Anesthesia and analgesia
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Anesthesia and analgesia · Jan 2004
Randomized Controlled Trial Clinical TrialThe effects of prolonged ambulation on labor with epidural analgesia.
Ambulation during labor is becoming more popular, although its impact on the progress of labor and on pain intensity remains unclear. We wondered whether prolonged ambulation with epidural analgesia had a possible effect on duration of labor and pain. In this prospective, randomized trial, 61 parturients with uncomplicated term pregnancies were allocated to be recumbent (n = 31) or to ambulate (n = 30). Epidural analgesia was provided with intermittent administrations of 0.08% bupivacaine-epinephrine plus 1 microg/mL of sufentanil. Of the 30 women assigned to the ambulatory group, 25 actually walked. Their ambulating time was 64 +/- 34 min (mean +/- SD), i.e., 29% +/- 16% of the first stage. There were no differences between the two groups in the length of labor and in pain visual analog scale scores. However, the ambulatory group received smaller doses of bupivacaine (6.4 +/- 2.2 mg/h versus 8.4 +/- 3.6 mg/h; P = 0.01) and of oxytocin (6.0 +/- 3.7 mUI/min versus 10.2 +/- 8.8 mUI/min; P < 0.05). A greater ability to void was also found in the ambulatory group (P < 0.01). Although the duration of labor and pain relief was unchanged, these findings support that ambulation during labor may be advantageous. ⋯ This study compared the duration of labor and pain relief between parturients receiving epidural analgesia who were ambulated or were recumbent. Whereas walking had no impact on either duration of labor or pain relief, it was associated with a reduction in both bupivacaine and oxytocin requirements.
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Anesthesia and analgesia · Jan 2004
Case ReportsPituitary apoplexy presenting as unilateral third cranial nerve palsy after coronary artery bypass surgery.
The new onset of pituitary apoplexy is a rare perioperative complication of coronary artery bypass surgery. A variety of clinical presentations of pituitary apoplexy have been reported including absence of clinical symptoms or headache, sudden deterioration of mental status, visual changes, Addisonian crisis, and ophthalmoplegia, including third cranial nerve palsy and/or ptosis. Early diagnosis and treatment usually results in excellent outcome. We report a case of pituitary apoplexy that presented with only a unilateral dilated pupil, ptosis, and vision change within 3 h after coronary artery bypass surgery. The patient recovered fully after early pituitary tumor resection and hormonal therapy. ⋯ Unilateral pupil dilation is a rare perioperative complication after coronary artery bypass surgery. We report a case of pituitary apoplexy that presented clinically as unilateral dilated pupil, ptosis, and visual loss shortly after coronary artery bypass surgery.
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Anesthesia and analgesia · Jan 2004
Clinical TrialA-type and B-type natriuretic peptides in cardiac surgical procedures.
This study was performed to determine the secretion pattern and prognostic value of A-type (ANP) and B-type (BNP) natriuretic peptide in patients undergoing cardiac surgical procedures. We measured ANP and BNP in patients undergoing coronary artery bypass grafting (CABG) with (n = 28) or without (n = 32) ventricular dysfunction and in patients undergoing mitral (n = 21) or aortic (n = 24) valve replacement, respectively. Postoperative mortality was recorded up to 730 days after operation. ANP, but not BNP, concentrations were closely associated with volume reloading of the heart after aortic cross-clamp in all patients. The secretion pattern of BNP during surgery was much less uniform. BNP, but not ANP, concentrations correlated with aortic cross-clamp time (r(2) = 0.32; P = 0.006) and postoperative troponin I concentrations (r(2) = 0.22; P = 0.0009) in bypass patients, and preoperative BNP increases were associated with a more frequent postoperative (2-yr) mortality in these patients. Markedly increased preoperative BNP concentrations in mitral (3-fold) and aortic (14-fold) valve disease patients did not further increase during cardiopulmonary surgery. The data suggest that ANP is primarily influenced by intravascular volume reloading of the heart after cross-clamp, whereas the secretion of BNP is related to other factors, such as duration of ischemia and long-term left ventricular pressure and/or excessive intravascular volume. BNP, but not ANP, was shown to be a mortality risk predictor in patients undergoing CABG. ⋯ A-type natriuretic peptide is primarily influenced by volume reloading of the heart after cross-clamp, whereas the secretion of B-type natriuretic peptide (BNP) is related to the duration of ischemia and long-term left ventricular pressure and/or volume overload. Preoperative BNP, but not postoperative BNP, concentrations predict long-term outcome after coronary artery bypass grafting.
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Anesthesia and analgesia · Jan 2004
Clinical TrialA novel infraclavicular brachial plexus block: the lateral and sagittal technique, developed by magnetic resonance imaging studies.
A new infraclavicular brachial plexus block method has the patient supine with an adducted arm. The target is any of the three cords behind the pectoralis minor muscle. The point of needle insertion is the intersection between the clavicle and the coracoid process. The needle is advanced 0 degrees -30 degrees posterior, always strictly in the sagittal plane next to the coracoid process while abutting the antero-inferior edge of the clavicle. We tested the new method using magnetic resonance imaging (MRI) in 20 adult volunteers, without inserting a needle. Combining 2 simulated needle directions by 15 degrees posterior and 0 degrees in the images of the volunteers, at least one cord in 19 of 20 volunteers was contacted. This occurred within a needle depth of 6.5 cm. In the sagittal plane of the method the shortest depth to the pleura among all volunteers was 7.5 cm. The MRI study indicates that the new infraclavicular technique may be efficient in reaching a cord of the brachial plexus, often not demanding more than two needle directions. The risk of pneumothorax should be minimal because the needle is inserted no deeper than 6.5 cm. However, this needs to be confirmed by a clinical study. ⋯ A new infraclavicular brachial plexus block method was investigated using magnetic resonance imaging without inserting needles in the volunteers. The study suggests two needle directions for performance of the block and that the risk of lung injury should be minimal. Expectations need to be confirmed by a clinical study.
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Anesthesia and analgesia · Jan 2004
Comparative StudySpinal chloroprocaine solutions: density at 37 degrees C and pH titration.
The density and pH of a local anesthetic are important characteristics in its use as an intrathecal drug. Preservative- and antioxidant-free formulations of chloroprocaine are available and are being investigated for short-duration spinal anesthesia. In this study, we evaluated the pH and density (to 5 significant digits in g/mL, at 37.0 degrees C) of these new chloroprocaine formulations. In addition to plain 2% and 3% chloroprocaine and 2% lidocaine, mixed solutions of 2% chloroprocaine with epinephrine or with bicarbonate were evaluated. Density was also measured after water dilution and after increasing amounts of added dextrose. Chloroprocaine, 2% or 3%, is hyperbaric relative to cerebrospinal fluid (CSF) before any addition of dextrose (density 1.00123 g/mL and 1.00257 g/mL, respectively). When diluted with water, all the solutions are hypobaric relative to CSF (density <1.00028 g/mL). Plain 2% lidocaine is the only dextrose-free solution measured to be hypobaric (density 1.00004 g/mL). Bisulfite-free 2-chloroprocaine remains very acidic (pH <4.0), but the pH can be increased to more than 7.0 with a small amount of bicarbonate (0.25-0.33 mL/10 mL). The increased density of plain chloroprocaine makes it a useful hyperbaric spinal drug without the addition of dextrose. ⋯ Dextrose-free 2-chloroprocaine is hyperbaric relative to cerebrospinal fluid at 37 degrees C, and therefore can be used for spinal anesthesia without dextrose. Bisulfite-free 2-chloroprocaine remains very acidic (pH <4.0). The pH can be increased to more than 7.0 with a small amount of bicarbonate (0.25-0.33 mL/10 mL).