Masui. The Japanese journal of anesthesiology
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Four patients with severe and intractable cancer pain were treated with continuous subarachnoid analgesia (CSA). All patients underwent placement of a 32-gauge subarachnoid catheter attached to an infusion pump allowing continuous administration of local anesthetic agent and morphine. ⋯ At present, CSA is not a routine treatment, because it may lead to severe complications. CSA produces excellent pain relief without disturbing consciousness and is recommended for the treatment of severe and intractable cancer pain.
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Optimal dose of epidural midazolam with saline for postoperative pain relief was investigated. Forty three patients for upper abdominal surgery were divided into 5 groups. Each group had either 10 ml saline only (saline group), 10 ml saline + midazolam 0.025 mg.kg-1 (0.025 group), 10 ml saline + midazolam 0.05 mg.kg-1 (0.05 group), 10 ml saline + midazolam 0.075 mg.kg-1 (0.075 group), or 10 ml saline + midazolam 0.1 mg.kg-1 (0.1 group) administered epidurally for complaint of postoperative pain. ⋯ TNA was about 2 hours in 0.025 and 0.05 groups, over 6 hours in 0.075 and 0.1 groups. Complete sleep was the cause of long TNA in 0.075 and 0.1 groups. It was concluded that optimal dose of epidural midazolam with saline 10 ml was 0.05 mg.kg-1 for postoperative pain relief after upper abdominal surgery.
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Paralysis after long-term administration of neuromuscular blocking agents especially pancuronium and vecuronium has been reported since 1970's. In this article, these papers were reviewed, and the etiology and the clinical features were analyzed. Most of the cases of muscle paralysis after prolonged use of pancuronium bromide were associated with concomitant use of large doses of steroids. ⋯ In patients with impaired hepatic and/or renal functions, metabolites of neuromuscular blocking agents might accumulate. In some patients with paralysis after neuromuscular blocking agents, underlying neuromuscular complications such as critical illness polyneuropathy have been implicated with the cause of the muscle paralysis. In order to avoid paralysis after long-term administration of neuromuscular blocking agents, following recommendations are made. 1) Monitor neuromuscular blockade. 2) Examine patient's neuromuscular status before starting to give relaxants. 3) Be careful in giving relaxants in patients with poor renal and/or hepatic functions. 4) Use smallest possible amount of relaxant. 5) Be careful about the drugs administered simultaneously especially steroids and antibiotics. 6) During the use of a neuromuscular blocking agent, perform physical therapy of extremities to avoid disuse atrophy especially when its administration is temporally terminated.
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Clinical Trial
[Continuous infusion of ketamine and midazolam for prolonged sedation in the intensive care unit].
The clinical effects and pharmacokinetics of ketamine and midazolam, administered continuously for prolonged sedation were studied in 7 critically ill patients under mechanical ventilation. Initially ketamine 1 mg.kg-1 and midazolam 0.1 mg.kg-1 were administered intravenously and these were followed by infusion at a rate of 1.0 mg.kg-1.hr-1 of ketamine and 0.05 mg.kg-1.hr-1 of midazolam. The infusion rate was changed every 30 minute with increments of 0.5 mg.kg-1.hr-1 of ketamine and 0.05 mg.kg-1.hr-1 of midazolam until the sedative score by Ramsy RAE reached rank 4 (i.e. slow response to loud verbal commands). ⋯ The time to clear response to verbal commands after cessation of the continuous infusion was 168 +/- 109 min. The plasma concentrations of ketamine and midazolam decreased rapidly, and plasma half-life of ketamine was about 1 hour and for midazolam less than 2 hours. In conclusion, continuous infusion of ketamine and midazolam was very useful to sedate critically ill patients under mechanical ventilation, with minimal effect on the cardiovascular system and rapid recovery of consciousness.
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Comparative Study Clinical Trial
[The reduction in the local anesthetic dose required for a caudal epidural block in infants and children using a Teflon cannula].
We investigated the spread of mepivacaine mixed with a radio-opaque substance in caudal epidural anesthesia for hernioplasty in 37 patients aged from 3 months to 5 years. All patients were placed in the left lateral position. Conventional caudal epidural anesthesia was performed on one group of patients (Group C) using a 23 gauge needle (25 mm in length). ⋯ When the volume for 13 segmental anesthesia (11.5 +/- 2.8 ml) was injected in Group C patients, the cephalad spread of the anesthetic reached Th12.6 +/- 1.2 on the left side, and Th12.5 +/- 1.1 on the right side. In conclusion, we detected no significant difference between Group C and Group N in the cephalad spread of the anesthetic. The required dose of local anesthetic for caudal epidural anesthesia using the Teflon cannula was about two-third the volume of that used for the conventional local anesthetic method.