Anesthesia and analgesia
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Anesthesia and analgesia · May 2004
Randomized Controlled Trial Clinical TrialInteractive music therapy as a treatment for preoperative anxiety in children: a randomized controlled trial.
In this study, we examined whether interactive music therapy is an effective treatment for preinduction anxiety. Children undergoing outpatient surgery were randomized to 3 groups: interactive music therapy (n = 51), oral midazolam (n = 34), or control (n = 38). The primary outcome of the study was children's perioperative anxiety. We found that children who received midazolam were significantly less anxious during the induction of anesthesia than children in the music therapy and control groups (P = 0.015 and P = 0.005, respectively). We found no difference in anxiety during the induction of anesthesia between children in the music therapy group and children in the control group. An analysis controlling for therapist revealed a significant therapist effect; i.e., children treated by one of the therapists were significantly less anxious than children in the other therapist group and the control group on separation to the operating room (OR) (P < 0.05) and on entrance to the OR (P < 0.05), but not on the introduction of the anesthesia mask (P = not significant). Children in the midazolam group were the least anxious even after controlling for therapist effect (P < 0.05). We conclude that music therapy may be helpful on separation and entrance to the OR, depending on the therapist. However, music therapy does not appear to relieve anxiety during the induction of anesthesia. ⋯ Depending on the music therapist, interactive music therapy may relieve anxiety on separation and entrance to the operating room but appears less effective during the induction of anesthesia.
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Anesthesia and analgesia · May 2004
ReviewA qualitative systematic review of the role of N-methyl-D-aspartate receptor antagonists in preventive analgesia.
We evaluated in a qualitative systematic review the effect of N-methyl-D-aspartate (NMDA) receptor antagonists on reducing postoperative pain and analgesic consumption beyond the clinical duration of action of the target drug (preventive analgesia). Randomized trials examining the use of an NMDA antagonist in the perioperative period were sought by using a MEDLINE (1966-2003) and EMBASE (1985-2003) search. Reference sections of relevant articles were reviewed, and additional articles were obtained if they evaluated postoperative analgesia after the administration of NMDA antagonists. The primary outcome was a reduction in pain, analgesic consumption, or both in a time period beyond five half-lives of the drug under examination. Secondary outcomes included time to first analgesic request and adverse effects. Forty articles met the inclusion criteria (24 ketamine, 12 dextromethorphan, and 4 magnesium). The evidence in favor of preventive analgesia was strongest in the case of dextromethorphan and ketamine, with 67% and 58%, respectively, of studies demonstrating a reduction in pain, analgesic consumption, or both beyond the clinical duration of action of the drug concerned. None of the four studies examining magnesium demonstrated preventive analgesia. ⋯ We evaluated, in a qualitative systematic review, the effect of N-methyl D-aspartate antagonists on reducing postoperative pain and analgesic consumption beyond the clinical duration of action of the target drug (preventive analgesia). Dextromethorphan and ketamine were found to have significant immediate and preventive analgesic benefit in 67% and 58% of studies, respectively.
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Anesthesia and analgesia · May 2004
Randomized Controlled Trial Clinical TrialAutomated cardiac output measurement by transesophageal color Doppler echocardiography.
Automated cardiac output measurement (ACOM), which integrates digital color Doppler velocities in space and in time, has been validated using transthoracic echocardiography but has not been tested using transesophageal echocardiography (TEE). Therefore, we determined the feasibility of the ACOM method by TEE in 36 patients undergoing cardiovascular surgery. Regions of interest for ACOM were placed within a color sector across the main pulmonary artery (PA), the mitral annulus, and the left ventricular outflow tract. Cardiac output was determined from the PA flow, the mitral flow, and the left ventricular ejection flow at each view using the ACOM method. We compared measurements of cardiac output derived from the ACOM method with measurements simultaneously obtained by thermodilution (TD). In the mitral flow analysis, the values derived from ACOM correlated well with those from TD (R(2) = 0.85; mean difference = 0.01 +/- 0.58 L/min in the 2-chamber view; R(2) = 0.78; mean difference = -0.10 +/- 0.68 L/min in the 4-chamber view). In the PA flow analysis, the values derived from ACOM did not correlate with those from TD (R(2) = 0.30). In the left ventricular outflow tract analysis, it was very difficult to obtain the optimal view (44%) in which color Doppler flow signals adequately appeared. Using the ACOM method, we obtained good correlation and agreement for cardiac output measurements in the mitral flow analysis compared with TD. The ACOM method is a practical and rapid method to measure cardiac output by TEE analysis of mitral flow. ⋯ Automated cardiac output measurement by transesophageal color Doppler echocardiography is a practical and rapid method to measure cardiac output. This technique is a promising new approach to echocardiographic quantification in the intraoperative setting.
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Anesthesia and analgesia · May 2004
Randomized Controlled Trial Clinical TrialA prospective, randomized evaluation of the effects of epidural needle rotation on the distribution of epidural block.
We evaluated the effects of turning the tip of the Tuohy needle 45 degrees toward the operative side before threading the epidural catheter (45 degrees -rotation group, n = 24) as compared to a conventional insertion technique with the tip of the Tuohy needle oriented at 90 degrees cephalad (control group, n = 24) on the distribution of 10 mL of 0.75% ropivacaine with 10 microg sufentanil in 48 patients undergoing total hip replacement. The catheter was introduced 3 to 4 cm beyond the tip of the Tuohy needle. A blinded observer recorded sensory and motor blocks on both sides, quality of analgesia, and volumes of local anesthetic used during the first 48 h of patient-controlled epidural analgesia. Readiness to surgery required 21 +/- 6 min in the control group and 17 +/- 7 min in the 45 degree-rotation group (P > 0.50). The maximum sensory level reached on the operative side was T10 (T10-7) in the control group and T9 (T10-6) in the 45 degree-rotation group (P > 0.50); whereas the maximum sensory level reached on the nonoperative side was T10 (T12-9) in the control group and L3 (L5-T12) in the 45 degree-rotation group (P = 0.0005). Complete motor blockade of the operative limb was achieved earlier in the 45 degree-rotation than in the control group, and motor block of the nonoperative side was more intense in patients in the control group. Two-segment regression of sensory level on the surgical side was similar in the two groups, but occurred earlier on the nonoperative side in the 45 degree-rotation group (94 +/- 70 min) than in the control group (178 +/- 40 min) (P = 0.0005). Postoperative analgesia was similar in the 2 groups, but the 45 degree-rotation group consumed less local anesthetic (242 +/- 35 mL) than the control group (297 +/- 60 mL) (P = 0.0005). We conclude that the rotation of the Tuohy introducer needle 45 degrees toward the operative side before threading the epidural catheter provides a preferential distribution of sensory and motor block toward the operative side, reducing the volume of local anesthetic solution required to maintain postoperative analgesia. ⋯ Turning the Tuohy introducer needle 45 degrees toward the operative side before threading the epidural catheter is a simple maneuver that produces a preferential distribution of epidural anesthesia and analgesia toward the operative side, minimizing the volume of local anesthetic required to provide adequate pain relief after total hip arthroplasty.
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Anesthesia and analgesia · May 2004
Randomized Controlled Trial Clinical TrialPostcesarean analgesia with spinal morphine, clonidine, or their combination.
In this randomized, double-blind trial in 240 women, we investigated the analgesic efficacy and duration of subarachnoid fentanyl 15 microg with morphine, clonidine, or both morphine and clonidine for cesarean delivery. A dose-finding analysis showed similar postoperative efficacy and side effects for groups receiving morphine 100 microg with clonidine 60, 90, or 150 microg. Data from these groups were combined (MC60-150, n = 113) and compared with groups receiving morphine 100 microg (n = 39), clonidine 150 microg (n = 39), or morphine 100 microg plus clonidine 30 microg (n = 41). The four groups differed in the time to patient-controlled morphine use and cumulative morphine consumption (P < 0.0001 and P < 0.001, respectively), with the longest duration and smallest dose in MC60-150. Pain scores were significantly different among groups. Onset of sensory block, ephedrine requirement and incidence of hypotension, patient satisfaction, and recovery were similar. Groups receiving clonidine had greater sedation, those receiving morphine had more severe pruritus, and group MC60-150 showed a trend to more vomiting intraoperatively. Compared with morphine 100 microg or clonidine 150 microg alone, the combination of subarachnoid morphine 100 microg and at least 60 microg of clonidine was found to increase the duration of postcesarean analgesia, reduce opioid requirement, and increase intraoperative sedation. ⋯ A multimodal approach to postcesarean analgesia, using subarachnoid bupivacaine, fentanyl, morphine 100 microg, and clonidine 60 microg, improves pain relief compared with morphine 100 microg or clonidine 150 microg alone, but increases intraoperative sedation and may increase perioperative vomiting.