Anesthesia and analgesia
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Anesthesia and analgesia · Mar 1998
Randomized Controlled Trial Clinical TrialFactors that predict the use of positive inotropic drug support after cardiac valve surgery.
Left ventricular dysfunction is common after cardiac surgery and is often treated with positive inotropic drugs (PIDs). We hypothesized that the use of PIDs after cardiac valve surgery would have significant associations with the valvular pathophysiology and surgical procedure, and unlike the case for patients undergoing coronary artery surgery, would be unrelated to duration of cardiopulmonary bypass (CPB) or of aortic clamping. One hundred forty-nine consenting patients undergoing cardiac valve surgery were studied. Patients with hepatic or renal failure, or New York Heart Association class IV cardiac symptoms, were excluded. Patients were considered to have received PIDs if they received an infusion of amrinone, dobutamine, epinephrine, or dopamine (> or = 5 microg x kg[-1] x min[-1]). PIDs were received by 78 patients (52%). In a univariate model, older age, history of congestive heart failure, decreasing left ventricular ejection fraction, longer durations of CPB, and concurrent coronary artery surgery significantly increased the likelihood of PID support. There was also significant variation by anesthesiologist in the administration of PIDs. The specific diseased valve and valvular stenosis or insufficiency did not influence the likelihood of receiving PID support. In a multivariable model, age, history of congestive heart failure, decreasing left ventricular ejection fraction, and anesthesiologist were significantly associated with the likelihood of PID support, but duration of CPB and concurrent coronary artery surgery were not. In conclusion, patient age and ventricular function, as well as physician preferences, predicted the need for inotropic drug support; however, neither the specific valvular lesion, nor duration of CPB were strongly predictive in a multivariable model. ⋯ We evaluated factors related to use of positive inotropic drugs after cardiac valve surgery. The likelihood of a patient receiving these drugs increases with advancing age and with more severe preoperative left ventricular dysfunction, but was not influenced by the specific diseased valve or the duration of cardiopulmonary bypass.
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Anesthesia and analgesia · Mar 1998
Randomized Controlled Trial Clinical TrialAlkalinization of lidocaine does not hasten the onset of axillary brachial plexus block.
We assessed the onset of sensory and motor blockade as well as the distribution of sensory blockade after axillary brachial plexus block with 1.5% lidocaine hydrochloride 1:200,000 epinephrine with and without sodium bicarbonate in 38 patients. The onset of analgesia and anesthesia was recorded over the distributions of the median, ulnar, radial, and medial cutaneous nerves of the forearm, medial cutaneous and lateral cutaneous nerves of the arm, and musculocutaneous nerve. The onset of motor blockade of elbow and wrist movements was also recorded. Data were analyzed by using survival techniques and compared by using log rank tests. Only the onset of analgesia in the medial cutaneous nerves of the arm and forearm, and the onset of anesthesia in the medial cutaneous nerve of the arm were significantly faster (P < 0.05) with alkalinization of lidocaine. Our study showed that alkalinization of lidocaine does not significantly hasten block onset in most terminal nerve distributions. ⋯ We examined whether alkalinizing a local anesthetic would quicken the onset of a regional upper limb nerve blockade. We found that alkalinization of lidocaine did not offer a significant clinical advantage in axillary brachial plexus blockade.
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Anesthesia and analgesia · Mar 1998
Randomized Controlled Trial Comparative Study Clinical TrialAn in vivo evaluation of four spinal needles used for the combined spinal-epidural technique.
The purpose of this study was to evaluate four pencil-point spinal needles commonly used for combined spinal-epidural (CSE) anesthesia. Four hundred-seven consecutive parturients undergoing cesarean delivery or labor analgesia received a CSE block with a randomly selected pencil-point spinal needle (Becton-Dickinson [B-D] 27-gauge, 119-mm Whitacre; B-D 27-gauge, 120-mm Durasafe; B-D 25-gauge, 120-mm Durasafe; or International Medical Devices' 26-gauge, 124-mm Gertie Marx). Success in obtaining cerebrospinal fluid (CSF) and the incidence of transient paresthesias and postdural puncture headache (PDPH) were compared by using chi2 testing; P < 0.05 was considered significant. Failure to obtain CSF (3%-5%) was not significantly different among spinal needles. The Gertie Marx 26-gauge needle was associated with significantly more paresthesias (29%) than the Whitacre 27-gauge needle (17%). The combined incidence of paresthesias with the Durasafe 25-gauge and Gertie Marx 26-gauge spinal needles (28%) was greater than the combined incidence of paresthesias with the Durasafe 27-gauge and Whitacre 27-gauge needles (18%). The incidence of PDPH did not differ among the four pencil-point spinal needles. We conclude that longer spinal needles are associated with a significantly more frequent incidence of transient paresthesias without residual effects. ⋯ The use of four pencil-point spinal needles in the combined spinal-epidural technique is associated with an inconsequential incidence of spinal headache, a low incidence of paresthesias that are transient with no long-term effects, and a high degree of success independent of spinal needle length.
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Anesthesia and analgesia · Mar 1998
Randomized Controlled Trial Clinical TrialDroperidol and the side effects of epidural morphine after cesarean section.
Epidural morphine produces analgesia with a high incidence of side effects that include pruritus, nausea, and vomiting. This study investigated whether epidural or i.v. droperidol could alleviate these symptoms. In a prospective, double-blind, randomized, controlled trial, 97 pregnant women undergoing cesarean section were randomly assigned to three groups. All received standard continuous epidural anesthesia. After delivery, each received 5 mg of epidural morphine with either no droperidol injection, 2.5 mg of epidural droperidol, or 2.5 mg of i.v. droperidol. The incidence, onset, duration, and severity of pruritus; the onset and severity of pain; and satisfaction were similar for each group, but the incidence and severity of nausea and vomiting was lower in the group that received i.v. droperidol (P < 0.01). Sedation was minimal throughout the study. Thus, epidural droperidol failed to alleviate the side effects caused by epidural morphine, but i.v.droperidol reduced both the incidence and severity of nausea and vomiting. These results suggest that droperidol acts systemically to counter the effects of epidural morphine but that it is not entirely effective. ⋯ A single dose of epidural morphine provides long-lasting pain relief for women who have undergone cesarean section, but it has some troublesome side effects (itching, nausea, vomiting). We performed a prospective, randomized, controlled trial in 97 such women to study whether droperidol could reduce these side effects. We found that i.v. droperidol reduced nausea and vomiting but did not prevent itching, and that epidural droperidol failed to prevent all side effects.
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Anesthesia and analgesia · Mar 1998
Diabetes mellitus and difficult laryngoscopy in renal and pancreatic transplant patients.
Limited mobility of the cervical spine or temperomandibular joint may contribute to increased difficulty of laryngoscopy in patients who have severe diabetes mellitus. The frequency of difficult laryngoscopy in diabetics undergoing renal and/or pancreatic transplants has been reported to be as high as 32%. We retrospectively reviewed the anesthetic records of all adult patients who underwent renal and/or pancreatic transplant and endotracheal intubation from January 1, 1985 to October 31, 1995. Characteristics specifically reviewed included the presence of diabetes mellitus, type of organ donor, age, gender, body mass index, previous difficult laryngoscopy, known characteristics potentially related to difficult laryngoscopy, and degree of difficulty with laryngoscopy. Laryngoscopy was graded as easy, minimally to moderately difficult, and moderately to extremely difficult to perform. Factors associated with any degree of difficult intubation were univariately assessed by using Fisher's exact test. Of 725 patients, 15 (2.1%) were identified as having difficult laryngoscopies, although all underwent successful endotracheal intubations. Factors associated with difficult laryngoscopy were diabetes mellitus (P = 0.002) and characteristics known to be related to difficult laryngoscopy (P = 0.02). These findings confirm an increase in the frequency of difficult laryngoscopy in diabetic patients undergoing renal and/or pancreatic transplant, although no laryngoscopies were rated as moderately to extremely difficult. We conclude that the frequency of difficult laryngoscopy in these diabetic patients is much lower than previous reports have suggested. ⋯ Previous studies have suggested that airway management of many diabetic patients may be difficult. Our medical record review of patients with severe diabetes undergoing organ transplants showed that extraordinary techniques were not required to successfully manage their airways.