British journal of anaesthesia
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Randomized Controlled Trial Comparative Study
Postoperative analgesia with intravenous fentanyl PCA vs epidural block after thoracoscopic pectus excavatum repair in children.
The aim of this prospective, randomized trial was to compare analgesia, sedation, and cardiorespiratory function in children after thoracoscopic surgery for pectus excavatum repair, using two types of analgesia--epidural block with bupivacaine plus fentanyl vs patient-controlled analgesia (PCA) with fentanyl. ⋯ I.V. fentanyl PCA is as effective as thoracic epidural for postoperative analgesia in children after thoracoscopic pectus excavatum repair. Bearing in mind the possible complications of epidural catheterization in children, the use of fentanyl PCA is recommended.
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Randomized Controlled Trial
Low-dose remifentanil to suppress haemodynamic responses to noxious stimuli in cardiac surgery: a dose-finding study.
High-dose remifentanil (1-5 microg kg-1 min-1), commonly used for cardiac surgery, has been associated with muscle rigidity, hypotension, bradycardia, and reduced cardiac output. The aim of this study was to determine an optimal lower remifentanil dose, which should be accompanied by fewer adverse events, that still effectively suppresses haemodynamic responses to typical stressful stimuli (i.e. intubation, skin incision, and sternotomy). ⋯ Remifentanil at 0.3 and 0.4 microg kg-1 min-1 in combination with a target-controlled propofol infusion in the pre-bypass period is well tolerated. It appears to mitigate potentially hazardous haemodynamic responses from stressful stimuli equally well as higher doses when compared with data from the literature.
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Uncertainty remains over the risk of epidural space infection after neuraxial blockade in the presence of systemic sepsis. For many years, we have provided epidural analgesia to children undergoing thoracotomy for the decortication of parapneumonic empyemas. Following recent publications asserting that epidural analgesia is absolutely contraindicated in this situation, we audited our management. The purpose of this audit was to document the effectiveness and the incidence of complications after epidural insertion in children with active sepsis from empyemas. ⋯ Epidural analgesia provides excellent pain relief after thoracotomy in children with empyema, with a low complication rate. Until evidence to the contrary emerges, it remains our technique of choice for thoracotomy, even in the presence of empyema.
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Postoperative atrial fibrillation (AF) is one of the most common complications after cardiothoracic surgery and is associated with an increased risk of stroke, and longer hospital stay. The pathophysiology of postoperative AF is uncertain, and its prevention remains unsatisfactory. Many previous studies have examined the predictors of AF after on-pump coronary artery bypass graft surgery (CABG), but there are few reports after off-pump CABG. ⋯ Our present findings indicate that ageing, the intraoperative fluid balance, and postoperative cardiac index are associated with the onset of AF after off-pump CABG.