Anesthesia and analgesia
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Anesthesia and analgesia · Jun 2003
Clinical TrialPerioperative myocardial ischemia in patients undergoing sternectomy shortly after coronary artery bypass grafting.
Coronary revascularization reduces cardiac complications associated with noncardiac surgery in patients with severe coronary disease. However, patients undergoing emergency noncardiac surgery soon after coronary bypass operations may still be vulnerable to ischemic myocardial events. We prospectively evaluated the incidence of myocardial ischemia in 82 consecutive patents scheduled for sternectomy in the first (Group 1; 35 patients) or second (Group 2; 47 patients) week after coronary artery bypass graft (CABG) surgery. The interval between CABG surgery and sternectomy in Groups 1 and 2 was 6 days (range, 4-7 days) and 11 days (range, 8-14 days), respectively. Electrocardiographic (ECG) changes consistent with myocardial ischemia were assessed with a two-channel Holter system for 48 h. There were no between-group differences in updated Acute Physiology and Chronic Health Evaluation score, use of beta-blockers, or perioperative hemodynamic changes. The incidence of ECG changes consistent with myocardial ischemia was fivefold more frequent in Group 1 (22.85% versus 4.25%; P < 0.05). Of the ischemic patients in Group 1, 25% experienced a perioperative acute myocardial infarction (one was fatal). There were no infarcts in Group 2. Thus, patients appear to be prone to coronary events during sternectomy performed early after CABG surgery. Although the incidence of ischemia did not differ from that previously reported after CABG surgery alone, further investigation is required to determine whether the findings obtained in this high-risk population are generalizable to patients undergoing noncardiac surgery soon after uneventful CABG surgery. ⋯ This study demonstrates an increased incidence of myocardial ischemia when sternectomy for mediastinitis is performed within one week of coronary artery bypass graft surgery, and this ischemia is associated with a 25% incidence of myocardial infarction.
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Anesthesia and analgesia · Jun 2003
Case ReportsRight ventricular exclusion surgery for arrhythmogenic right ventricular dysplasia with cardiomyopathy.
The authors describe the management of a patient with arrhythmogenic right ventricular dysplasia treated with right ventricular exclusion surgery.
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Anesthesia and analgesia · Jun 2003
Clinical TrialDiluent volume for epidural fentanyl and its effect on analgesia in early labor.
Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. We designed the current study to determine the influence of the diluent volume of the epidural fentanyl bolus (e.g., whether it has an effect on the onset and duration of analgesia). Sixty laboring primigravid women received a 3-mL epidural test dose of lidocaine with epinephrine and then received a fentanyl 100- micro g bolus in either a 2-mL, 10-mL, or 20-mL volume. Pain scores and side effects were recorded for each patient. The onset of analgesia was similar in all three groups. The mean duration before re-dose was not significantly different in the 2-mL group (108 +/- 40 min), the 10-mL group (126 +/- 57 min), or the 20-mL group (126 +/- 41 min). No patient in any group experienced any detectable motor block; one patient (2-mL group) complained of mild knee weakness and was not allowed to ambulate. In early laboring patients, the volume in which 100 micro g of epidural fentanyl (after a lidocaine-epinephrine test dose) is administered does not affect the onset or duration of analgesia, nor does it affect the ability to ambulate. ⋯ In early laboring patients, the volume in which 100 micro g of epidural fentanyl (after a lidocaine-epinephrine test dose) is administered does not affect the onset or duration of ambulatory analgesia.
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Anesthesia and analgesia · Jun 2003
Case ReportsPostdural puncture headache: an imaging-guided management protocol.
We propose an imaging-based algorithm for the management of headache caused by the inadvertent puncture of dura that occurs sporadically during epidural analgesia. Its implementation can identify those postdural puncture headache cases that cannot benefit from epidural blood patches, and their unnecessary application can consequently be avoided.
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Anesthesia and analgesia · Jun 2003
The use of advanced simulation in the training of anesthesiologists to treat chemical warfare casualties.
Training anesthesiologists to treat nerve gas intoxication in a mass casualty scenario is a complicated task. The scenario is an unfamiliar medical situation involving the need to decontaminate patients before providing definitive medical treatment, and the need for physical protection to the medical team before decontamination. We describe the development of a simulation-based training program. In one site of a virtual hospital, anesthesiologists were trained in initial airway and breathing resuscitation before decontamination while wearing full protective gear. In another site, they were trained in the treatment of critically-ill patients with combined conventional and chemical injuries or severe intoxication. Intubation simulators of newborn, pediatric, and adult patients, advanced full-scale simulators, and actors simulating patients were used. Initial airway, breathing, and antidotal treatment were performed successfully, with or without full protective gear. The gas mask did not interfere with orotracheal intubation, but limited effective communication within the medical team. Chemical protective gloves were the limiting factor in the performance of medical tasks such as fixing the orotracheal tube. Twenty-two participants (88%) pointed out that the simulated cases represented realistic problems in this scenario, and all 25 participants found the simulated-based training superior to previous traditional training they had in this field. Using advanced simulation, we were able to train anesthesiologists to treat nerve gas intoxication casualties and to learn about the limitations of providing medical care in this setting. ⋯ Advanced medical simulation can be used to train anesthesiologists to treat nonconventional warfare casualties. The limitations of medical performance in full protective gear can be learned from this training.