 2003
Clinical TrialThe effect of right versus left lateral decubitus positions on induction of spinal anesthesia for cesarean delivery.
Induction of spinal anesthesia for cesarean delivery in the left lateral (LL) decubitus position combined with intraoperative left uterine displacement may result in pooling of local anesthetic onto one side of the body. We studied the effect of the right lateral (RL) and LL decubitus positions during placement of spinal anesthesia on the intrathecal spread of 0.5% hyperbaric bupivacaine plus fentanyl in 60 term parturients. Though all parturients acquired a loss of cold sensation at T4 15 min after intrathecal injection, more parturients in the LL group than in the RL group did so at 5 min (P < 0.05). The maximum levels of sensory blockades, amounts of fluid, vasopressor, and supplementary analgesia used, and the incidence of postoperative complications were similar. We conclude that the two positions can be used equally well when hyperbaric bupivacaine and fentanyl are used in cesarean delivery under spinal anesthesia. ⋯ We conducted a double-blinded randomized trial comparing the spread of spinal anesthesia placed with a parturient in either the right or left lateral position. There was a faster onset in the left lateral group; however, the maximum block heights and the time taken to achieve them were similar in both groups.