British journal of anaesthesia
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We describe a 73-yr-old woman anaesthetized for a laminectomy. She suffered from hepatic failure with mild encephalopathy complicated by several exacerbations associated with sedative and opioid therapy. ⋯ We used remifentanil to provide intraoperative and postoperative analgesia, because it has a short duration of action and does not require hepatic metabolism. We closely monitored the respiratory and the neurological status throughout the administration and conclude that remifentanil can provide perioperative analgesia in patients at risk of developing hepatic encephalopathy.
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Alpha2-adrenergic agonists given intrathecally result in antinociception and intracerebroventricularly (ICV) in sedation. To examine whether different alpha2-adrenergic receptor subtypes differentially mediate antinociception and sedation, we measured the relative potency of three alpha2-adrenergic agonists, dexmedetomidine (DMET), clonidine (CLON) and UK-14.304 (UK), after spinal and ICV administration. Each agonist was given either alone or in the presence of systemically administered yohimbine, which acts as a competitive alpha2-antagonist in unanaesthetized rats. ⋯ Again, yohimbine pretreatment produced a right shift of the ICV sedation dose-response curves (UK > DMET > CLON). Thus, we conclude that the spinal analgesic effects of DMET, CLON and UK appear to be mediated by two sites. After ICV delivery, DMET, CLON and UK appear to act at a common supra-spinal site to produce sedation and this site resembles that acted upon by UK in the spinal cord.
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Randomized Controlled Trial Comparative Study Clinical Trial
Effects of lightwand (Trachlight) compared with direct laryngoscopy on circulatory responses to tracheal intubation.
We compared the effects of the lightwand technique on circulatory responses to tracheal intubation with those of direct-vision laryngoscopy. Forty adult patients received propofol and vecuronium, and their lungs were ventilated for 2 min via a mask with 5% sevoflurane in oxygen, after which the trachea was intubated orally using either the lightwand (Trachlight, n = 20) or the Macintosh laryngoscope (n = 20). ⋯ There were no differences between the lightwand technique and direct-vision laryngoscopy in changes in mean arterial pressure and heart rate during and after tracheal intubation. We conclude that the effects of the lightwand technique on circulatory responses to tracheal intubation were similar to those of direct-vision laryngoscopy.
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Randomized Controlled Trial Clinical Trial
Pharmacological vasodilatation improves efficiency of rewarming from hypothermic cardiopulmonary bypass.
An afterdrop in core temperature after hypothermic cardiopulmonary bypass (CPB) is related to inadequate peripheral rewarming. We proposed that pharmacological vasodilatation during rewarming on bypass would improve peripheral rewarming and reduce the degree of afterdrop. Fifty-nine of 120 patients were randomized to receive a sodium nitroprusside (SNP) infusion during the rewarming stage of hypothermic CPB. ⋯ Patients receiving SNP had a warmer mean peripheral temperature (MPT) (32.9 degrees C vs 32.4 degrees C; P = 0.05) on termination of CPB. Postoperative core temperature fell less in the SNP group (35.6 degrees C vs 35.2 degrees C; P = 0.01) as did MPT (31.8 degrees C vs 31.2 degrees C; P = 0.004). SNP-induced vasodilatation during rewarming from hypothermic CPB improves peripheral rewarming, reduces the degree of postoperative core and peripheral hypothermia and reduces time to extubation.
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Meta Analysis
Meta-analysis of the efficacy of extradural clonidine to relieve postoperative pain: an impossible task.
Clonidine, an alpha2 adrenoceptor agonist, has anti-hypertensive and anti-nociceptive effects. It is commonly used in association with local anaesthetics and opioids to enhance the quality and duration of extradural analgesia in the postoperative period, and to decrease the incidence of side effects. As a sole analgesic, it has seldom been used to relieve postoperative pain. ⋯ The data from these studies were difficult to interpret because of the tremendous variation in variables, especially dose of clonidine, level of extradural injection, time of administration, type of anaesthesia, type of surgery, and reference and rescue drugs. The simultaneous extradural use of local anaesthetics and opioids further hindered data interpretation, and precluded any meta-analysis. Proposals for a standard study design are made to help comparison between studies involving extradural clonidine and postoperative pain.