European journal of anaesthesiology
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Randomized Controlled Trial Comparative Study Clinical Trial
Epidural infusions of sufentanil with and without bupivacaine: comparison with diamorphine-bupivacaine.
The requirements for supplementary 3 ml epidural injections of bupivacaine 0.5% (top-ups) were used in a randomized double-blind study to compare the effects of five types of thoracic epidural infusions given at 2.5 ml h-1 for the first 24 h after major surgery to the upper abdomen in 99 patients and the lower abdomen in 72. The infusions were: bupivacaine 0.167% alone; diamorphine 0.167 mg ml-1 (0.417 mg h-1) in bupivacaine 0.167%; sufentanil 2 micrograms ml-1 (5 micrograms h-1) in 0.167% bupivacaine; sufentanil 4 micrograms ml-1 (10 micrograms h-1) in 0.167% bupivacaine; and sufentanil 4 micrograms ml-1 (10 micrograms h-1) in normal saline. The patients who had upper abdominal surgery were on average older than those having lower abdominal surgery and a larger proportion of them were female. ⋯ Although the two sufentanil-bupivacaine mixtures were indistinguishable in analgesic effectiveness after either upper or lower abdominal surgery, the lower (5 micrograms h-1) dose rate of sufentanil gave a significantly higher average breathing rate and lower average PaCO2 for the first 24 h after lower (but not upper) abdominal surgery. Blood samples were taken (as an afterthought) from 11 patients receiving sufentanil 10 micrograms h-1, just before the epidural infusion was stopped. The concentrations were mostly above the range for systemic analgesia, but below the values that would have been expected if a steady state had been achieved.
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Comparative Study
Haemodynamic effects of pneumoperitoneum for laparoscopic surgery: a comparison of CO2 with N2O insufflation.
We studied the haemodynamic effects of intra-abdominal insufflation with either CO2 (n = 15) or N2O (n = 15) in patients undergoing laparoscopic surgery. Haemodynamic variables were measured at increasing levels of intra-abdominal pressure up to 20 mmHg. In the CO2 group cardiac index decreased from 2.6 +/- 0.6 to 2.0 +/- 0.4 litre min-1 m-2 (mean +/- SD, P < 0.001) and in the N2O group from 2.6 +/- 0.5 to 1.8 +/- 0.4 litre min-1 m-2 (P < 0.001)). ⋯ In both groups central venous O2 tension and saturation decreased at maximum intra-abdominal pressure and increased after release of the pneumoperitoneum. The results indicate that laparoscopic insufflation with either CO2 or N2O results in cardiovascular depression. Insufflation with N2O may decrease blood pressure, whereas mean arterial pressure is better preserved with CO2 insufflation.
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Spinal anaesthesia resulted in unblocked segments in a patient who had undergone three previous spinal operations. Scar tissue, which often forms both extra-durally and intra-durally after spinal surgery, was probably the cause of the patchy sensory blockade.