8822 articles - 08.09.10
1: Anesth Analg. 2010 Aug 27; [Epub ahead of print]
Carney J, Finnerty O, Rauf J, Curley G, McDonnell JG, Laffey JG.
From the *Department of Anaesthesia, Clinical Sciences Institute, National University of Ireland, Galway; and.
Background: The transversus abdominis plane (TAP) block provides effective postoperative analgesia in adults undergoing major abdominal surgery. Its efficacy in children remains unclear, with no randomized clinical trials in this population. In this study, we evaluated its analgesic efficacy over the first 48 postoperative hours after appendectomy performed through an open abdominal incision, in a randomized, controlled, double-blind clinical trial. Methods: Forty children undergoing appendectomy were randomized to undergo unilateral TAP block with ropivacaine (n = 19) versus placebo (n = 21) in addition to standard postoperative analgesia comprising IV morphine analgesia and regular diclofenac and acetaminophen. All patients received a standard general anesthetic, and after induction of anesthesia, a TAP block was performed using the landmark technique with 2.5 mg . kg(-1) ropivacaine 0.75% or an equal volume (0.3 mL . kg(-1)) of saline on the ipsilateral side to the incision. Results: The TAP block with ropivacaine reduced mean (+/-SD) morphine requirements in the first 48 postoperative hours (10.3 +/- 12.7 vs 22.3 +/- 14.7 mg; P < 0.01) compared with placebo block. The TAP block also reduced postoperative visual analog scale pain scores at rest and on movement compared with placebo. Interval morphine consumption was reduced over the first 24 postoperative hours. There were no between-group differences in the incidence of sedation or nausea and vomiting. There were no complications attributable to the TAP block. Conclusions: Unilateral TAP block, as a component of a multimodal analgesic regimen, provided superior analgesia compared with placebo in the first 48 postoperative hours after appendectomy in children.
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PMID: 20802056 [PubMed - as supplied by publisher]2: Anesth Analg. 2010 Aug 24; [Epub ahead of print]
Critchley LA, Lee A, Ho AM.
From the Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
Numerous cardiac output (CO) monitors have been produced that provide continuous rather than intermittent readings. Bland and Altman has become the standard method for validating their performance against older standards. However, the Bland and Altman method only assesses precision and does not assess how well a device detects serial changes in CO (trending ability). Currently, there is no consensus on how trending ability, or trend analysis, should be performed. Therefore, we performed a literature review to identify articles published between 1997 and 2009 that compared methods of continuous CO measurement. Identified articles were grouped according to measurement technique and statistical methodology. Articles that analyzed trending ability were reviewed with the aim of finding an acceptable statistical method. Two hundred two articles were identified. The most popular methods were pulse contour (69 articles), Doppler (54), bioimpedance (38), and transpulmonary or continuous thermodilution (27). Forty-one articles addressed trending, and of these only 23 provided an in-depth analysis. Several common statistical themes were identified: time plots, regression analysis, Bland and Altman using change in CO (DeltaCO), and the 4-quadrant plot, which used direction of change of DeltaCO to determine the concordance. This plot was further refined by exclusion of data when values were small. Receiver operating characteristic curves were used to define the exclusion zone. In animal studies, a reliable reference standard such as an aortic flowprobe was frequently used, and regression or time plots could be used to show trending. Clinical studies were more problematic because data collection points were fewer (8-10 per subject). The consensus was to use the 4-quadrant plot with exclusion zones and apply concordance analysis. A concordance rate of >92% when using a 15% zone indicated good trending. A new method of presenting trend data (DeltaCO) on a polar plot is proposed. Agreement was shown by the angle with the horizontal axis and DeltaCO by the distance from the center. Trending can be assessed by the vertical limits of the data, similar to the Bland and Altman method.
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PMID: 20736431 [PubMed - as supplied by publisher]3: Anesth Analg. 2010 Aug 12; [Epub ahead of print]
Lee A, Chan SK, Chen PP, Gin T, Lau AS, Chiu CH.
From the Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong.
Background: Acute pain services have received widespread acceptance and formal support from institutions and organizations, but available evidence on their costs and benefits is scarce. Although there is good agreement on the provision of acute pain services after many major surgical procedures, there are other procedures for which the benefits are unclear. Data are required to justify any expansion of acute pain services. In this randomized, controlled clinical trial we compared the costs and effects of acute pain service care on clinical outcomes with conventional pain management on the ward. Patients included in the trial were considered by their anesthesiologist to have either arm be suitable for the procedure. Methods: Four hundred twenty-three patients undergoing major elective surgery were randomized either to an anesthesiologist-led, nurse-based acute pain service group with patient-controlled analgesia or to a control group with IM or IV boluses of opioid analgesia. Both groups were treated with medications to treat opioid-related adverse effects and received the usual care from health professionals assigned to the ward. The main outcome measures were quality of recovery scores, pain intensity measures, global measure of treatment effectiveness, and overall pain treatment cost. Cost-effectiveness acceptability curves were drawn to detect a difference in the joint cost-effect relationship between groups. Results: There was no difference in quality of recovery score on postoperative day 1 between treatment and control groups (mean difference, 0; 95% confidence interval [CI], -0.7 to 0.7; P = 0.94) or in the rate of improvement in quality of recovery score (mean difference, -0.1; 95% CI, -0.4 to 0.1; P = 0.34). The proportion of patients with 1 or more days of highly effective pain management was higher in the acute pain service group than in the control group (86% vs. 75%; P < 0.01). Costs were higher in the acute pain service group (mean difference, US$46; 95% CI, $44 to $48 per patient; P < 0.001). A cost-effectiveness acceptability curve showed that the acute pain service was more cost effective than was control for providing highly effective pain management if the decision maker was willing to pay more than US$546 per patient per 1 day with highly effective treatment. Conclusion: In extending the role of the acute pain service to a specific group of major surgical procedures, the acute pain service was likely to be cost effective.
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PMID: 20705784 [PubMed - as supplied by publisher]4: Anesthesiology. 2010 Sep;113(3):585-92.
Badgett RG, Lawrence VA, Cohn SL.
Department of Medicine, University of Texas Health Science Center at San Antonio, and Audie L. Murphy Memorial Veterans Affairs Hospital, San Antonio, Texas, USA. rbadgett@kumc.edu
BACKGROUND: Randomized controlled trials and meta-analyses provide conflicting guidance on the role of beta-adrenergic receptor blockers (beta-blockers) in reducing perioperative complications. We hypothesize that variability in trial results may be due in part to heterogeneous properties of beta-blockers. First, we propose that the extent of beta-blocker metabolism by cytochrome P-450 and the time available to titrate the dosage before surgery (titration time) may interact; dependence on P-450 may be most harmful when titration time is short. Second, beta-blockers vary in their selectivity for the beta-1 receptor and reduced selectivity may contribute to cerebral ischemia. METHODS: We used meta-analysis and meta-regression of existing trials to explore the role of these pharmacological properties. RESULTS: We found that both of these pharmacological factors are significantly associated with reduced efficacy of beta-blockers. CONCLUSIONS: Pharmacological properties of beta-blockers may contribute to heterogeneous trial results. Many trials have used metoprolol, which is extensively metabolized by cytochrome P450 and is less selective for the beta-1 receptor. For these two reasons, the efficacy of metoprolol to prevent perioperative cardiac complications should be compared with the efficacy of other beta-blockers.
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PMID: 20693881 [PubMed - in process]5: Br J Anaesth. 2010 Aug 3; [Epub ahead of print]
Page DE, Taylor DM.
University of Melbourne, Parkville, VIC 3050, Australia.
BACKGROUND: /st> We compared the efficacy, acceptability, and safety of a topical vapocoolant alkane spray and 1% plain s.c. lidocaine in reducing pain from i.v. cannulation. METHODS: /st> This was a non-blinded, randomized, controlled trial, in a large emergency department. Adult patients requiring i.v. cannulation were enrolled. The vapocoolant was administered from a pressure pack, at a distance of 12 cm for 2 s, and cannulation was undertaken within 15 s. Alternatively, 1% plain lidocaine 0.2 ml was administered s.c. using a 27 G needle, and cannulation was undertaken after a minimum of 30 s. The primary outcomes were anaesthetic administration and cannulation pain (0-100 mm visual analogue scale). Convenience of anaesthetic use and patient satisfaction were measured using a five-point Likert scale. RESULTS: /st> One hundred and ten patients were enrolled in each group. The groups did not differ in age, gender, cannulation anxiety, cannulator experience, cannulation indication or site, or cannula size. Median anaesthetic administration pain scores were 0 and 11 mm in the vapocoolant and lidocaine groups, respectively (P<0.001). Median cannulation pain scores were 9 and 0 mm, respectively (P<0.001). Vapocoolant was associated with greater cannulation success (83.6% vs 67.3%, P=0.005), less time to administer (median 9.0 vs 84.5 s, P<0.001), and more staff convenience (median 5 vs 4, P<0.001). Median patient satisfaction was 4 in both groups. Unexpected events were rare and minor. CONCLUSIONS: /st> Although vapocoolant reduces cannulation pain less than lidocaine, it has a number of important advantages. Vapocoolant offers a useful alternative in the emergency department setting.
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PMID: 20682573 [PubMed - as supplied by publisher]6: Br J Anaesth. 2010 Sep;105(3):255-63. Epub 2010 Aug 3.
Apfel CC, Saxena A, Cakmakkaya OS, Gaiser R, George E, Radke O.
Perioperative Clinical Research Core, Department of Anesthesia and Perioperative Care, University of California at San Francisco, 1600 Divisadero St., San Francisco, CA, USA. apfelc@anesthesia.ucsf.edu
No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. We conducted a quantitative systematic review to identify all available evidence for the prevention of postdural puncture headache (PDPH) and included 17 studies with 1264 patients investigating prophylactic epidural blood patch (PEBP), epidural morphine, intrathecal catheters, and epidural or intrathecal saline. The relative risk (RR) for headache after PEBP was 0.48 [95% confidence interval (CI): 0.23-0.99] in five non-randomized controlled trials (non-RCTs) and 0.32 (0.10-1.03) in four randomized controlled trials (RCTs). The RR for epidural morphine (based on a single RCT) was 0.25 (0.08-0.78). All other interventions were based on non-RCTs and failed statistical significance, including long-term intrathecal catheters with an RR of 0.21 (0.02-2.65). There are a number of promising options to prevent PDPH, yet heterogeneity between the studies and publication bias towards small non-RCTs with positive results limits the available evidence. Thus, a large multicentre RCT is needed to determine the best preventative practices.
Publication Types: Research Support, Non-U.S. Gov't
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PMID: 20682567 [PubMed - in process]7: Br J Anaesth. 2010 Sep;105(3):361-7. Epub 2010 Jul 13.
Inomata S, Maeda T, Shimizu T, Satsumae T, Tanaka M.
Department of Anesthesiology, Institute of Clinical Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba City, Ibaraki 305-8575, Japan. inomatas@md.tsukuba.ac.jp
BACKGROUND: Sevoflurane can be used as a sole agent for intubation in children, but studies have suggested that it is associated with emergence agitation. Fentanyl infusions can be used both to facilitate intubation and decrease emergence agitation. We investigated the effects of fentanyl on conditions at intubation and on emergence from sevoflurane anaesthesia without confounding nitrous oxide or premedication. METHODS: IRB approval and informed consent were obtained. Subjects comprised 150 ASA physical status I or II (age, 2-6 yr). Anaesthesia was induced with sevoflurane in oxygen and maintained using a predetermined concentration of sevoflurane. Subjects were randomly allocated to receive one of three doses of fentanyl: vehicle only (control group), a bolus dose of 1 microg kg(-1) followed by a continuous infusion of 0.5 microg kg(-1) h(-1) (F1 group), or a bolus dose of 2 microg kg(-1) followed by a continuous infusion of 1 microg kg(-1) h(-1) (F2 group). Sevoflurane minimum alveolar concentration for tracheal intubation (MAC(TI)) and emergence agitation score were assessed. RESULTS: MAC(TI) values were 2.49%, 1.61%, and 1.16% in control, F1, and F2 groups, respectively (P<0.05). Agitation scores were 11.5, 7.0, and 2.6 in control, F1, and F2 groups, respectively (P<0.05). CONCLUSIONS: Fentanyl infusion consisting of a bolus dose of 2 microg kg(-1) followed by a continuous infusion of 1 microg kg(-1) h(-1) facilitates tracheal intubation and smooth emergence in children anaesthetized using sevoflurane. Clinical trial registration: this study was started in 2000 and was finished in 2008. We had no registration number. IRB approval was obtained.
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PMID: 20627877 [PubMed - in process]8: Anesthesiology. 2010 Aug;113(2):482-95.
Spahn DR.
Institute of Anesthesiology, University Hospital and University of Zurich, Zurich, Switzerland. donat.spahn@usz.ch
A systematic search was conducted to determine the characteristics of perioperative anemia, its association with clinical outcomes, and the effects of patient blood management interventions on these outcomes in patients undergoing major orthopedic surgery. In patients undergoing total hip or knee arthroplasty and hip fracture surgery, preoperative anemia was highly prevalent, ranging from 24 +/- 9% to 44 +/- 9%, respectively. Postoperative anemia was even more prevalent (51% and 87 +/- 10%, respectively). Perioperative anemia was associated with a blood transfusion rate of 45 +/- 25% and 44 +/- 15%, postoperative infections, poorer physical functioning and recovery, and increased length of hospital stay and mortality. Treatment of preoperative anemia with iron, with or without erythropoietin, and perioperative cell salvage decreased the need for blood transfusion and may contribute to improved patient outcomes. High-impact prospective studies are necessary to confirm these findings and establish firm clinical guidelines.
Publication Types: Research Support, Non-U.S. Gov't Review
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PMID: 20613475 [PubMed - indexed for MEDLINE]9: Anesthesiology. 2010 Aug;113(2):378-85.
Bellani G, Foti G, Spagnolli E, Milan M, Zanella A, Greco M, Patroniti N, Pesenti A.
Department of Experimental Medicine, University of Milan-Bicocca, Monza, Italy.
BACKGROUND: The aim of this study was to test the hypothesis that, during weaning from mechanical ventilation, when the pressure support level is reduced, oxygen consumption increases more in patients unable to sustain the decrease in ventilatory assistance (weaning failure). METHODS: Patients judged eligible for weaning were enrolled. Starting from 20 cm H2O, pressure support was decreased in 4-cm H2O steps, lasting 10 min each, until 0 cm H2O; this level was kept for 1 h. The average oxygen consumption from the last 3 min of each step, along with other ventilatory variables, was measured by indirect calorimetry (M-CAiOVX "metabolic module," Engstrom Carestation; GE Healthcare, Madison, WI) and recorded. Patients were defined as belonging to the failure group if, at any moment, they developed signs of respiratory distress according to standard criteria, or to the success group otherwise. RESULTS: Twenty-eight patients were studied. In most patients, the minimum oxygen consumption was not recorded at the highest pressure support applied. Sixteen patients were able to complete the weaning trial successfully, whereas 12 failed it; the success group had a minimum oxygen consumption lower than failure group (mean +/- SD: 174 +/- 44 vs. 215 +/- 53 ml/min, P < 0.05). Moreover, although respiratory drive (assessed by P0.1) increased more in the failure group, this group had a lower increase in oxygen consumption, contradicting our hypothesis. CONCLUSIONS: Patients failing a decremental pressure support trial, in comparison with those who succeed, had an higher baseline oxygen consumption and were not able to increase their oxygen consumption in response to an increased demand.
Publication Types: Clinical Trial Comparative Study
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PMID: 20613464 [PubMed - indexed for MEDLINE]10: BMC Anesthesiol. 2010 Jun 30;10:11.
Abdelmalak B, Maheshwari A, Mascha E, Srivastava S, Marks T, Tang WW, Kurz A, Sessler DI.
Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, Ohio, USA. ds@or.org.
ABSTRACT: BACKGROUND: The perioperative period is characterized by an intense inflammatory response. Perioperative inflammation promotes postoperative morbidity and increases mortality. Blunting the inflammatory response to surgical trauma might thus improve perioperative outcomes. We are studying three interventions that potentially modulate perioperative inflammation: corticosteroids, tight glucose control, and light anesthesia. METHODS/DESIGN: The DeLiT Trial is a factorial randomized single-center trial of dexamethasone vs placebo, intraoperative tight vs. conventional glucose control, and light vs deep anesthesia in patients undergoing major non-cardiac surgery. Anesthetic depth will be estimated with Bispectral Index (BIS) monitoring (Aspect medical, Newton, MA). The primary outcome is a composite of major postoperative morbidity including myocardial infarction, stroke, sepsis, and 30-day mortality. C-reactive protein, a measure of the inflammatory response, will be evaluated as a secondary outcome. One-year all-cause mortality as well as post-operative delirium will be additional secondary outcomes. We will enroll up to 970 patients which will provide 90% power to detect a 40% reduction in the primary outcome, including interim analyses for efficacy and futility at 25%, 50% and 75% enrollment. DISCUSSION: The DeLiT trial started in February 2007. We expect to reach our second interim analysis point in 2010. This large randomized controlled trial will provide a reliable assessment of the effects of corticosteroids, glucose control, and depth-of-anesthesia on perioperative inflammation and morbidity from major non-cardiac surgery. The factorial design will enable us to simultaneously study the effects of the three interventions in the same population, both individually and in different combinations. Such a design is an economically efficient way to study the three interventions in one clinical trial vs three. TRIAL REGISTRATION: This trial is registered at Clinicaltrials.gov #: NTC00433251.
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PMID: 20591163 [PubMed - in process]11: BMC Anesthesiol. 2010 Jun 29;10:10.
Rigby-Jones AE, Sneyd JR, Vijn P, Boen P, Cross M.
Peninsula College of Medicine & Dentistry, University of Plymouth, The John Bull Building, Research Way, Tamar Science Park, Plymouth PL6 8BU, UK. robert.sneyd@pms.ac.uk.
ABSTRACT: BACKGROUND: Org 25435 is a new water-soluble alpha-amino acid ester intravenous anaesthetic which proved satisfactory in animal studies. This study aimed to assess the safety, tolerability and efficacy of Org 25435 and to obtain preliminary pharmacodynamic and pharmacokinetic data. METHODS: In the Short Infusion study 8 healthy male volunteers received a 1 minute infusion of 0.25, 0.5, 1.0, or 2.0 mg/kg (n = 2 per group); a further 10 received 3.0 mg/kg (n = 5) or 4.0 mg/kg (n = 5). Following preliminary pharmacokinetic modelling 7 subjects received a titrated 30 minute Target Controlled Infusion (TCI), total dose 5.8-20 mg/kg. RESULTS: Within the Short Infusion study, all subjects were successfully anaesthetised at 3 and 4 mg/kg. Within the TCI study 5 subjects were anaesthetised and 2 showed signs of sedation. Org 25435 caused hypotension and tachycardia at doses over 2 mg/kg. Recovery from anaesthesia after a 30 min administration of Org 25435 was slow (13.7 min). Pharmacokinetic modelling suggests that the context sensitive half-time of Org 25435 is slightly shorter than that of propofol in infusions up to 20 minutes but progressively longer thereafter. CONCLUSIONS: Org 25435 is an effective intravenous anaesthetic in man at doses of 3 and 4 mg/kg given over 1 minute. Longer infusions can maintain anaesthesia but recovery is slow. Hypotension and tachycardia during anaesthesia and slow recovery of consciousness after cessation of drug administration suggest this compound has no advantages over currently available intravenous anaesthetics.
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PMID: 20587019 [PubMed - in process]12: Br J Anaesth. 2010 Aug;105(2):155-61. Epub 2010 Jun 25.
Peng PW, Li C, Farcas E, Haley A, Wong W, Bender J, Chung F.
Department of Anesthesia, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, Ontario, Canada. philip.peng@uhn.on.ca
BACKGROUND: The objective of this study was to examine the effects of low-dose pregabalin on the analgesic efficacy, side-effects, and recovery profile in patients undergoing laparoscopic cholecystectomy. METHODS: One hundred and sixty-two patients aged 18-65 yr, of ASA physical status I-III, undergoing elective outpatient laparoscopic cholecystectomy were recruited and randomized in this prospective, placebo-controlled, double-blind study to receive one of the following study medications orally: pregabalin 50 mg, pregabalin 75 mg, or placebo, 1 h before surgery and then every 12 h after operation for a total of three doses. Postoperative numeric pain scores, analgesic consumption, recovery score (QoR-40), and side-effects (opioid-related symptom distress scale) were assessed in the early postoperative period (every 15 min during the first hour, at 90, 120 min, 6, and 12 h) and at days 1, 2, and 7. Data were analysed using an intention-to-treat method. RESULTS: Compared with the placebo group, the pain scores were lower in the pregabalin 75 mg group in the first 90 min after surgery (P<0.05). Pregabalin 50 mg resulted in pain reduction at 30 and 45 min (P<0.05) relative to placebo. The analgesic consumption, side-effects, and recovery scores were similar among the three groups. CONCLUSIONS: Perioperative administration of pregabalin 75 mg provided limited analgesic benefit in the postoperative period. An updated meta-analysis confirms this finding (see Supplementary material).
Publication Types: Randomized Controlled Trial Research Support, Non-U.S. Gov't
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PMID: 20581215 [PubMed - indexed for MEDLINE]13: Anesthesiology. 2010 Aug;113(2):327-42.
Nguyen HP, Zaroff JG, Bayman EO, Gelb AW, Todd MM, Hindman BJ; IHAST-MIDS and IHAST Investigators.
Department of Medicine, Kaiser San Francisco Medical Center, San Francisco, California, USA.
BACKGROUND: Perioperative hypothermia has been reported to increase the occurrence of cardiovascular complications. By increasing the activity of sympathetic nervous system, perioperative hypothermia also has the potential to increase cardiac injury and dysfunction associated with subarachnoid hemorrhage. METHODS: The Intraoperative Hypothermia for Aneurysm Surgery Trial randomized patients undergoing cerebral aneurysm surgery to intraoperative hypothermia (n = 499, 33.3 degrees +/- 0.8 degrees C) or normothermia (n = 501, 36.7 degrees +/- 0.5 degrees C). Cardiovascular events (hypotension, arrhythmias, vasopressor use, myocardial infarction, and others) were prospectively followed until 3-month follow-up and were compared in hypothermic and normothermic patients. A subset of 62 patients (hypothermia, n = 33; normothermia, n = 29) also had preoperative and postoperative (within 24 h) measurement of cardiac troponin-I and echocardiography to explore the association between perioperative hypothermia and subarachnoid hemorrhage-associated myocardial injury and left ventricular function. RESULTS: There was no difference between hypothermic and normothermic patients in the occurrence of any single cardiovascular event or in composite cardiovascular events. There was no difference in mortality (6%) between groups, and there was only a single primary cardiovascular death (normothermia). There was no difference between hypothermic and normothermic patients in postoperative versus preoperative left ventricular regional wall motion or ejection fraction. Compared with preoperative values, hypothermic patients had no postoperative increase in cardiac troponin-I (median change 0.00 microg/l), whereas normothermic patients had a small postoperative increase (median change + 0.01 microg/l, P = 0.038). CONCLUSION: In patients undergoing cerebral aneurysm surgery, perioperative hypothermia was not associated with an increased occurrence of cardiovascular events.
Publication Types: Clinical Trial Comparative Study Randomized Controlled Trial Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't
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PMID: 20571361 [PubMed - indexed for MEDLINE]14: Anesth Analg. 2010 Aug;111(2):482-7. Epub 2010 Jun 7.
Beilin Y, Halpern S.
Department of Anesthesiology, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029-6574, USA. Yaakov.beilin@mountsinai.or
Neuraxial analgesia is frequently administered to women in labor. For many years, bupivacaine has been used because of its long duration of action, lack of excessive motor block, and minimal fetal and neonatal effects. However, bupivacaine is one of the most cardiotoxic local anesthetics in current use and motor block is still a problem. Many local anesthetics such as bupivacaine exist in 2 forms, levorotatory and dextrorotatory. Ropivacaine, an amide local anesthetic produced in the pure levorotatory form addresses some of the concerns related to bupivacaine. In this article, we present the literature comparing ropivacaine and bupivacaine to determine whether there is an advantage to using one of these local anesthetics for labor analgesia. We found that there is no advantage to the routine use of ropivacaine for labor analgesia.
Publication Types: Review
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PMID: 20529986 [PubMed - indexed for MEDLINE]15: Anesth Analg. 2010 Aug;111(2):515-9. Epub 2010 Jun 7.
Frenzel JC, Kee SS, Ensor JE, Riedel BJ, Ruiz JR.
M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Mail Stop 409, Houston, TX 77030, USA. jfrenzel@mdanderson.or
BACKGROUND: Clinical practice guidelines summarize evidence from science and attempt to translate those findings into clinical practice. Pervasive and consistent adoption of these guidelines into daily provider practice has proven slow. METHODS: Using postoperative nausea and vomiting (PONV) prophylaxis guideline compliance as our metric, we compared the effects of continuing medical education (CME) alone (I), CME with a single snapshot of provider compliance (II), and ongoing reporting of provider compliance data without further CME (III). We retrospectively analyzed guideline compliance of 23,279 anesthetics at the University of Texas M.D. Anderson Cancer Center. Compliance was defined as a patient with 1 risk factor for PONV receiving at least 1 antiemetic, 2 risk factors receiving at least 2 antiemetics, and 3 risk factors receiving at least 3 antiemetics. Drugs of the same class were counted as single antiemetic administration. Propofol-based anesthetic techniques were counted as receiving 1 antiemetic. Patients with 0 risk factors for PONV were not included. We estimated the compliance rates for each of the 4 time periods of the study adjusting for multiple observations on the same clinician. Individual performance feedback was given once at 6 months after intervention I coincident with a refresher presentation on PONV (start of intervention II) and on an ongoing quarterly basis during intervention III. RESULTS: Compliance rates were not significantly influenced with CME (intervention I) compared with baseline behavior (54.5% vs 54.4%, P = 0.9140). Significant improvement occurred during the time period when CME was paired with performance data (intervention II) compared with intervention I (59.2% vs 54.4%, P = 0.0002). Further significant improvement occurred when data alone were presented (intervention III) compared with intervention II (65.1% vs 59.2%, P < 0.0001). For patients with 3 risk factors, we saw significant improvement in compliance rates during intervention III (P = 0.0002). In post hoc analysis of overtreatment, the percentage differences between the baseline and time period III decreased as the number of risk factors increased. CONCLUSIONS: We observed the greatest improvement in guideline compliance with ongoing personal performance feedback. Provider feedback can be an effective tool to modify clinical practice but can have unanticipated consequences.
Publication Types: Research Support, Non-U.S. Gov't
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PMID: 20529985 [PubMed - indexed for MEDLINE]16: Anesth Analg. 2010 Aug;111(2):568-72. Epub 2010 Jun 7.
Camponovo C, Fanelli A, Ghisi D, Cristina D, Fanelli G.
Department of Anesthesiology, University of Pittsburgh Medical Center, 5230 Center Avenue, Suite M-104, Pittsburgh, PA 15232, USA.
BACKGROUND: In this prospective, double-blind, randomized trial we compared 60 mg and 40 mg of 2% hyperbaric prilocaine with 60 mg of 2% plain prilocaine for spinal anesthesia in terms of sensory block onset in outpatients undergoing elective short-duration (<60 minutes) surgery under spinal anesthesia. METHODS: Ninety patients were enrolled and randomly allocated to receive 1 of the 3 treatments. Times to sensory and motor block onsets, time to the maximum sensory block level, readiness for surgery, time to first urinary voiding, time to Bromage's score 0, and side effects were registered blindly. A blinded observer also questioned patients about transient neurological symptoms 24 hours and 7 days after spinal anesthesia. RESULTS: Mean times to achieve a T10 level of sensory block were comparable in the 3 groups. However, 20% of patients receiving plain prilocaine did not achieve a T10 level. The 2 hyperbaric dosages (60 mg and 40 mg) showed significantly faster times to motor block onset (P = 0.0091, P = 0.0097), to the maximum sensory block level (P = 0.0297, P = 0.0183), to motor block offset (P = 0.0004, P < 0.0001), and to first urinary voiding (P = 0.0013, P = 0.0002, respectively) than did plain prilocaine. No major adverse reactions or transient neurological symptoms were observed in the study. CONCLUSIONS: Spinal anesthesia with 60 mg or 40 mg of 2% hyperbaric prilocaine is comparable to 60 mg of 2% plain prilocaine in terms of onset of sensory block at T10. The hyperbaric solution showed faster times to motor block onset and shorter duration of surgical block, suggesting its superiority for the ambulatory setting.
Publication Types: Comparative Study Randomized Controlled Trial Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20529983&dopt=ExternalLink
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PMID: 20529983 [PubMed - indexed for MEDLINE]17: Anaesthesia. 2010 Aug;65(8):792-8. Epub 2010 Jun 2.
Cave G, Harvey M, Prince G, Lahner D, Desmet J.
Emergency Department Hutt Hospital, Lower Hutt, New Zealand.
Intravenous lipid emulsion is established therapy for bupivacaine induced cardiotoxicity. The benefit of combined hypertonic saline and lipid treatment is unexplored. In this experiment, sedated rabbits were resuscitated from bupivacaine-induced asystole with intravenous lipid according to the Association of Anaesthetists of Great Britain and Ireland's guideline, or by identical lipid dosing with hypertonic saline: 6 mEq x kg(-1) 21% sodium chloride. Early electrocardiography QRS prolongation was less with lipid plus hypertonic saline (mean (SD) QRS 0.19 (0.07) s lipid only vs 0.09 (0.01) s lipid plus hypertonic saline; p = 0.003) at 9 min though not different from the lipid only group at 20 min. No difference was observed in rates of circulatory return (7/10 lipid only and 9/10 lipid plus hypertonic saline; p = 0.58) or survival (5/10 lipid only and 6/10 lipid plus hypertonic saline; p = 1.00). Some benefit to cardiac conduction may be afforded by hypertonic saline co-administered with lipid emulsion in bupivacaine-induced cardiotoxicity.
Publication Types: Evaluation Studies
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20528840&dopt=ExternalLink
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PMID: 20528840 [PubMed - indexed for MEDLINE]18: Anesthesiology. 2010 Jul;113(1):74-82.
Singla NK, Singla SK, Chung F, Kutsogiannis DJ, Blackburn L, Lane SR, Levin J, Johnson B, Pergolizzi JV Jr.
Lotus Clinical Research Inc, Huntington Hospital, Pasadena, California 91105, USA. neil@lotuscr.com
BACKGROUND: In recent years, there has been an increased interest in using a multimodal approach with combined agents to treat postoperative nausea and vomiting. This study evaluated whether the addition of an oral dose of the neurokinin-1 receptor antagonist casopitant improved the antiemetic efficacy of an intravenous dose of ondansetron hydrochloride. METHODS: The authors enrolled 702 premenopausal or perimenopausal, nonsmoking, female patients aged 18-55 yr with a history of postoperative nausea and vomiting and/or motion sickness undergoing a laparoscopic or laparotomic gynecologic surgical procedure or laparoscopic cholecystectomy with general anesthesia. Subjects were randomized to one of five treatment arms: standard ondansetron 4 mg with casopitant at 0, 50, 100, or 150 mg, or 0 mg ondansetron with casopitant at 150 mg (the latter arm was considered an exploratory study group and was included in the safety analysis but not in the efficacy analysis). RESULTS: A significantly greater proportion of patients in all of the active casopitant plus ondansetron groups achieved a complete response (i.e., no vomiting, retching, rescue medication, or premature withdrawal) during the first 24 h postoperatively versus those in the ondansetron-alone group (59-62% vs. 40%, respectively; P = 0.0006). All active doses seemed to be well tolerated; headache, dizziness, and constipation were the most frequently reported adverse events. CONCLUSIONS: Compared with ondansetron alone, the casopitant and ondansetron combination results in superior emesis prevention during the first 24 h postoperatively in female patients with known risk factors for postoperative nausea and vomiting.
Publication Types: Clinical Trial, Phase II Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20526194&dopt=ExternalLink
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PMID: 20526194 [PubMed - indexed for MEDLINE]19: Br J Anaesth. 2010 Jul;105(1):26-33. Epub 2010 May 28.
Bion JF, Abrusci T, Hibbert P.
University Department of Anaesthesia and ICM, N5, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK. t.abrusci@uhb.ac.uk
Unreliable delivery of best practice care is a major component of medical error. Critically ill patients are particularly susceptible to error and unreliable care. Human factors analysis, widely used in industry, provides insights into how interactions between organizations, tasks, and the individual worker impact on human behaviour and affect systems reliability. We adopt a human factors approach to examine determinants of clinical reliability in the management of critically ill patients. We conducted a narrative review based on a Medline search (1950-March 2010) combining intensive/critical care (units) with medical errors, patient safety, or delivery of healthcare; keyword and Internet search 'human factors' or 'ergonomics'. Critical illness represents a high-risk, complex system spanning speciality and geographical boundaries. Substantial opportunities exist for improving the safety and reliability of care of critically ill patients at the level of the task, the individual healthcare provider, and the organization or system. Task standardization (best practice guidelines) and simplification (bundling or checklists) should be implemented where scientific evidence is strong, or adopted subject to further research ('dynamic standardization'). Technical interventions should be embedded in everyday practice by the adjunctive use of non-technical (behavioural) interventions. These include executive 'adoption' of clinical areas, systematic methods for identifying hazards and reflective learning from error, and a range of techniques for improving teamworking and communication. Human factors analysis provides a useful framework for understanding and rectifying the causes of error and unreliability, particularly in complex systems such as critical care.
Publication Types: Research Support, Non-U.S. Gov't Review
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20511333&dopt=ExternalLink
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PMID: 20511333 [PubMed - indexed for MEDLINE]20: Anesth Analg. 2010 Aug;111(2):496-505. Epub 2010 May 27.
Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS, Vaughn J, Nisman M.
Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, 2650 Ridge Ave., Evanston, IL 60201, USA. dgmurphy2@yahoo.co
BACKGROUND: Patients undergoing shoulder surgery in the beach chair position (BCP) may be at risk for adverse neurologic events due to cerebral ischemia. In this investigation, we sought to determine the incidence of cerebral desaturation events (CDEs) during shoulder arthroscopy in the BCP or lateral decubitus position (LDP). METHODS: Data were collected on 124 patients undergoing elective shoulder arthroscopy in the BCP (61 subjects) or LDP (63 subjects). Anesthetic management was standardized in all patients. Regional cerebral tissue oxygen saturation (Scto(2)) was quantified using near-infrared spectroscopy. Baseline heart rate, mean arterial blood pressure, arterial oxygen saturation, and Scto(2) were measured before patient positioning and then every 3 minutes for the duration of the surgical procedure. Scto(2) values below a critical threshold (> or = 20% decrease from baseline or absolute value < or = 55% for >15 seconds) were defined as a CDE and treated using a predetermined protocol. The number of CDEs and types of intervention used to treat low Scto(2) values were recorded. The association between intraoperative CDEs and impaired postoperative recovery was also assessed. RESULTS: Anesthetic management was similar in the BCP and LDP groups, with the exception of more interscalene blocks in the LDP group. Intraoperative hemodynamic variables did not differ between groups. Scto(2) values were lower in the BCP group throughout the intraoperative period (P < 0.0001). The incidence of CDEs was higher in the BCP group (80.3% vs 0% LDP group), as was the median number of CDEs per subject (4, range 0-38 vs 0, range 0-0 LDP group, all P < 0.0001). Among all study patients without interscalene blocks, a higher incidence of nausea (50.0% vs 6.7%, P = 0.0001) and vomiting (27.3% vs 3.3%, P = 0.011) was observed in subjects with intraoperative CDEs compared with subjects without CDEs. CONCLUSIONS: Shoulder surgery in the BCP is associated with significant reductions in cerebral oxygenation compared with values obtained in the LDP.
Publication Types: Clinical Trial Comparative Study Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20508134&dopt=ExternalLink
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PMID: 20508134 [PubMed - indexed for MEDLINE]