Anesthesia and analgesia
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Anesthesia and analgesia · Feb 2004
Case ReportsRigid bronchoscope-assisted endotracheal intubation: yet another use of the gum elastic bougie.
We describe a technique by which a gum elastic bougie (GEB) is used to facilitate an anticipated difficult endotracheal intubation in a patient undergoing rigid bronchoscopy. After placing the GEB through the lumen of the rigid bronchoscope, the GEB-suction catheter assembly was used to safely withdraw the bronchoscope in a manner mimicking the withdrawal of an intubating laryngeal mask airway (LMA) over the endotracheal tube using a stabilizer rod. The rationale for management and potential advantages of this approach versus use of an airway exchange catheter (including increased stability of an intubation guide) are discussed. ⋯ We describe a technique of using a gum elastic bougie to facilitate an endotracheal intubation in a patient undergoing rigid bronchoscopy, which can be useful in a variety of clinical situations when the rigid bronchoscope is used in patients with abnormal airway.
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Anesthesia and analgesia · Feb 2004
Randomized Controlled Trial Multicenter Study Clinical TrialThe safety and efficacy of a fentanyl patient-controlled transdermal system for acute postoperative analgesia: a multicenter, placebo-controlled trial.
A noninvasive method of delivery of parenteral opioids for management of acute pain may offer logistic advantages for patients and nursing staff. A patient-controlled transdermal system (PCTS) under development consists of a preprogrammed, self-contained drug-delivery system that uses electrotransport technology (E-TRANS, ALZA Corp, Mountain View, CA) to deliver 40 micro g of fentanyl HCl over 10 min per on-demand dose for patient-controlled analgesia (PCA). In this randomized, double-blinded, placebo-controlled trial we compared the efficacy and safety of on-demand fentanyl HCl PCTS 40 microg against placebo for postoperative pain up to 24 h after major abdominal, orthopedic, or thoracic surgery in 205 patients. The primary efficacy measurement was the percentage of patients withdrawn from the study because of inadequate analgesia after completing at least 3 h of treatment. Secondary efficacy measures included mean pain intensity (using visual analog scales), patient global assessments, and investigator global assessments. Of 189 patients considered evaluable for efficacy, 25% of patients in the fentanyl HCl PCTS 40 microg group withdrew because of inadequate analgesia, compared with 40.4% of the placebo group (P < 0.05). Use of fentanyl HCl PCTS 40 micro g was associated with lower VAS scores and higher mean patient and investigator global assessment scores compared with placebo. No patient experienced clinically relevant respiratory depression. This study showed that a fentanyl HCl PCTS 40 microg for PCA was superior to placebo and well tolerated for the control of moderate to severe postoperative pain for up to 24 h after major surgery. ⋯ This multicenter, randomized, double-blinded, placebo-controlled trial showed that an on-demand fentanyl HCl patient-controlled transdermal system (PCTS) was superior to placebo and well tolerated for the control of moderate to severe postoperative pain for up to 24 h after major surgery. This fentanyl HCl PCTS is a preprogrammed, needle free, self-contained drug-delivery system that uses electrotransport technology (iontophoresis) to deliver 40 microg of fentanyl per on-demand dose.
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Anesthesia and analgesia · Feb 2004
Randomized Controlled Trial Clinical TrialRapid onset of cutaneous anesthesia with EMLA cream after pretreatment with a new ultrasound-emitting device.
In this randomized, double-blinded, placebo-controlled, crossover trial of 42 human subjects, we examined the speed of onset of cutaneous anesthesia by eutectic mixture of local anesthetics (EMLA) cream after brief (approximately 10-s) pretreatment of the underlying skin with low-frequency (55 kHz) ultrasound. Four treatments were compared: ultrasound pretreatment followed by application of 1 g EMLA or placebo cream for 5 min, 10 min, 15 min, and 60 min without ultrasound pretreatment as positive control. Pain was tested by pricks with a 20 g needle. Pain scores and patient preference for EMLA or placebo cream were measured at each time point. Based on both pain scores and patient preference, cutaneous anesthesia was achieved in the EMLA groups as compared with placebo at all time points. After ultrasound pretreatment and then 5, 10, or 15 min after EMLA cream application, pain scores and overall preference were statistically indistinguishable from EMLA cream application for 60 min (without ultrasound pretreatment). There were no significant adverse effects. Low-frequency ultrasound pretreatment appears to be safe and effective in producing rapid onset of EMLA cream in this model, with results as early as 5 min. ⋯ A prospective, randomized, double-blinded, placebo-controlled clinical trial demonstrated rapid onset of cutaneous anesthesia by pretreatment of the skin with ultrasound before application of EMLA cream.
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Anesthesia and analgesia · Feb 2004
Clinical TrialThe incidence of laryngospasm with a "no touch" extubation technique after tonsillectomy and adenoidectomy.
In this case series, we evaluated the incidence of laryngospasm using a clearly defined awake tracheal extubation technique in 20 children undergoing elective tonsillectomy with or without adenoidectomy. This technique required patients to be turned to the recovery position at the end of the procedure before discontinuing the volatile anesthetics. No further stimulation, besides continuous oximetry monitoring, was allowed until the patients spontaneously woke up ("no touch" technique). The incidence of laryngospasm, oxygen saturation, and coughing was recorded. No cases of laryngospasm, oxygen desaturation, or severe coughing occurred in our patient population. ⋯ This study re-emphasizes the importance of a sound anesthetic technique in tracheally extubating pediatric patients.
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Anesthesia and analgesia · Feb 2004
Resident training level and quality of anesthesia care in a university hospital.
In this study, we analyzed the relationship between resident training and patient safety in anesthesia. A retrospective quality improvement database review was used to calculate the relative risk of any quality problem and specific types of quality problems (injury, escalation of care, or operational inefficiency) between anesthesia teams with CA1, CA2, and CA3 residents. It was expected that teams with less experienced residents (CA1) would have more frequent quality problems than teams with more experienced residents (CA2 and CA3 teams). Data showed that risk of injury did not differ between CA1, CA2, and CA3 teams. CA2 teams had higher rates of critical incidents and escalation of care than CA1 and CA3 teams and higher rates of operational inefficiency than CA3 teams. The CA2 yr is when residents move into specialty training, requiring more advanced skills and a larger knowledge base. Their higher relative risk for critical incidents, escalation of care, and operational inefficiencies may reflect lack of experience, uncertainty, and less skill mastery compared with CA3 residents. The higher inefficiency and escalation of care rates associated with CA2 teams may translate into larger costs for the institution. ⋯ Appropriate supervision of anesthesia residents helps to ensure patient safety. Anesthesia management problems are most common during the CA2 yr and result in higher costs for the institution.