ABSTRACT
Airway anaesthesia using atomised lidocaine for awake oral fibreoptic intubation in morbidly obese patients was evaluated using two doses of local anaesthetic. In this randomised, blinded prospective study, 40 ml of atomised 1% (n = 11) or 2% (n = 10) lidocaine was administered with high oxygen flow as carrier. Outcomes included time for intubation, patient tolerance to airway manipulation, haemodynamic parameters, the bronchoscopist's overall satisfaction, and serial serum lidocaine concentrations. Patients receiving lidocaine 1% had a longer mean (SD) time from the start of topicalisation to tracheal tube cuff inflation than those receiving lidocaine 2% (8.6 (0.9) min vs 6.9 (0.5) min, respectively; p < 0.05). Patients in the 1% cohort demonstrated increased responses to airway manipulation (p < 0.0001), reflecting lower bronchoscopist's satisfaction scores (p < 0.03). Haemodynamic responses to topicalisation and airway manipulation were similar in both groups. Peak plasma concentration was lower in the 1% group (mean (SD) 1.4 (0.3) and 3.8 (0.5) μg.ml−1, respectively; p < 0.001). Airway anaesthesia using atomised lidocaine for awake oral fibreoptic intubation in the morbidly obese is efficacious, rapid and safe. Compared with lidocaine 1%, the 2% dose provides superior intubating conditions.
Thursday, January 14, 2010
Effects of Dexmedetomidine and Propofol on Lower Esophageal Sphincter and Gastroesophageal Pressure Gradient in Healthy Volunteers
Abstract
Background: Many anesthetics reduce lower esophageal sphincter pressure (LESP). Reduced pressure and consequent reduction in the gastroesophageal pressure gradient (GEPG) thus promotes gastroesophageal reflux and may contribute to aspiration pneumonia and associated morbidity. Therefore, the authors compared LESP and GEPG during dexmedetomidine and propofol sedation.
Methods: Using a randomized, double-blind, crossover design, 11 healthy volunteers were sedated on 2 separate days. Baseline LESP and GEPG were recorded each day. Subsequently, on each day volunteers received three 40-min-long sedative infusions of increasing doses of 0.6, 1.2, and 2.4 ng/ml dexmedetomidine or 1, 2, and 4 [mu]g/ml propofol. LESP and GEPG were recorded during inhalation and expiration at 20 and 40 min after starting each infusion phase, and these measurements were averaged. Results are presented as mean (95% confidence interval).
Results: Two subjects did not return for the dexmedetomidine study day, and the dexmedetomidine results were unusable in another; propofol results in these volunteers were nonetheless retained for analysis. There were no significant differences in LESP and GEPG as a function of drug. However, there was a small but significant 7.4 (-1.6 to -13.2) mmHg (approximately 25%) dose-dependent decrease in LESP over the range of targeted low to high blood levels of each drug.
Conclusions: Both dexmedetomidine and propofol have similar effects on LESP and GEPG. Although both of the drugs cause some decrease in LESP at high concentrations, it is unlikely that this effect would promote gastroesophageal reflux during sedation.
Background: Many anesthetics reduce lower esophageal sphincter pressure (LESP). Reduced pressure and consequent reduction in the gastroesophageal pressure gradient (GEPG) thus promotes gastroesophageal reflux and may contribute to aspiration pneumonia and associated morbidity. Therefore, the authors compared LESP and GEPG during dexmedetomidine and propofol sedation.
Methods: Using a randomized, double-blind, crossover design, 11 healthy volunteers were sedated on 2 separate days. Baseline LESP and GEPG were recorded each day. Subsequently, on each day volunteers received three 40-min-long sedative infusions of increasing doses of 0.6, 1.2, and 2.4 ng/ml dexmedetomidine or 1, 2, and 4 [mu]g/ml propofol. LESP and GEPG were recorded during inhalation and expiration at 20 and 40 min after starting each infusion phase, and these measurements were averaged. Results are presented as mean (95% confidence interval).
Results: Two subjects did not return for the dexmedetomidine study day, and the dexmedetomidine results were unusable in another; propofol results in these volunteers were nonetheless retained for analysis. There were no significant differences in LESP and GEPG as a function of drug. However, there was a small but significant 7.4 (-1.6 to -13.2) mmHg (approximately 25%) dose-dependent decrease in LESP over the range of targeted low to high blood levels of each drug.
Conclusions: Both dexmedetomidine and propofol have similar effects on LESP and GEPG. Although both of the drugs cause some decrease in LESP at high concentrations, it is unlikely that this effect would promote gastroesophageal reflux during sedation.
Thursday, December 17, 2009
Comparison Of Total Intravenous Anaesthesia, Spinal Anaesthesia And Local Block For Day Care Inguinal Herniorrhaphy
– Local anaesthesia has a rapid turnover time but it is the least preferred technique. TIVA and spinal anaesthesia are comparable in terms of clinical efficacy however, spinal anaesthesia is the most economical and preferred technique.
A Study of Perioperative Hyperglycemia in Patients With Diabetes Having Colon, Spine, and Joint Surgery
Patients with diabetes often have impaired wound healing and an increased rate of postoperative complications with surgery. Most research has focused on the effect of hyperglycemia in the postoperative period, but there is limited evidence to guide blood glucose (bG) control throughout the perioperative period. This retrospective study explored the effect of hyperglycemia in the PACU on postoperative complications, length of stay (LOS), and in-hospital mortality in patients with diabetes undergoing spine, colon, or joint surgery. Findings revealed that the total LOS for patients with a PACU bG >200 mg/dL was significantly longer than for patients with a maximum bG of 140 to 200 mg/dL. Further, the rate of total complications increased significantly as bG levels increased. More prospective, controlled studies on the management of perioperative hyperglycemia are recommended for consideration.
Single dose of preoperative analgesia with gabapentin (600 mg) is safe and effective in monitored anesthesia care for nasal surgery
– Monitored anesthesia care combined with preoperative analgesia with a low dose of (600 mg) oral gabapentin is an efficient option with tolerable side effects for patients undergoing ear, nose and throat ambulatory surgery.
Obstetric analgesia: a comparison of patient-controlled meperidine, remifentanil, and fentanyl in labour
Douma MR et al. – The efficacy of meperidine, fentanyl, and remifentanil patient–controlled analgesia (PCA) for labour analgesia varied from mild to moderate. Remifentanil PCA provided better analgesia than meperidine and fentanyl PCA, but only during the first hour of treatment. In all groups, pain scores returned to pre–treatment values within 3 h after the initiation of treatment.
Friday, December 4, 2009
Intensive insulin treatment
1Department of Intensive Care Medicine, Royal North Shore Hospital of Sydney, St Leonards, Australia; 2Faculty of Medicine, University of Sydney, Sydney, Australia; 3Department of Critical Care and Trauma, The George Institute for International Health,Sydney, Australia
Hyperglycaemia is common in acute illness and more severe hyperglycaemia is associated with worse outcomes in critically ill patients in general and after acute myocardial infarction, stroke, and trauma. Normalization of blood glucose by intensive insulin therapy has been shown to reduce morbidity and mortality in one study in surgical intensive care patients; a subsequent study in medical intensive care patients resulted in reduced morbidity but not a reduction in mortality. Multicentre studies and current meta-analyses in the critically ill have not demonstrated improved outcomes when normalization of blood glucose was targeted; furthermore all studies to date have detected an increased risk of hypoglycaemia in patients subjected to intensive insulin therapy. At present, universal treatment guidelines or recommendations to target strict normoglycaemia must be considered premature. Further data will be available after the completion of the NICE-SUGAR study which has recruited 6103 patients; the NICE SUGAR study will add significant power to future meta-analyses and may help define the role of intensive insulin therapy in critically ill patients.
Post-operative nausea and vomiting
Post-operative nausea and vomiting (PONV) is a common clinical problem with widespread effects on morbidity, patient satisfaction and cost. Although a myriad of risk factors have been postulated as having the potential to increase its incidence, a risk scoring system using four factors – female sex, non-smoking status, past history of PONV and use of post-operative opioids – identifies most at-risk individuals. Prevention and treatment is multi-factorial and aimed at risk-reduction, pharmacological and non-pharmacological techniques.
Titrated propofol induction vs. continuous infusion in children undergoing magnetic resonance imaging
Background: Propofol is the popular intravenous (i.v.) anaesthetic for paediatric sedation because of its rapid onset and recovery. We compared the efficacy and safety of a single dose and conventional infusion of propofol for sedation in children who underwent magnetic resonance imaging (MRI).
Methods: This was a double-blind, randomized-controlled study. One hundred and sixty children were assigned to group I (single dose) or II (infusion). Sedation was induced with i.v. propofol 2 mg/kg, and supplemental doses of propofol 0.5 mg/kg were administered until adequate sedation was achieved. After the induction of sedation, we treated patients with a continuous infusion of normal saline at a rate of 0.3 ml/kg/h in group I and the same volume of propofol in group II. In case of inadequate sedation, additional propofol 0.5 mg/kg was administered and the infusion rate was increased by 0.05 ml/kg/h. Induction time, sedation time, recovery time, additional sedation and adverse events were recorded.
Results: Recovery time was significantly shorter in group I compared with group II [0 (0–3) vs. 1 (0–3), respectively, P<0.001]. Group I (single dose) had significantly more patients with recovery time 0 compared with group II (infusion) (65/80 vs. 36/80, respectively, P<0.001). Induction and sedation times were not significantly different between groups. There was no significant difference in the frequency of additional sedation and adverse events between groups.
Conclusion: A single dose of propofol without a continuous infusion can provide appropriate sedation in children undergoing MRI for <30 min.
Surgery in the Patient with Renal Dysfunction
Preoperative evaluation of patients with renal dysfunction often requires the collaborative efforts of the primary care physician, nephrologist, surgeon, and anesthesiologist. Renal dysfunction is typically a spectrum of disease with multisystem effects. Optimization of preexisting medical issues is the key, as is a thorough understanding of the potential perioperative risks for further renal injury. Surgical or anesthetic techniques may require alteration for the patient with significant renal dysfunction. Identification of those at risk for renal injury may allow for preventative therapies in the perioperative period. This article focuses on defining the population at risk, a framework for preoperative evaluation, and developments in the area of perioperative renal protection.
Surgery in the Patient with Liver Disease
Liver dysfunction is a prominent entity in Western medicine that has historically affected patients suffering from chronic viral or alcoholic hepatitis. The incidence of these conditions has not changed dramatically in recent years but the overall number of patients with liver dysfunction has increased considerably with the emergence of the obesity epidemic. Nonalcoholic fatty liver disease (NAFLD) has become increasingly recognized as the most common cause of chronic liver disease in the United States. Although the rate of progression of NAFLD to overt cirrhosis is low, the high prevalence of this condition, combined with the moderate degree of liver dysfunction it engenders, has resulted in a significant increase in the number of patients with liver disease that can be encountered by a surgical practice. Any degree of clinically evident liver disease in a prospective surgical patient should raise concern for the entire surgical team. This particularly applies to intraabdominal surgery whereby the presence of hepatomegaly, portal hypertension, variceal bleeding, and ascites can turn even the most routine operation into a morbid and life-threatening procedure. Nonabdominal surgery avoids some of the technical challenges presented by liver disease but the anesthetic management of a cirrhotic patient still makes any operation potentially more dangerous. In this article, approaches to minimize the risk when surgery becomes necessary in the presence of liver disease are discussed.
Perioperative management of diabetes: Translating evidence into practice
Glycemic control before, during, and after surgery reduces the risk of infectious complications; in critically ill surgical patients, intensive glycemic control may reduce mortality as well. The preoperative assessment is important in determining risk status and determining optimal management to avoid clinically significant hyper- or hypoglycemia. While patients with type 1 diabetes should receive insulin replacement at all times, regardless of nutritional status, those with type 2 diabetes may need to stop oral medications prior to surgery and might require insulin therapy to maintain blood glucose control. The glycemic target in the perioperative period needs to be clearly communicated so that proper insulin replacement, consisting of basal (long-acting), prandial (rapid-acting), and supplemental (rapid-acting) insulin can be implemented for optimal glycemic control. The postoperative transition to subcutaneous insulin, if needed, can begin 12 to 24 hours before discontinuing intravenous insulin, by reinitiation of basal insulin replacement. Basal/bolus insulin regimens are safer and more effective in hospitalized patients than supplemental-scale regular insulin.
Thursday, November 26, 2009
Effect of different anesthetic agents on oculocardiac reflex in pediatric strabismus surgery
Abstract
Methods Two hundred and eighty children, 1 to 9 years old, undergoing elective strabismus surgery, were randomly assigned to eight groups; ketamine-sevoflurane (KS), ketamine-desflurane (KD), ketamine-propofol (KP), ketamine-remifentanil (KR), midazolam-sevoflurane (MS), midazolam-desflurane (MD), midazolam-propofol (MP), and midazolam-remifentanil (MR). No premedication was given. Anesthesia was induced using ketamine 1 mg·kg−1 or midazolam 0.15 mg·kg−1 with 66% N2O in O2. Laryngeal mask airways (LMAs) were placed with rocuronium 0.5 mg·kg−1. Anesthesia was maintained with sevoflurane 2–3 vol. %, desflurane 5–6 vol. %, propofol 7–8 mg·kg−1·h−1, or remifentanil 0.75 µg·kg−1 over 1 min, followed by a continuous infusion of remifentanil 0.5 µg·kg−1·min−1 with 66% N2O in O2. Heart rate (HR) was recorded during extraocular muscle (EOM) manipulation. OCR was defined as a reduction in HR of more than 20% induced by the traction of an EOM.
A comparison of intra-articular magnesium and/or morphine with bupivacaine for postoperative analgesia after arthroscopic knee surgery
Methods Eighty patients undergoing arthroscopic menisectomy were randomized blindly into four intra-articular groups: group B+Mor+Mg received 20 ml 0.25% bupivacaine, morphine 2 mg, and magnesium 150 mg; group B+Mor received 20 ml 0.25% bupivacaine and morphine 2 mg; group B+Mg received 20 ml 0.25% bupivacaine and magnesium 150 mg; and group B received 20 ml 0.25% bupivacaine. Pain scores at rest and during movement, analgesic duration, and total analgesic consumption were recorded.
Results Group B+Mor and group B+Mg patients had equally effective postoperative analgesia. Group B+Mor+Mg patients had significantly reduced visual analogue scale (VAS) values both at rest and during movement and significantly increased time to first postoperative analgesic request, as well as significantly reduced total analgesic consumption, compared with the other groups.
Conclusion Intra-articular administration of magnesium sulfate or morphine, with bupivacaine, had comparable analgesic effects in the doses used. Their combination provided more effective postoperative analgesia than either drug alone.
Presurgical fentanyl vs caudal block and the incidence of adverse respiratory events in children after orchidopexy
Background: There is controversy about the etiology of early postoperative hypoxemia. Age, weight, intubation, surgical procedure, use of muscle relaxants, and/or administration of opioids may affect the incidence of early postoperative hypoxemia. In this prospective, randomized, and single-blinded study, we evaluated whether the administration of caudal analgesia vs i.v. fentanyl affected the number of children who develop postextubation adverse upper airway respiratory events, (upper airway obstruction, laryngospasm) and/or early postoperative hypoxemia.
Methods/materials: Institutional approval and written parental informed consents were obtained. Thirty-eight healthy outpatient boys, aged 1–6 years, scheduled for elective orchidopexy were randomized to receive pain relief either with a presurgical caudal block or by i.v. fentanyl. The primary outcome of the study was the number of children who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.
Results: The number of boys who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia in the caudal group was less compared with those in the fentanyl group (P = 0.04).
Conclusions: Compared to fentanyl, placement of a presurgical caudal block in boys scheduled for orchidopexy was associated with a lower incidence of postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.
Methods/materials: Institutional approval and written parental informed consents were obtained. Thirty-eight healthy outpatient boys, aged 1–6 years, scheduled for elective orchidopexy were randomized to receive pain relief either with a presurgical caudal block or by i.v. fentanyl. The primary outcome of the study was the number of children who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.
Results: The number of boys who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia in the caudal group was less compared with those in the fentanyl group (P = 0.04).
Conclusions: Compared to fentanyl, placement of a presurgical caudal block in boys scheduled for orchidopexy was associated with a lower incidence of postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.
Epidural steroid injections: An update on mechanisms of injury and safety
Epidural steroid injections (ESIs) are the most commonly performed intervention in the United States to manage chronic and subacute low back and neck pain with radiculopathy. ESIs have been used for decades for the treatment of discogenic and osteoarthritic radicular conditions originating from the cervical, thoracic, and lumbar spine, as well as spondylosis, nonspecific radiculitis, and spinal stenosis.
With the ever-increasing use of epidural steroids, there has been a disproportionate increase in popularity of transforaminal ESIs in particular. Since 2002, there has been a growing body of largely transforaminal epidural steroid case report literature that describes paralysis, stroke, and death that immediately follows the performance of these procedures. These complications are thought to be related to a combination of factors, which may include the technique used, underlying pathophysiology that is being treated, anatomical variations in the blood supply, as well as the specific injectate used.
This article discusses the pathogenesis of these complications and puts the role of steroids in their causation into perspective.
With the ever-increasing use of epidural steroids, there has been a disproportionate increase in popularity of transforaminal ESIs in particular. Since 2002, there has been a growing body of largely transforaminal epidural steroid case report literature that describes paralysis, stroke, and death that immediately follows the performance of these procedures. These complications are thought to be related to a combination of factors, which may include the technique used, underlying pathophysiology that is being treated, anatomical variations in the blood supply, as well as the specific injectate used.
This article discusses the pathogenesis of these complications and puts the role of steroids in their causation into perspective.
Sunday, November 22, 2009
Management of back pain in pregnancy
Back pain during pregnancy is a common problem experienced by many pregnant women. Physiological changes during pregnancy are a contributing factor for the development of back pain. Laxity of the sacroiliac joints causes instability and development of sacroiliac pain. The pain may be severe and can interfere with daily activities. Neurological examination is usually normal. A positive straight leg-rising test may indicate herniated disc, which is rare during pregnancy. Noncontrast magnetic resonance imaging is safe in pregnancy. To date, there are no identified adverse effects of the magnetic resonance on the developing fetus, but long-term effects need to be examined. Most back pain in pregnancy can be treated conservatively. Acetaminophen is the drug of choice to treat pain during pregnancy. Epidural steroid injection (ESI) may be considered in certain cases. Data in the literature are deficient regarding the use of ESI in pregnancy, but it appears to be safe based on expert clinical experience. More work is needed to examine the long-term effect of ESI on the mother and the fetus. Surgery is usually postponed until the postpartum period, unless there is progressive neurological deficits or cauda equina syndrome.
Ultrasound guidance for epidural steroid injections
– Ultrasound (US) guidance is practiced widely in regional anesthesia. It is becoming increasingly used for pain medicine interventions. US–guided neuraxial analgesia has also been demonstrated despite many technical challenges. The applicability of US guidance for neuraxial steroid injections adds the dimension of complications secondary to particulate steroids. This review will discuss the available evidence for the use of US in neuraxial analgesia and for epidural steroid injections (ESIs), the technique and limitations, and the potential uses of US for ESIs.
Friday, November 20, 2009
The Efficacy and Safety of Continuous Intravenous Administration of Remifentanil for Birth Pain Relief: An Open Study of 205 Parturients
OBSTETRIC ANESTHESIOLOGY
In an observational study, we prospectively evaluated the efficacy and safety of remifentanil in 205 parturients. Remifentanil was administered as a continuous infusion. The initial infusion of 0.025 µg · kg–1 · min–1 was increased in a stepwise manner to a maximum dose of 0.15 µg · kg–1 · min–1. Maternal pain, other maternal and fetal variables, side effects, and satisfaction were recorded. The mean (±sd) visual analog score before the start of the infusion was 9.4 ± 1.2 cm and decreased to 5.1 ± 0.4 cm after 5 min and 3.6 ± 1.5 cm after 30 min. The maternal side effects were minimal and no fetal or neonatal side effects were noted.
In an observational study, we prospectively evaluated the efficacy and safety of remifentanil in 205 parturients. Remifentanil was administered as a continuous infusion. The initial infusion of 0.025 µg · kg–1 · min–1 was increased in a stepwise manner to a maximum dose of 0.15 µg · kg–1 · min–1. Maternal pain, other maternal and fetal variables, side effects, and satisfaction were recorded. The mean (±sd) visual analog score before the start of the infusion was 9.4 ± 1.2 cm and decreased to 5.1 ± 0.4 cm after 5 min and 3.6 ± 1.5 cm after 30 min. The maternal side effects were minimal and no fetal or neonatal side effects were noted.
Thursday, November 19, 2009
Time course of rocuronium-induced neuromuscular block after pre-treatment with magnesium sulphate: a randomised study
Background: A previously published study suggested that pre-treatment with magnesium sulphate (MgSO4) had no impact on the speed of onset of rocuronium-induced neuromuscular block. We set out to verify this assumption.
Methods: Eighty patients (18–60 years) were randomly allocated to MgSO4 60 mg/kg or placebo (saline). Study drugs were given intravenously for 15 min before induction of anaesthesia with propofol, sufentanil and rocuronium 0.6 mg/kg. Anaesthesia was maintained with a target-controlled propofol infusion. Neuromuscular transmission was measured using train-of-four (TOF)-Watch SX® acceleromyography.
Results: Onset was analysed in 37 MgSO4 and 38 saline patients, and recovery in 35 MgSO4 and 37 saline patients. Onset time (to 95% depression of T1) was on average 77 [SD=18] s with MgSO4 and 120 [48] s with saline (P<0.001). The total recovery time (DurTOF0.9) was on average 73.2 [22] min with MgSO4 and 57.8 [14.2] min with saline (P<0.003). The clinical duration (Dur25%) was on average 44.7 [14] min with MgSO4 and 33.2 [8.1] min with saline (P<0.0002). The recovery index (Dur25–75%) was on average 14.0 [6] min with MgSO4 and 11.2 [5.2] min with saline (P<0.02). The recovery time (Dur25%TOF0.9) was on average 28.5 [11.7] min with MgSO4 and 24.7 [8.4] min with saline (P=0.28).
Conclusion: Magnesium sulphate given 15 min before propofol anaesthesia reduces the onset time of rocuronium by about 35% and prolongs the total recovery time by about 25%.
Methods: Eighty patients (18–60 years) were randomly allocated to MgSO4 60 mg/kg or placebo (saline). Study drugs were given intravenously for 15 min before induction of anaesthesia with propofol, sufentanil and rocuronium 0.6 mg/kg. Anaesthesia was maintained with a target-controlled propofol infusion. Neuromuscular transmission was measured using train-of-four (TOF)-Watch SX® acceleromyography.
Results: Onset was analysed in 37 MgSO4 and 38 saline patients, and recovery in 35 MgSO4 and 37 saline patients. Onset time (to 95% depression of T1) was on average 77 [SD=18] s with MgSO4 and 120 [48] s with saline (P<0.001). The total recovery time (DurTOF0.9) was on average 73.2 [22] min with MgSO4 and 57.8 [14.2] min with saline (P<0.003). The clinical duration (Dur25%) was on average 44.7 [14] min with MgSO4 and 33.2 [8.1] min with saline (P<0.0002). The recovery index (Dur25–75%) was on average 14.0 [6] min with MgSO4 and 11.2 [5.2] min with saline (P<0.02). The recovery time (Dur25%TOF0.9) was on average 28.5 [11.7] min with MgSO4 and 24.7 [8.4] min with saline (P=0.28).
Conclusion: Magnesium sulphate given 15 min before propofol anaesthesia reduces the onset time of rocuronium by about 35% and prolongs the total recovery time by about 25%.
Wednesday, November 18, 2009
Malignant Hyperthermia - Diagnostics, Treatment and Anaesthetic Management
In malignant hyperthermia (MH) susceptible individuals volatile anaesthetics and the depolarizing muscle relaxant succinylcholine may induce a potentially lethal hypermetabolic syndrome of skeletal muscle due to an uncontrolled sarcoplasmic calcium release. Immediate discontinuation of triggering agents, oxygenation, correction of acidosis and electrolyte abnormalities and dantrolene application are essential for MH treatment. This article reviews the clinical symptoms of MH, the diagnostic criteria and the actual guidelines for treatment and management of anaesthesia in susceptible individuals.
Tuesday, November 17, 2009
Ketamine, but not priming, improves intubating conditions during a propofol–rocuronium induction
Purpose Both ketamine and priming may shorten the onset time of rocuronium. This study investigates the effects of ketamine and priming as components of a propofol induction on intubating conditions and onset of neuromuscular block.
Methods This prospective randomized double-blind study was performed in 120 American Society of Anesthesiologists (ASA) I–II patients who were assigned to one of four groups of 30 patients each: control, priming, ketamine, and ketamine-priming. Ketamine 0.5 mg ∙ kg−1 or saline was given before priming and induction. Rocuronium 0.06 mg ∙ kg−1 or saline was injected 2 min before propofol 2.5 mg ∙ kg−1. This was followed by rocuronium 0.6 mg ∙ kg−1 or by rocuronium 0.54 mg ∙ kg−1 if priming was given. Intubation was performed one minute later. Intubating conditions were graded as excellent, good, or poor. Heart rate, noninvasive blood pressure, and train-of-four (TOF) response were monitored.
Results Intubating conditions were graded excellent in 20% of the control group, 30% of the priming group, 47% of the ketamine group, and 57% of the ketamine-priming group. Analysis using forward stepwise regression indicated that ketamine improved intubating conditions (P = 0.001) but priming did not (P = 0.35). Time to reach a TOF count of zero was shortened by ketamine (P = 0.001) but not by priming (P = 0.94): 216 ± 20 s in the control group, 212 ± 27 s in the priming group, 162 ± 18 s in the ketamine group, and 168 ± 22 s in the ketamine-priming group.
Conclusion A low-dose ketamine used with a propofol–rocuronium induction improved intubating conditions and shortened onset time. Priming did not influence intubating conditions or onset time.
Methods This prospective randomized double-blind study was performed in 120 American Society of Anesthesiologists (ASA) I–II patients who were assigned to one of four groups of 30 patients each: control, priming, ketamine, and ketamine-priming. Ketamine 0.5 mg ∙ kg−1 or saline was given before priming and induction. Rocuronium 0.06 mg ∙ kg−1 or saline was injected 2 min before propofol 2.5 mg ∙ kg−1. This was followed by rocuronium 0.6 mg ∙ kg−1 or by rocuronium 0.54 mg ∙ kg−1 if priming was given. Intubation was performed one minute later. Intubating conditions were graded as excellent, good, or poor. Heart rate, noninvasive blood pressure, and train-of-four (TOF) response were monitored.
Results Intubating conditions were graded excellent in 20% of the control group, 30% of the priming group, 47% of the ketamine group, and 57% of the ketamine-priming group. Analysis using forward stepwise regression indicated that ketamine improved intubating conditions (P = 0.001) but priming did not (P = 0.35). Time to reach a TOF count of zero was shortened by ketamine (P = 0.001) but not by priming (P = 0.94): 216 ± 20 s in the control group, 212 ± 27 s in the priming group, 162 ± 18 s in the ketamine group, and 168 ± 22 s in the ketamine-priming group.
Conclusion A low-dose ketamine used with a propofol–rocuronium induction improved intubating conditions and shortened onset time. Priming did not influence intubating conditions or onset time.
Monday, November 16, 2009
Tracheal intubation in patients with rigid collar immobilisation of the cervical spine: a comparison of Airtraq® and LMA CTrach™ devices*
The aim of this study was to evaluate the effectiveness of the Airtraq® and CTrach™ in lean patients with simulated cervical spine injury after application of a rigid cervical collar. Eighty-six consenting adult patients of ASA physical status 1 or 2, who required elective tracheal intubation were included in this study in a randomised manner. Anaesthesia was induced using 1 μg.kg−1 fentanyl, 3 mg.kg−1 propofol and 0.6 mg.kg−1 rocuronium, following which a rigid cervical collar was applied. Comparison was then made between tracheal intubation techniques using either the AirTraq or CTrach device. The mean (SD) time to see the glottis was shorter with the Airtraq than the CTrach (11.9 (6.8) vs 37.6 (16.7)s, respectively; p < 0.001). The mean (SD) time taken for tracheal intubation was also shorter with the Airtraq than the CTrach (25.6 (13.5) and 66.3 (29.3)s, respectively; p < 0.001). There was less mucosal damage in the Airtraq group (p = 0.008). Our findings demonstrate that use of the Airtraq device shortened the tracheal intubation time and reduced the mucosal damage when compared with the CTrach in patients who require cervical spine immobilisation.
Thursday, November 12, 2009
Comparison of the laryngeal mask airway Supreme and laryngeal mask airway Classic in adults
Background and objective: The laryngeal mask airway (LMA) is an important airway device that was developed in 1983. From the first classic LMA models up to now, LMA models have been developed that are easily and quickly inserted, provide ventilation at higher airway pressures, have lower cuff pressure, a reduced risk of gastric aspiration and cause fewer stress responses. We aimed to compare the LMA Classic with the LMA Supreme in assessing the success rate and time for insertion, number of attempts and leak pressure.
Methods: A total of 70 patients of ASA group I or II were included in our study. Regarding the airway device used during surgery, the patients were randomly assigned into two groups: the LMA Supreme group and the LMA Classic group. In order to provide common conditions for inserting the laryngeal mask, insertion was made while the bispectral index was between 50 and 60 and T1 was 0. The success rate of inserting the LMA, the duration of insertion, the number of attempts, the insertion complications, ventilation parameters, haemodynamic parameters and postoperative adverse effects were recorded for each group.
Results: In the LMA Classic group and the LMA Supreme group, the LMA was successfully inserted in 27 (88.5%) and 34 (97%) patients, respectively. The duration of insertion in the LMA Supreme group was shorter and the cuff pressure was lower than that in the LMA Classic group (P < 0.001).
Conclusion: The LMA Supreme is superior to the LMA Classic because of its ease of insertion with low cuff pressure and high oropharyngeal leakage pressure
Methods: A total of 70 patients of ASA group I or II were included in our study. Regarding the airway device used during surgery, the patients were randomly assigned into two groups: the LMA Supreme group and the LMA Classic group. In order to provide common conditions for inserting the laryngeal mask, insertion was made while the bispectral index was between 50 and 60 and T1 was 0. The success rate of inserting the LMA, the duration of insertion, the number of attempts, the insertion complications, ventilation parameters, haemodynamic parameters and postoperative adverse effects were recorded for each group.
Results: In the LMA Classic group and the LMA Supreme group, the LMA was successfully inserted in 27 (88.5%) and 34 (97%) patients, respectively. The duration of insertion in the LMA Supreme group was shorter and the cuff pressure was lower than that in the LMA Classic group (P < 0.001).
Conclusion: The LMA Supreme is superior to the LMA Classic because of its ease of insertion with low cuff pressure and high oropharyngeal leakage pressure
Sexuality During Pregnancy
Introduction. Sexuality is an important part of health and well-being. Sexual behavior modifies as pregnancy progresses, influenced by biological, psychological, and social factors.
Aim. To evaluate changes in sexual perceptions and activities during pregnancy and to determine sexual dysfunctions in that period.
Main Outcome Measures. Sexual perceptions (desire from the partner, feelings of attractiveness, and fear of sexual intercourse), sexual activities during pregnancy (sexual intercourse frequency, the most frequent sexual intercourse trimester, sexual activity during the birth week, type(s) of sexual intercourse, changes in sexual satisfaction and desire compared with the pre-pregnancy period, and changes in sexual intercourse frequency during each trimester compared with the pre-pregnancy period), and sexual dysfunctions.
Methods. Puerperal women were asked to anonymously complete a self-administered and structured questionnaire at the day of discharge from hospital.
Results. One hundred and eighty-eight women, aged between 17 years and 40 years with a mean age of 28.9 years, were analyzed. The first trimester was considered the most frequent period of sexual intercourse (44.7%), followed by the second trimester (35.6%). Fifty-five percent reported a decrease of sexual activity during the third trimester. Fear of sexual intercourse was referred by 23.4% of the women questioned. Sexual satisfaction was unchanged in 48.4% of the subjects and decreased in 27.7% (P < 0.0001); sexual desire is reported to be unchanged in 38.8% and decreased in 32.5% (P = 0.196) of the population. Vaginal, oral, anal sex, and masturbation were performed by 98.3%, 38.1%, 6.6%, and 20.4% of the women, respectively.
Conclusions. We determined in our study that sexual satisfaction do not change in pregnancy compared with the pre-pregnancy patterns despite a decline of sexual activity during the third trimester. A discussion of expected changes in sexuality should be routinely done by the doctor in order to improve couples' perception of possible sexual modifications induced by pregnancy. Pauleta JR, Pereira NM, and Graça LM. Sexuality during pregnancy. J Sex Med **;**:**–**.
Aim. To evaluate changes in sexual perceptions and activities during pregnancy and to determine sexual dysfunctions in that period.
Main Outcome Measures. Sexual perceptions (desire from the partner, feelings of attractiveness, and fear of sexual intercourse), sexual activities during pregnancy (sexual intercourse frequency, the most frequent sexual intercourse trimester, sexual activity during the birth week, type(s) of sexual intercourse, changes in sexual satisfaction and desire compared with the pre-pregnancy period, and changes in sexual intercourse frequency during each trimester compared with the pre-pregnancy period), and sexual dysfunctions.
Methods. Puerperal women were asked to anonymously complete a self-administered and structured questionnaire at the day of discharge from hospital.
Results. One hundred and eighty-eight women, aged between 17 years and 40 years with a mean age of 28.9 years, were analyzed. The first trimester was considered the most frequent period of sexual intercourse (44.7%), followed by the second trimester (35.6%). Fifty-five percent reported a decrease of sexual activity during the third trimester. Fear of sexual intercourse was referred by 23.4% of the women questioned. Sexual satisfaction was unchanged in 48.4% of the subjects and decreased in 27.7% (P < 0.0001); sexual desire is reported to be unchanged in 38.8% and decreased in 32.5% (P = 0.196) of the population. Vaginal, oral, anal sex, and masturbation were performed by 98.3%, 38.1%, 6.6%, and 20.4% of the women, respectively.
Conclusions. We determined in our study that sexual satisfaction do not change in pregnancy compared with the pre-pregnancy patterns despite a decline of sexual activity during the third trimester. A discussion of expected changes in sexuality should be routinely done by the doctor in order to improve couples' perception of possible sexual modifications induced by pregnancy. Pauleta JR, Pereira NM, and Graça LM. Sexuality during pregnancy. J Sex Med **;**:**–**.
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