The effect of intrathecal fentanyl on Cerebral State Index-guided sedation during spinal anaesthesia*

This study investigated the effect of intrathecal fentanyl on the dose of propofol during sedation guided by Cerebral State Index monitoring. Seventy patients were randomly assigned to receive either fentanyl 25 μg (n = 35) or normal saline (n = 35) with hyperbaric bupivacaine 12.5 mg for spinal anaesthesia. Propofol was infused to maintain a Cerebral State Index value of 65–75 for 30 min. The propofol infusion time and dose required to reach a Cerebral State Index value of 75 were recorded together with the time required to reach a Cerebral State Index value higher than 90 after cessation of sedation. The onset time for sedation was faster and the recovery time was slower in the fentanyl group compared to those in the saline group (p = 0.018 and 0.027, respectively). The propofol doses required for onset and maintenance of sedation were significantly lower in the fentanyl group compared to those in the control group (p = 0.018 and < 0.001, respectively). In conclusion, adding intrathecal fentanyl 25 μg during spinal anaesthesia significantly reduced the dose of propofol required for sedation and prolonged the subsequent recovery time.

Perioperative pain management in the patient treated with opioids: Continuing Professional Development

Purpose The objective of this continuing professional development module is to describe the perioperative anesthesia and pain management of patients taking opioids because of chronic pain or drug addiction.
Principal findings The number of patients under opioid treatment is increasing. Pain management is problematic in these patients, because regular opioid intake is associated with mechanisms of tolerance and dependence. More recently, opioid-induced hyperalgesia phenomena have been brought to light. As a rule, the usual opioid dose should be administered with the appropriate conversions, and additional requirements should be anticipated because of the surgical procedure. Local and regional anesthesia, and multimodal analgesia are indicated whenever possible. For the patient addicted to heroin or other opioids, the perioperative period is not a suitable time to initiate weaning.
Conclusion The physiological and pharmacological changes caused by chronic opioid intake must be understood in order to provide optimal pain management with respect to each individual and the type of procedure.

Inotrope and Vasopressor Therapy of Septic Shock

When fluid administration fails to restore an adequate arterial pressure and organ perfusion in patients with septic shock, therapy with vasoactive agents should be initiated. The ultimate goals of such therapy in shock are to restore effective tissue perfusion and to normalize cellular metabolism. The efficacy of hemodynamic therapy in sepsis should be assessed by monitoring a combination of clinical and hemodynamic parameters. Although specific end points for therapy are debatable, and therapies will inevitably evolve as new information becomes available, the idea that clinicians should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis remains a fundamental principle.

Depth of anesthesia

– The present review article provides a summary of the recent literature evaluating the technology for monitoring depth of anesthesia and patient outcomes associated with its use. The goal of precisely dosed general anesthesia guided by brain monitoring remains elusive.

Ultrasound-guided arterial catheterization: a narrative review

– A description of the procedure is provided, along with an online supplemental video. Most studies indicate that first–pass success will be improved with US–guided (USG) arterial catheterization. The technique is easy to learn, particularly if one is already familiar with USG for central venous catheter placement. More research, including formal analyses of cost effectiveness, is needed.
Abstract Arterial catheterization is the second most common invasive procedure performed in the intensive care unit. Despite the ubiquity of the procedure, complications including failure to place the catheter occur. While many clinicians are familiar with the use of ultrasound (US) guidance to decrease complication rates of central venous catheter insertion, fewer are familiar with the use of ultrasound to guide arterial catheterization. This manuscript reviews the evidence for the utility of ultrasound for this indication. Technical aspects of the procedure and limitations of the existing evidence are reviewed. A description of the procedure is provided, along with an online supplemental video. Most studies indicate that first-pass success will be improved with US-guided (USG) arterial catheterization. The technique is easy to learn, particularly if one is already familiar with USG for central venous catheter placement. More research, including formal analyses of cost effectiveness, is needed.
Electronic supplementary material The online version of this article (doi:10.1007/s00134-009-1699-6) contains supplementary material, which is available to authorized users.
Keywords Catheterization - Artery - Ultrasonography - Review

Use of oral ketamine in chronic pain management: A review

The analgesic effect of ketamine is primarily based on the antagonism of the N-methyl-D-aspartate (NMDA) receptor. Activation of NMDA receptors may play a crucial role in the pathogenesis of chronic pain. Little formal research has been performed on the efficacy and safety of ketamine in chronic pain, especially concerning long-term oral administration. This review provides an overview of the available clinical data on the use of oral ketamine in chronic pain management. A literature search was performed in MEDLINE, EMBASE and the Cochrane Library, resulting in 22 relevant articles. Because most retrieved articles were of a descriptive nature (e.g. case reports and case series) a quantitative analysis was not possible. There was no consistent dose–response relation. A recommended starting dosage in ketamine-naive patients is 0.5mg/kg racemic ketamine or 0.25mg/kg S-ketamine as a single oral dose. The dosage is increased by the same amount if required. For a continuous analgesic effect it is usually given 3–4 times daily. The injection fluid can be taken orally. When parenteral ketamine is switched to oral administration the daily dosage can be kept equal and, depending on clinical effect and/or adverse effects, is slowly increased. The pharmacologically active metabolite norketamine is believed to contribute to the analgesic effect of oral ketamine. Lack of evidence regarding efficacy, and the poor safety profile, do not support routine use of oral ketamine in chronic pain management. Oral ketamine may have a limited place as add-on therapy in complex chronic pain patients if other therapeutic options have failed.

Total intravenous anaesthesia techniques for ambulatory surgery

-Purpose of review: The purpose of the present review is to provide an updated discussion on the use of total intravenous anaesthesia (TIVA) for ambulatory surgery, based on results from recent studies put into the context of issues already known.

Recent findings: The current use of TIVA for ambulatory surgery seems to be abundant. It is encouraged by the simplicity of the method, increased experience and declining costs with the propofol and remifentanil combination. The TIVA methods are well tolerated and perceived to give good quality patient care; with rapid, clear-headed emergence and low incidence of postoperative nausea and vomiting. Cost-efficacy and other benefits of recovery from TIVA versus alternative techniques of anaesthesia seem to depend more on the patient and the individual perioperative setting than on the TIVA concept per se. Further development of TIVA will include the refinement of target control systems, the introduction of new drugs and adjuvants and advanced equipment for automatic drug delivery, as well as improved effect monitoring.

Summary: TIVA is well tolerated and simple. It is associated with less postoperative nausea and vomiting than inhalational anaesthesia and has no residual paralyses as are possible with locoregional techniques. Propofol with remifentanil seems to be the dominating TIVA technique, delivered either by conventional pumps or by target control systems.

Anesthésie locorégionale pour la chirurgie esthétique de la face et du cou

-La chirurgie plastique connaît un développement important, c’est un domaine d’application des blocs de la face. Les indications chirurgicales sont multiples, dont un nombre important peut être pratiqué en ambulatoire. Après quelques rappels anatomiques, les techniques d’anesthésie locorégionale appliquées à chaque type de chirurgie sont détaillées. La réalisation de ces blocs obéit aux règles générales de toute anesthésie, en particulier en ce qui concerne la surveillance clinique et l’asepsie.

Ambulatory hernia surgery under local anesthesia is feasible and safe in obese patients

– The authors conclude that ambulatory abdominal wall hernia repair under local anesthesia is feasible in obese patients. Because of the increased length of surgery in these patients, monitored sedation and prophylactic antibiotic cover should be used. The slight decrease in patient satisfaction is balanced by the lower risks and higher costs associated with full general anesthetic.

Spinal mepivacaine with fentanyl for outpatient knee arthroscopy surgery: a randomized controlled trial

– When compared with 45 mg isobaric mepivacaine 1.5%, an intrathecal dose of 30 mg isobaric mepivacaine 1.5% plus 10 microg fentanyl produces reliable anesthesia, hastens block regression, shortens stay in Phase I recovery, and enables earlier ambulation for patients undergoing unilateral knee arthroscopy.

Comparison of Local Anesthetic Effects of Tramadol With Prilocaine During Circumcision Procedure

– A combination of tramadol 5% plus adrenaline can provide a safe and effective local anesthesia during circumcision procedure and postoperative period in children.
Objectives

To compare the local anesthetic effects of tramadol hydrochloride with prilocaine for circumcision procedure.
Methods

This study included 40 patients with American Surgical Association-I scores. Patients were randomly allocated to receive either 5% tramadol (2 mg/kg) plus adrenaline (0.0125/mL) (group 1, n = 20) or 2% prilocaine plus adrenaline (0.0125/mL) (group 2, n = 20). The degree of burning sensation and pain at the injection site were documented. Sensory block was assessed 1 minute after injection and the patients were asked to grade touch and pinprick sensation. Five minutes after drug administration, incision was performed and intensity of pain, felt by the patient was evaluated on a 4-point scale (0-3). Pain at the injection site and local skin reactions were also recorded.
Results

Mean ages were 9.7 and 10.3 years for groups 1 and 2, respectively. Mean duration of surgery was 19.6 minutes. In control visit, 2 of 20 (10%) in group 1 and 10 of 20 (50%) children in group 2 reported extra need for oral ibuprofen (P <.05). First analgesic medication time was 9.5 (± 2.1) hours in group 1 and 8.7 (± 3.1) hours in group 2 (P >.05). Total postoperative ibuprofen consumptions were 10 and 50 mg for groups 1 and 2, respectively (P <.05).
Conclusions

A combination of tramadol 5% plus adrenaline can provide a safe and effective local anesthesia during circumcision procedure and postoperative period in children.

Transient neurological symptoms after spinal anaesthesia with levobupivacaine 5 mg/ml or lidocaine 20 mg/ml

– After spinal anaesthesia with levobupivacaine, the incidence of TNS was much less than after lidocaine. However, it appears that TNS may occur in association with levobupivacaine.
Transient neurological symptoms (TNS) after spinal anaesthesia have been reported most commonly in association with lidocaine, but have been observed with other local anaesthetics. The aim of this prospective, randomized, double-blind study was to investigate the incidence of TNS after spinal anaesthesia with either levobupivacaine or lidocaine.

Methods: Patients undergoing inguinal hernia, appendectomy, varicose vein or minor orthopaedic operations were included in the study (60 patients; 47 male, 13 female, overall mean age 30 years). All patients had an American Society of Anesthesiologists score of I or II. The patients were randomly assigned to receive spinal anaesthesia with either 20 mg isobaric levobupivacaine (5 mg/ml) or 80 mg isobaric lidocaine (20 mg/ml). Onset of sensory and motor block and side effects were recorded. On post-operative days 1, 2, and 3, patients were interviewed by an investigator blinded to the spinal anaesthetic used. The patients were classified as having TNS if, following recovery from anaesthesia, there was pain in the buttocks, thighs and/or lower limbs.

Results: In the levobupivacaine group, one patient (3.33%) experienced TNS, whereas in the lidocaine group, eight (26.6%) experienced TNS (P=0.002). Maximum times to arrival of sensory blocks were shorter with lidocaine (P<0.001). The levobupivacaine and lidocaine groups did not differ significantly in terms of the highest dermatome included in sensory block or motor block grade.

Conclusion: After spinal anaesthesia with levobupivacaine, the incidence of TNS was much less than after lidocaine. However, it appears that TNS may occur in association with levobupivacaine.

ANALGESIA Ropivacaine Spinal Anesthesia Is Not Antagonized by Ondansetron Pretreatment

– The authors investigated a possible effect of ondansetron on the duration of sensory and motor block produced by ropivacaine. Ondansetron had no effect on the subarachnoid sensory or motor block produced by ropivacaine.

Use of intra-articular lidocaine as analgesia in anterior shoulder dislocation: a review and meta-analysis of the literature

– Based on the current literature, it appears that the intra–articular lidocaine (IAL) method provides, at a minimum, the same level of pain control and reduction success as the procedural sedation method, while markedly reducing the time spent by the patient in the emergency department and the cost of treatment. The likelihood of complications is arguably less with the use of IAL. Although more research is this area is merited, physicians may consider IAL as an alternative to procedural sedation and analgesia (PSA) in the management of anterior shoulder dislocations.

A Randomized Comparison of Low Doses of Hyperbaric Bupivacaine in Combined Spinal-Epidural Anesthesia for Cesarean Delivery

– The lowest dose of hyperbaric bupivacaine (7 mg) provided equally rapid onset and effective anesthesia for cesarean delivery while reducing the incidence of hypotension compared with 8 and 9 mg. However, because of its shorter duration of anesthesia, it may be feasible only when the block can be reinforced using a functional epidural catheter.

A Comparison of Gabapentin and Ketamine in Acute and Chronic Pain After Hysterectomy

– Gabapentin and ketamine are similar in improving early pain control and in decreasing opioid consumption; however, gabapentin also prevented chronic pain in the first 6 postoperative months.

INNOVATIVE LIGHTED STYLET

– Intubation of trachea using lighted stylet is easy, safe, effective and rapid alternative method of airway management. The innovative lighted stylet has an added advantage that it can be used to intubate trachea with RAE tube where conventional lighted stylet fails.

Pediatric Pain After Ambulatory Surgery: Where's the Medication?

– A large proportion of children receive little analgesic medication after surgery and research efforts should be directed to the discrepancy between high ratings of postoperative pain provided by parents and the low dosing of analgesics they use for their children.

Three concentrations of levobupivacaine for ilioinguinal/iliohypogastric nerve block in ambulatory pediatric surgery

– The aim is to compare the postoperative analgesia of three different concentrations of levobupivacaine for ilioinguinal/iliohypogastric (II/IH) block in children undergoing inguinal hernia repair. II/IH nerve block using 0.4 mL kg^–1 of 0.25% levobupivacaine provided satisfactory postoperative pain relief after inguinal herniorraphy.

CT Scans Identify Patients With Severe H1N1 at Risk for Developing Pulmonary Emboli

LEESBURG, Va -- October 14, 2009 -- Utilising computed tomography (CT) scans, researchers have found that patients with severe cases of the influenza A(H1N1) are at risk for developing severe complications, including pulmonary emboli (PE).

The study is published online, ahead of print, in the American Journal of Roentgenology. The study will be published in the December print issue of the journal.

The study included 66 patients diagnosed with the H1N1. Two study groups were formed. Group 1 consisted of 14 patients who were severely ill and required admission to the intensive care unit (ICU) and group 2 consisted of 52 patients who were not severely ill and did not require ICU admission.

All 66 patients underwent chest x-rays for the detection of H1N1 abnormalities. Ten patients from the ICU group and 5 patients from the largely outpatient group, underwent CT scans.

"Pulmonary emboli were seen on CT in 5 of 14 ICU patients," said lead author Prachi P. Agarwal, MD, University of Michigan, Ann Arbor, Michigan.

"Our study suggests that patients who are severely ill with H1N1 are also at risk for developing PE, which should be carefully sought for on contrast-enhanced CT scans," she said.

"With the upcoming annual influenza season in the United States, knowledge of the radiologic features of H1N1 is important, as well as the virus's potential complications, said Dr. Agarwal.

"The majority of patients undergoing chest x-rays with H1N1 have normal radiographs. CT scans proved valuable in identifying those patients at risk of developing more serious complications as a possible result of the H1N1 virus, and for identifying a greater extent of disease than is appreciated on chest radiographs," she said.


SOURCE: American Roentgen Ray Society

Bispectral Index Monitoring of Midazolam Sedation During Flexible Bronchoscopy

– The authors suggest that the BIS value during flexible bronchoscopy is associated with the satisfaction of patients and they may be able to predict patients' satisfaction.

Perioperative Use of β-Blockers in the Elderly Patient

– This article examines common comorbidities in the elderly who may benefit from the chronic use of beta–blockers, prophylactic perioperative use of beta–blockers including timing, dosage, and choice of beta–blocker, the pharmacologic effects of aging, and recommendations on the use of beta–blockers.

THE ‘BEST FIT’ ENDOTRACHEAL TUBE IN CHILDREN

– The age–based and 5th fingernail width–based predictions of ETT size are more accurate than length–based and multivariate–based formulae in terms of mean value and case matching.

Obstructive Sleep Apnea Is Not a Risk Factor for Difficult Intubation in Morbidly Obese Patients

– In MO patients undergoing bariatric surgery in the "ramped position," there was no relationship between the presence and severity of OSA, BMI, or NC and difficulty of intubation or laryngoscopy grade. Only a Mallampati score of 3 or 4 or male gender predicted difficult intubation.

A prospective, randomised, cross-over trial comparing the EndoFlex® and standard tracheal tubes in patients with predicted easy intubation

– Patients with a grade 2 (19/50) or 3 (6/50) laryngoscopic view had shorter intubation times, easier intubation and reduced insertion attempts with the EndoFlex. The EndoFlex is a satisfactory alternative to a standard–type tracheal tube, even with an anterior larynx.