Anesthesia and analgesia
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Anesthesia and analgesia · Mar 2003
Randomized Controlled Trial Clinical TrialThe effect of spinal bupivacaine in combination with either epidural clonidine and/or 0.5% bupivacaine administered at the incision site on postoperative outcome in patients undergoing lumbar laminectomy.
Spinal anesthesia has numerous advantages over general anesthesia for patients undergoing lumbar laminectomy and microdisk surgery. In this study, we evaluated the addition of epidural clonidine and/or bupivacaine, injected at the incision site, on postoperative outcome variables in patients undergoing lower spine procedures using spinal anesthesia. One hundred twenty patients having lumbar spine surgery received bupivacaine spinal anesthesia supplemented by 150 microg of epidural clonidine with or without incisional bupivacaine, epidural placebo plus incisional bupivacaine, or placebo with incisional saline. Demographic data, intraoperative hemodynamics, blood loss, pain, nausea, urinary retention, hospital discharge, and other variables were compared by using either analysis of variance or chi(2) analysis. Demographics were similar. IV fluids, blood loss, incidence of intraoperative bradycardia, and hypotension were not different among groups. Postanesthesia care unit pain scores were lower and demand for analgesics was less in patients who received both the clonidine and subcutaneous bupivacaine. Patients who received epidural clonidine also had improved postoperative hemodynamics. Hospital discharge, urinary retention, and other variables were not different. We conclude that epidural clonidine as a supplement to spinal anesthesia produced no perioperative complications and improved postoperative pain and hemodynamic stability in patients undergoing lower spine procedures. ⋯ Spinal anesthesia with supplemental epidural clonidine in combination with incision site subcutaneous bupivacaine was evaluated both intra- and postoperatively and compared with spinal anesthesia alone for lower lumbar spine procedures. Both epidural clonidine and subcutaneous incisional bupivacaine, added to spinal anesthesia for lumbar spine surgery, improves pain relief and reduces the need for postoperative opioids with their associated side effects.
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Anesthesia and analgesia · Mar 2003
Randomized Controlled Trial Clinical TrialIntrathecal fentanyl, sufentanil, or placebo combined with hyperbaric mepivacaine 2% for parturients undergoing elective cesarean delivery.
Worldwide, long-acting bupivacaine is the most popular local anesthetic for spinal anesthesia in parturients undergoing elective cesarean delivery. With advances in surgical techniques, e.g., the Misgav Ladach method, and shorter duration of surgery, the local anesthetic mepivacaine, with an intermediate duration of action, may be a reasonable alternative. Our aim in the present study was to evaluate the effects of 2% hyperbaric mepivacaine alone, or combined with either intrathecal fentanyl (5 and 10 microg), or sufentanil (2.5 and 5 microg), on sensory, motor, and analgesic block characteristics, hemodynamic variables, and neonatal outcome in a randomized, prospective, and double-blinded study (n = 100, 20 parturients per group, singleton pregnancy, >37 wk of gestation). No parturient experienced intraoperative pain. The average duration of motor block Bromage 3 in all groups was 68 min, and resolution time to Bromage 0 was 118 min. Maximal cephalad sensory block level was T3-6 and could be established within 6 min. Complete analgesia was significantly prolonged in all groups receiving intrathecal opioids, yet, with sufentanil 5 microg, even the duration of effective analgesia was significantly extended. Neonatal outcome was not affected by intrathecal opioid administration. In conclusion, 2% hyperbaric mepivacaine is a feasible local anesthetic for spinal anesthesia in parturients undergoing elective cesarean delivery, particularly with short duration of surgery. ⋯ Sensory, motor, and analgesic block characteristics of the local anesthetic mepivacaine alone or combined with intrathecal opioids were studied in parturients undergoing elective cesarean delivery in a randomized, double-blinded clinical trial. Mepivacaine was found to be an acceptable local anesthetic for spinal anesthesia in parturients undergoing cesarean delivery. In combination with sufentanil 5 microg, complete and effective analgesia were significantly prolonged.
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Anesthesia and analgesia · Mar 2003
Clinical TrialPatient-controlled epidural analgesia in children: can they do it?
Extensive clinical experience and many studies support the use of i.v. patient-controlled analgesia (i.v. PCA) and regional anesthesia techniques for the treatment of postoperative pain in children. In contrast, little has been reported about the ability of children to use patient-controlled epidural analgesia (PCEA) or about the efficacy of this technique. We report a descriptive analysis of prospectively recorded data in 128 children (132 procedures) in whom PCEA was used for acute postoperative pain control. Satisfactory analgesia was obtained in 119 patients (90.1%) for up to 103 h with no episodes of desaturation and without clinical evidence of toxicity or serious adverse effects. Analgesia was satisfactory with the initial settings in 89 patients; in 38 others, this was achieved with changes in PCEA settings or solution. Five patients were switched to i.v. PCA because of inadequate analgesia. Eight patients with satisfactory analgesia were converted to i.v. PCA because of adverse effects. Children as young as 5 yr had the cognitive ability to understand and the willingness to use PCEA, consistent with reported use of i.v. PCA. Careful attention should be paid to the total hourly local anesthetic dose to avoid exceeding the recommended limits. Our prospectively collected data demonstrate that PCEA provides satisfactory analgesia with a small incidence of adverse side effects in children and should be considered along with other strategies in pediatric postoperative pain management. ⋯ A descriptive analysis of prospectively recorded data in 132 children receiving patient-controlled epidural analgesia for postoperative pain relief demonstrates satisfactory analgesia without serious toxicity or side effects in children as young as 5 yr. This modality should be considered as another strategy in pediatric postoperative pain management.
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Anesthesia and analgesia · Mar 2003
Postcardiac surgery complications: association of acute renal dysfunction and atrial fibrillation.
Postoperative creatinine increase is associated with adverse outcome after cardiac surgery. Although postoperative stroke and renal dysfunction are associated after cardiac surgery, suggesting a common systemic insult, a similar assessment of atrial fibrillation and renal dysfunction has not been performed. Therefore, we tested the hypothesis that patients with new-onset atrial fibrillation complicating coronary bypass surgery have a greater postoperative creatinine increase. Data were obtained for 453 elective coronary bypass surgery patients with no history of atrial fibrillation. Multivariate regression analyses of factors associated with peak fractional change in creatinine demonstrated a two-way interaction between age and atrial fibrillation (variable estimate, -1.1; P = 0.002). Similar results were obtained in a secondary multivariate model analyzing factors associated with peak postoperative creatinine (variable estimate, -0.01; P = 0.04). We confirmed our hypothesis that patients with new-onset atrial fibrillation are more likely to have acute renal dysfunction after cardiac surgery. The association of atrial fibrillation and creatinine increase diminishes with advancing age. These data are consistent with a common pathophysiology that contributes in an age-dependent fashion to the etiology of both acute renal dysfunction and atrial fibrillation after coronary bypass surgery. ⋯ We found an independent association between new-onset atrial fibrillation and postoperative creatinine increase that is influenced by age. The degree to which atrial fibrillation is associated with postoperative creatinine increase diminishes with advancing age. This interaction suggests that a common etiology for these two complications may be more important in younger patients.