British journal of anaesthesia
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Randomized Controlled Trial Comparative Study Clinical Trial
A prospective, randomized comparison of interpleural and paravertebral analgesia in thoracic surgery.
We have undertaken a prospective, randomized comparison of the superficially similar techniques of interpleural and paravertebral (extrapleural) analgesia in 53 patients undergoing posterolateral thoracotomy. Local anaesthetic placed anterior to the superior costotransverse ligament and posterior to the parietal pleura produces a paravertebral block and instilled between the parietal and visceral pleurae produces an interpleural block. Patients received preoperative and postoperative continuous bupivacaine paravertebral blocks in group 1 and interpleural blocks in group 2. ⋯ PFT were significantly better (P = 0.03-0.0001) in group 1, and PORM was lower and hospital stay approximately 1 day less in this group. Five patients in group 2 became temporarily confused, probably because of bupivacaine toxicity (P = 0.02). We conclude that bupivacaine deposited paravertebrally produced greater preservation of lung function and fewer side effects than bupivacaine administered interpleurally.
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We describe the successful use of the short-acting, non-depolarizing neuromuscular blocking agent, mivacurium, in a patient with myotonic dystrophy. Increased sensitivity to mivacurium was demonstrated using train-of-four monitoring, with a single dose of mivacurium providing adequate block for 90 min of surgery. Spontaneous recovery appeared prolonged with a recovery index (25-75% T1) of 10 min and a recovery time (5-95% T1) of 30 min. The use of reversal agents and anticholinergic agents was avoided.
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Clinical Trial
Double lung transplantation without cardiopulmonary bypass: arterial to end-tidal carbon dioxide partial pressure differences.
Bilateral lung transplantation without cardiopulmonary bypass consists of two sequential single lung transplantations. Variations in ventilatory status during the procedure led us to study the (PaCO2-PE'CO2) gradient to see if PE'CO2 might reflect PaCO2. The gradient was studied in 14 patients at six times during operation. (PaCO2-PE'CO2) (kPa) was mean 1.97 (SD 0.7) after induction, 3.2 (1.4) during single lung ventilation, 1.9 (1.1) after clamping of the contralateral pulmonary artery, 2.96 (1.6) after ventilation and vascularization of the first transplant and the remaining native lung, 0.99 (0.8) during single lung ventilation with the first transplant and 1.3 (0.8) during ventilation of both transplants. With ventilation by the allograft lung(s) alone, the small (PaCO2-PE'CO2) value demonstrated improvement in ventilatory status, enabled PaCO2 to be assessed by PE'CO2 and demonstrated efficiency of the grafts.
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Randomized Controlled Trial Comparative Study Clinical Trial
Onset of neuromuscular block after tourniquet inflation: comparison of suxamethonium with vecuronium.
To determine the influence of circulatory factors on onset of neuromuscular block, we have measured twitch height in an arm with a tourniquet inflated during onset and compared this with data from a control arm in 20 patients under fentanyl-thiopentone-nitrous oxide-isoflurane anaesthesia. Patients were allocated randomly to receive either vecuronium 0.1 mg kg-1 (n = 10) or suxamethonium 1 mg kg-1 (n = 10). The EMG response of the first dorsal interosseous to single twitch stimulation of the ulnar nerve every 10 s was recorded in both arms. ⋯ Maximum block was only 74 (20)% in the tourniquet arm compared with 97 (5)% in the perfused arm (P < 0.05). The difference in maximum neuromuscular block between arms was 4 (3)% in the vecuronium group and 22 (17)% in the suxamethonium group (P < 0.01). We conclude that during onset, neuromuscular block continued to increase in spite of interruption of blood flow, and this increase was greater with vecuronium than with suxamethonium.(ABSTRACT TRUNCATED AT 250 WORDS)
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Randomized Controlled Trial Comparative Study Clinical Trial
EEG arousal during laryngoscopy and intubation: comparison of thiopentone or propofol supplemented with nitrous oxide.
We studied EEG arousal after laryngoscopy and intubation with standardized bolus induction of anaesthesia. Twenty patients were prospectively allocated randomly to induction with propofol 3 mg kg-1 (n = 10) or thiopentone (6 mg kg-1 (n = 10) and 50% nitrous oxide in oxygen. Neuromuscular block was produced with vecuronium 0.2 mg kg-1 given 30 s after induction. ⋯ This EEG arousal was greater in the thiopentone group, despite the fact that EEG depression was similar to that produced by propofol before laryngoscopy and intubation. Propofol and thiopentone in combination with nitrous oxide had similar cortical depressant effects, but propofol appeared to depress subcortical nociceptive processing more than thiopentone. While the degree of cortical EEG depression seems less useful for predicting reaction to subsequent nociception, EEG arousal reactions may prove suitable for monitoring intra-anaesthetic nociception and its modulation.