Continuous cardiac output measurement by un-calibrated pulse wave analysis and pulmonary artery catheter in patients with septic shock.

Septic shock is a serious medical condition. With increased concerns about invasive techniques, a number of non-invasive and semi-invasive devices measuring cardiac output (CO) have become commercially available. The aim of the present study was to determine the accuracy, precision and trending abilities of the FloTrac and the continuous pulmonary artery catheter thermodilution technique determining CO in septic shock patients. Consecutive septic shock patients were included in two centres and CO was measured every 4 h up to 48 h by FloTrac (APCO) and by pulmonary artery catheter (PAC) using the continuous (CCO) and intermittent (ICO) technique. Forty-seven septic shock patients with 326 matched sets of APCO, CCO and ICO data were available for analysis. Bland and Altman analysis revealed a mean bias ±2 SD of 0.0 ± 2.14 L min(-1) for APCO-ICO (%error = 34.5 %) and 0.23 ± 2.55 L min(-1) for CCO-ICO (%error = 40.4 %). Trend analysis showed a concordance of 85 and 81 % for APCO and CCO, respectively. In contrast to CCO, APCO was influenced by systemic vascular resistance and by mean arterial pressure. In septic shock patients, APCO measurements assessed by FloTrac but also the established CCO measurements using the PAC did not meet the currently accepted statistical criteria indicating acceptable clinical performance.

Nonleg venous thrombosis in critically ill adults: a nested prospective cohort study.

IMPORTANCE: Critically ill patients are at risk of venous thrombosis, and therefore guidelines recommend daily thromboprophylaxis. Deep vein thrombosis (DVT) commonly occurs in the lower extremities but can occur in other sites including the head and neck, trunk, and upper extremities. The risk of nonleg deep venous thromboses (NLDVTs), predisposing factors, and the association between NLDVTs and pulmonary embolism (PE) or death are unclear. OBJECTIVE: To describe the frequency, anatomical location, risk factors, management, and consequences of NLDVTs in a large cohort of medical-surgical critically ill adults. DESIGN, SETTING, AND PARTICIPANTS: A nested prospective cohort study in the setting of secondary and tertiary care intensive care units (ICUs). The study population comprised 3746 patients, who were expected to remain in the ICU for at least 3 days and were enrolled in a randomized clinical trial of dalteparin vs standard heparin for thromboprophylaxis. MAIN OUTCOMES AND MEASURES: The proportion of patients who had NLDVTs, the mean number per patient, and the anatomical location. We characterized NLDVTs as prevalent or incident (identified within 72 hours of ICU admission or thereafter) and whether they were catheter related or not. We used multivariable regression models to evaluate risk factors for NLDVT and to examine subsequent anticoagulant therapy, associated PE, and death. RESULTS Of 3746 trial patients, 84 (2.2%) developed 1 or more non-leg vein thromboses (superficial or deep, proximal or distal). Thromboses were more commonly incident (n = 75 [2.0%]) than prevalent (n = 9 [0.2%]) (P < .001) and more often deep (n = 67 [1.8%]) than superficial (n = 31 [0.8%]) (P < .001). Cancer was the only independent predictor of incident NLDVT (hazard ratio [HR], 2.22; 95% CI, 1.06-4.65). After adjusting for Acute Physiology and Chronic Health Evaluation (APACHE) II scores, personal or family history of venous thromboembolism, body mass index, vasopressor use, type of thromboprophylaxis, and presence of leg DVT, NLDVTs were associated with an increased risk of PE (HR, 11.83; 95% CI, 4.80-29.18). Nonleg DVTs were not associated with ICU mortality (HR, 1.09; 95% CI, 0.62-1.92) in a model adjusting for age, APACHE II, vasopressor use, mechanical ventilation, renal replacement therapy, and platelet count below 50 × 10(9)/L. CONCLUSIONS AND RELEVANCE Despite universal heparin thromboprophylaxis, nonleg thromboses are found in 2.2% of medical-surgical critically ill patients, primarily in deep veins and proximal veins. Patients who have a malignant condition may have a significantly higher risk of developing NLDVT, and patients with NLDVT, compared with those without, appeared to be at higher risk of PE but not higher risk of death. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00182143.

Thrombocytopenia in critically ill patients receiving thromboprophylaxis: frequency, risk factors, and outcomes.

BACKGROUND: Thrombocytopenia is the most common hemostatic disorder in critically ill patients. The objective of this study was to describe the incidence, risk factors, and outcomes of thrombocytopenia in patients admitted to medical-surgical ICUs. METHODS: Three thousand seven hundred forty-six patients in 67 centers were enrolled in a randomized trial in which unfractionated heparin was compared with low-molecular-weight heparin (LMWH) for thromboprophylaxis. Patients who had baseline platelet counts < 75 × 10(9)/L or severe coagulopathy at screening were excluded. We analyzed the risk of developing mild (100-149 × 10(9)/L), moderate (50-99 × 10(9)/L), and severe (< 50 × 109/L) thrombocytopenia during an ICU stay. We also assessed independent and time-varying predictors of thrombocytopenia and the effect of thrombocytopenia on major bleeding, transfusions, and death. RESULTS: The incidences of mild, moderate, and severe thrombocytopenia were 15.3%, 5.1%, and 1.6%, respectively. The predictors of each category of thrombocytopenia were APACHE (Acute Physiology and Chronic Health Evaluation) II score, use of inotropes or vasopressors, and renal replacement therapy. The risk of moderate thrombocytopenia was lower in patients who received LMWH thromboprophylaxis but higher in surgical patients and in patients who had liver disease. Each category of thrombocytopenia was associated with subsequent bleeding and transfusions. Moderate and severe thrombocytopenia were associated with increased ICU and hospital mortality. CONCLUSION: A high severity of illness, prior surgery, use of inotropes or vasopressors, renal replacement therapy, and liver dysfunction are associated with a higher risk of thrombocytopenia developing in the ICU, whereas LMWH thromboprophylaxis is associated with a lower risk. Patients who develop thrombocytopenia in the ICU are more likely to bleed, receive transfusions, and die.

Adding a conduit to GlideScope blade facilitates tracheal intubation. Prospective randomized study.

OBJECTIVE: To determine the effect of modifying the GlideScope (GVL) blade on the intubation time. METHODS: This prospective study was conducted at the Department of Anesthesia, King Abdulaziz University Hospital, Jeddah, Saudi Arabia between June 2011 and October 2011. Sixty patients requiring endotracheal tube (ETT) intubation for elective surgery in whom airway was anticipated normal were randomly allocated to one of 2 groups. Group M (n=30): intubated via a modified GVL blade in which a tube conduit along the side of the GVL blade was created to allow the passage of ETT through the cords. Group C (n=30): intubated with the conventional GVL blade and rigid intubating stylet. RESULTS: Time to successful tracheal intubation (TTI) was 39.6+/-2.1 seconds in Group M versus 66.4+/-8.3 seconds in Group C (p=0.0001), tracheal intubation was deemed more easily in Group M than in Group C (VAS 2+/-1 versus 6+/-1, p=0.0001), and all patients in Group M were successfully intubated on the first attempt when compared with 90% in Group C (p=0.009). CONCLUSION: The addition of a conduit to the GVL blade made the passage of the ETT easier and TTI shorter without increasing adverse events or intubation failure.

Effects of local low-dose rocuronium on the quality of peribulbar anesthesia for cataract surgery.

OBJECTIVES: Peribulbar anesthesia is associated with delayed and/or incomplete orbital akinesia compared with retrobulbar anesthesia. This study examined the effects of adding rocuronium 5 mg to two different concentrations of lidocaine-bupivacaine mixture on onset time of orbital and eyelid akinesia in patients undergoing cataract surgery. METHODS: In a double-blind study, 90 patients were equally randomized to receive a mixture of 0.5 ml normal saline, 4 ml lidocaine 2%, and 4 ml bupivacaine 0.5% (group I), a mixture of rocuronium 0.5 ml (5 mg), 4 ml lidocaine 2%, and 4 ml bupivacaine 0.5% (group II), or a mixture of rocuronium 0.5 ml (5 mg), 4 ml lidocaine 1%, and 4 ml bupivacaine 0.25% (group III). Orbital akinesia was assessed on a 0-8 score (0 = no movement, 8 = normal) at 2 min intervals for 10 min. Time to adequate anesthesia was also recorded. Results are presented as mean±SD. RESULTS: Ocular movement score decreased during the assessment period in all groups. However, at 2 min after block administration, the score decreased to 4±2 (95% CI 3,5) in groups II and III compared with 5±2 (95% CI 4,6) in group I (P<0.01). Time to adequate condition to begin surgery was 9.8±2.9 vs. 6.9±4.1 vs. 7.9±3.9 min for groups I, II, and III, respectively (P=0.01). CONCLUSION: The addition of rocuronium 5 mg to a mixture of lidocaine 2% and bupivacaine 0.5% shortened the onset time of peribulbar anesthesia in patients undergoing cataract surgery without causing adverse effects.

Broncho-pleuropericardial fistula complicating staphylococcal sepsis.

This is a rare case of broncho-pleuropericardial fistula in a 12-year-old female who presented with fever, painful joint swelling, and pleural and pericardial effusion secondary to disseminated methicillin-sensitive Staphylococcus aureus infection. The pleural and pericardial effusion were drained, however, air leak was observed from both tubes and was synchronous with mechanical inspiration. A broncho-pleuropericardial fistula was suspected and confirmed with computed tomography. This case report demonstrated that disseminated S. aureus bacteremia could result in broncho-pleuropericardial fistula. The ability of disseminated staphylococcal infection to produce pnemopericardium should be added to the list of other complications associated with disseminated staphylococcal sepsis.

Effects of sitting up for five minutes versus immediately lying down after spinal anesthesia for Cesarean delivery on fluid and ephedrine requirement; a randomized trial.

BACKGROUND: Patient position after spinal anesthesia has had variable effects on blood pressure and ephedrine requirements. The aim of this study was to determine the effects that sitting the patient up for five minutes after spinal anesthesia would have on intraoperative fluid and ephedrine requirements. METHODS: The study included 120 women at term gestation who were scheduled for Cesarean delivery under spinal anesthesia. After anesthetic administration, the women were randomized either to sit up for five minutes then lie down (Group S) or to lie down immediately (Group L) to a tilted supine position. A blinded observer recorded sensory block level, systolic blood pressure, heart rate, ephedrine and fluid requirements, adverse events, and time to motor recovery (modified Bromage score of 2). RESULTS: Group S had a lower intraoperative sensory block height than Group L [T4 (1) vs T2 (1), respectively; P < 0.001]; Group S also required less ephedrine (8% vs 47%, respectively; P < 0.001), received less fluid [709 (59) mL vs 789 (90) mL, respectively; P < 0.001], and experienced less nausea and vomiting (5% vs 22%, respectively; P = 0.014) and shortness of breath (3% vs 28%, respectively; P < 0.001) intraoperatively. In Group S, the odds of requiring ephedrine were 0.09 compared with 0.89 in Group L (odds ratio 0.10). There were no differences in systolic blood pressure (P = 0.127) or heart rate (P = 0.831) over time between groups. Time to a modified Bromage score of 2 was longer in Group S than in Group L [101 (15) min vs 88 (14) min, respectively; P < 0.001]. CONCLUSIONS: Sitting the patient up for five minutes rather than laying the patient down immediately after spinal anesthesia for Cesarean delivery decreased intraoperative sensory block height, ephedrine and fluid requirements, and intraoperative nausea, vomiting, and shortness of breath without affecting systolic blood pressure or the success of the anesthetic. However, the method resulted in delayed postoperative motor recovery.

A Canadian Critical Care Trials Group project in collaboration with the international forum for acute care trialists - Collaborative H1N1 Adjuvant Treatment pilot trial (CHAT): study protocol and design of a randomized controlled trial.

BACKGROUND: Swine origin influenza A/H1N1 infection (H1N1) emerged in early 2009 and rapidly spread to humans. For most infected individuals, symptoms were mild and self-limited; however, a small number developed a more severe clinical syndrome characterized by profound respiratory failure with hospital mortality ranging from 10 to 30%. While supportive care and neuraminidase inhibitors are the main treatment for influenza, data from observational and interventional studies suggest that the course of influenza can be favorably influenced by agents not classically considered as influenza treatments. Multiple observational studies have suggested that HMGCoA reductase inhibitors (statins) can exert a class effect in attenuating inflammation. The Collaborative H1N1 Adjuvant Treatment (CHAT) Pilot Trial sought to investigate the feasibility of conducting a trial during a global pandemic in critically ill patients with H1N1 with the goal of informing the design of a larger trial powered to determine impact of statins on important outcomes. METHODS/DESIGN: A multi-national, pilot randomized controlled trial (RCT) of once daily enteral rosuvastatin versus matched placebo administered for 14 days for the treatment of critically ill patients with suspected, probable or confirmed H1N1 infection. We propose to randomize 80 critically ill adults with a moderate to high index of suspicion for H1N1 infection who require mechanical ventilation and have received antiviral therapy for ≤ 72 hours. Site investigators, research coordinators and clinical pharmacists will be blinded to treatment assignment. Only research pharmacy staff will be aware of treatment assignment. We propose several approaches to informed consent including a priori consent from the substitute decision maker (SDM), waived and deferred consent. The primary outcome of the CHAT trial is the proportion of eligible patients enrolled in the study. Secondary outcomes will evaluate adherence to medication administration regimens, the proportion of primary and secondary endpoints collected, the number of patients receiving open-label statins, consent withdrawals and the effect of approved consent models on recruitment rates. DISCUSSION: Several aspects of study design including the need to include central randomization, preserve allocation concealment, ensure study blinding compare to a matched placebo and the use novel consent models pose challenges to investigators conducting pandemic research. Moreover, study implementation requires that trial design be pragmatic and initiated in a short time period amidst uncertainty regarding the scope and duration of the pandemic. TRIAL REGISTRATION NUMBER: ISRCTN45190901.

Outcome of reintubated patients after scheduled extubation.

PURPOSE: The main objective of study was to evaluate the outcome of patients who require reintubation after elective extubation. MATERIALS AND METHODS: This is an observational, prospective cohort study including mechanically ventilated patients who passed successfully a spontaneous breathing trial. Patients were observed for 48 hours after extubation. During this time, reintubation or use of noninvasive positive pressure ventilation was considered as a failure. Reintubated patients were followed after the reintubation to register complications and outcome. RESULTS: A total of 1,152 extubated patients were included in the analysis. Three hundred thirty-six patients (29%) met the criteria for extubation failure. Extubation failure was independently associated with mortality (odds ratio, 3.29; 95% confidence interval, 2.19-4.93). One hundred eighty patients (16% of overall cohort) required reintubation within 48 hours after extubation. Median time from extubation to reintubation was 13 hours (interquartile range, 6-24 hours). Reintubation was independently associated with mortality (odds ratio, 5.18; 95% confidence interval, 3.38-7.94; P < .001). Higher mortality of reintubated patients was due to the development of complications after the reintubation. CONCLUSIONS: In a large cohort of scheduled extubated patients, one third of patients developed extubation failure, of whom half needed reintubation. Reintubation was associated with increased mortality due to the development of new complications after reintubation.

Minimally invasive monitoring of cardiac output in the cardiac surgery intensive care unit.

Cardiac output monitoring in the cardiac surgery patient is standard practice that is traditionally performed using the pulmonary artery catheter. However, over the past 20 years, the value of pulmonary artery catheters has been challenged, with some authors suggesting that its use might be not only unnecessary but also harmful. New minimally invasive devices that measure cardiac output have become available. In this paper, we review their operative principles, limitations, and utility in an integrated approach that could potentially change patients' outcome. However, it is now clear that it is how the monitor is used (ie, the protocol or therapy associated with its use, or its lack thereof), and not the monitor per se, that should be questioned when a patient's outcome is being evaluated.

The impact of time to tracheostomy on mechanical ventilation duration, length of stay, and mortality in intensive care unit patients.

INTRODUCTION: This study examined the potential effects of time to tracheostomy on mechanical ventilation duration, intensive care unit (ICU), and hospital length of stay (LOS), and ICU and hospital mortality. METHODS: Cohort observational study was conducted in a tertiary care medical-surgical ICU based on a prospectively collected ICU database. We included 531 consecutive patients who were admitted between March 1999 and February 2005, and underwent tracheostomy during their ICU stay. The effect of time to tracheostomy on the different outcomes assessed was estimated using multivariate regression analyses (linear or logistic, based on the type of variables). Other independent variables that were included in the analyses included selected admission characteristics. RESULTS: Mean +/- SD was 12.0 +/- 7.3 days for time to tracheostomy, and 23.1 +/- 18.9 days for ICU LOS. Time to tracheostomy was associated with an increased duration of mechanical ventilation (beta-coefficient = 1.31 for each day; 95% confidence interval [CI], 1.14-1.48), ICU LOS (beta-coefficient = 1.31 for each day; 95% CI, 1.13-1.48), and hospital LOS (beta-coefficient = 1.80 for each day; 95% CI, 0.65-2.94). On the other hand, time to tracheostomy was not associated with increased ICU or hospital mortality. CONCLUSIONS: Time to tracheostomy was independently associated with increased mechanical ventilation duration, ICU LOS, and hospital LOS, but was not associated with increased mortality. Performing tracheostomy earlier in the course of ICU stay may have an effect on ICU resources and could entail significant cost-savings without adversely affecting patient mortality.

Hysterectomy for benign conditions in a university hospital in Saudi Arabia.

BACKGROUND AND OBJECTIVE: Hysterectomy is a common surgical procedure among women with a lifetime prevalence of 10%. The indications and complications of this procedure have not been previously reported from a teaching institution in Saudi Arabia. We examined the indications for hysterectomy and the surgical morbidity for women undergoing hysterectomy at a university hospital in Saudi Arabia. PATIENTS AND METHODS: We reviewed the records of women who underwent hysterectomies for benign gynecological conditions between January 1990 and December 2002, at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, comparing patient characteristics, indications for hysterectomy and the rate of complications in women undergoing abdominal hysterectomy (AH) versus vaginal hysterectomy (VH). RESULTS: Of 251 women, 199 (79%) underwent AH and 52 (21%) underwent VH. An estimated blood loss of >/=500 mL occurred in 104 patients (52.3%) in the AH group and in 20 patients (38.5%) in the VH group (difference not statistically significant). The most common indications for hysterectomy were uterine fibroids (n=107, 41.6%) and dysfunctional uterine bleeding (n=68, 27.1%). The most common indication for VH was uterine prolapse (n=45, 86.5%). The overall complication rates were 33.5%, 15.4% and 30.4% in women who underwent AH, VH and both, respectively. Intraoperative and postoperative complications occurred in 24 (9.7%) patients in the AH group and in 51 patients in the VH group (20.3%). Postoperative infection occurred in 42/199 (21.6%) in the AH group and 5/52 (9.6%) in the VH group (difference not statistically significant). CONCLUSIONS: We describe a large series of hysterectomies, which provides information for surgeons on the expected rate of complications following hysterectomy for benign conditions. We found that the rate of complications was not significantly higher than other centers internationally.

Intravenous acetaminophen vs oral ibuprofen in combination with morphine PCIA after Cesarean delivery.

PURPOSE: To compare the effects of iv acetaminophen with those of oral ibuprofen with respect to postoperative pain control and morphine requirements in patients receiving morphine patient-controlled iv analgesia (PCIA) after Cesarean delivery. METHODS: Forty-five term patients scheduled for Cesarean delivery were randomized to receive acetaminophen 1 g iv every six hours plus oral placebo (group A) or ibuprofen 400 mg po every six hours plus iv placebo (group I); the first dose of study drug was given 30 min preoperatively. Postoperatively, all patients received PCIA for 48 hr using morphine bolus dose 2 mg iv, lockout interval ten minutes, and no basal infusion. Visual analogue scale (VAS; 0 to 10) at rest and morphine requirements were recorded every hour for four hours then every four hours for a total of 48 hr postoperatively. Patient satisfaction was recorded on a ten-point scale (from 1 to 10) 48 hr postoperatively. RESULTS: Visual analogue scale scores decreased similarly in both groups over time, however, there were no differences between groups at any time during the study period (estimated marginal means: 1.4 +/- SEM 0.2 vs 1.9 +/- SEM 0.2 for groups A and I, respectively, P = 0.124). Cumulative doses of postoperative morphine were 98 +/- 37 vs 93 +/- 33 mg for groups A and I, respectively (P = 0.628). Patient satisfaction with analgesia was high in both groups (9 +/- 1 vs 9 +/- 1, P = 0.93). CONCLUSION: Intravenous acetaminophen is a reasonable alternative to oral ibuprofen as an adjunct to morphine patient-controlled analgesia after Cesarean delivery.

Anesthesiologist-controlled versus patient-controlled propofol sedation for shockwave lithotripsy.

PURPOSE: To compare anesthesiologist-controlled sedation (ACS) with patient-controlled sedation (PCS), with respect to propofol requirements, sedation, and recovery, in patients undergoing extracorporeal shockwave lithotripsy for urinary calculi. METHODS: Sixty-four patients were randomized, in this double-blind study, to receive propofol sedation according to one of two regimens: infusion of 200 microg.kg(-1) .min(-1) for ten minutes reduced thereafter to 50-150 microg.kg(-1) .min(-1) titrated by an anesthesiologist, according to patient response (group ACS), or propofol administered by patient-controlled analgesia (bolus dose 300 microg.kg(-1), lockout interval three minutes, no basal infusion), (group PCS). All patients received midazolam 10 microg.kg(-1) iv and fentanyl 1 microg.kg(-1) iv preoperatively, followed by fentanyl infused at a rate of 0.5 microg.kg(-1) .hr(-1) throughout the procedure. Sedation and analgesia were assessed using the A-line ARX index and visual analogue scale, respectively. Psychomotor recovery and readiness for recovery room discharge were assessed using the Trieger dot test and postanesthesia discharge score, respectively. Patient satisfaction was assessed on a seven-point scale (1-7). RESULTS: In comparison to group PCS, patients in group ACS received more propofol (398 +/- 162 mg vs 199 +/- 68 mg, P < 0.001), were more sedated (A-line ARX index: 35 +/- 16 vs 73 +/- 16, P < 0.001), experienced less pain (visual analogue scale: 0 +/- 0 vs 3 +/- 1, P < 0.001), and were more satisfied (median [Q1, Q3]: 7 [7, 7] vs 6 [6, 7], P < 0.001). In contrast, patients in group PCS had faster psychomotor recovery (Trieger dot test median [Q1, Q3]: 8 [4, 16] vs 16 [12, 26] dots missed, P = 0.002) and achieved postanesthesia discharge score >/=9 earlier (median [Q1, Q3]: 40 [35, 60] vs 88 [75, 100] min, P < 0.001) compared with group ACS. CONCLUSION: In comparison to PCS for patients undergoing extracorporeal shockwave lithotripsy, propofol/fentanyl ACS is associated with increased propofol administration, deeper sedation levels, and greater patient comfort. However, ACS is associated with slower recovery and a longer time to meet discharge criteria, when compared to PCS.

Diagnostic accuracy of a bedside qualitative immunochromatographic test for acute myocardial infarction.

OBJECTIVE: To evaluate the diagnostic efficacy of a bedside immunochromatographic test (CardioDetect) that identifies human heart-type fatty acid-binding protein in whole blood. METHODS: Sixty-four patients with chest pain had CardioDetect test performed together with serial determination of serum troponin I (TnI) and creatine kinase (CK). CardioDetect results were interpreted twice, 24 hours apart, by 3 independent observers who were blinded to patients' clinical and laboratory data. Acute myocardial infarction was diagnosed by a physician blinded to the results of the CardioDetect test. Sensitivity, specificity, positive and negative predictive values, diagnostic accuracy, and receiver operating characteristic curves were determined for all tests at 4 predefined times. Intraobserver and interobserver reliabilities were determined. RESULTS: At less than 4 hours after chest pain, CardioDetect had a sensitivity and specificity of 62.5% and 100% compared with 50% and 80% for TnI and 37.5% and 80% for CK, respectively. At more than 4 hours but 12 hours or less in duration, the sensitivity of CardioDetect and TnI was 100%, whereas that of CK was 85.7%. Intraobserver agreement and interobserver reliability were high for CardioDetect (kappa >0.80 [P < .0001] and intraclass correlation coefficient, >0.90, respectively). CONCLUSION: CardioDetect was a reliable point-of-care test for the early diagnosis (<12 hours) of acute myocardial infarction in the ED.

Dexmedetomidine in combination with morphine PCA provides superior analgesia for shockwave lithotripsy.

PURPOSE: To compare the analgesic effects of dexmedetomidine/morphine with those of tramadol/midazolam in patients undergoing extracorporeal shockwave lithotripsy (ESWL) for urinary calculi. METHODS: Sixty patients were randomized to receive either dexmedetomidine 1 micro g*kg(-1) iv followed by 0.5 micro g*kg(-1)*hr(-1) infusion together with morphine patient-controlled analgesia [(PCA); 2 mg bolus, five minutes lockout, 2 mg*hr(-1) infusion; (Group DEX)], or tramadol 1.5 mg*kg(-1) pre-mixed with midazolam 30 micro g*kg(-1) iv followed by tramadol PCA [20 mg bolus, five minute lockout, 20 mg*hr(-1) infusion; (Group TRA)]. Pain was assessed at baseline and every 15 min thereafter. Patients' and urologist's satisfaction with analgesia and sedation were determined on a seven-point scale ranging from 1 (extremely dissatisfied) to 7 (extremely satisfied). Patient's discharge time was also documented. RESULTS: Visual analogue scale scores over time were consistently lower in Group DEX compared with Group TRA (P = 0.001). Patients' satisfaction with analgesia (5 +/- 1 vs 4 +/- 2, P = 0.012) and with sedation (6 +/- 1 vs 5 +/- 1, P = 0.020), and urologist's satisfaction (6 +/- 1 vs 4 +/- 2, P = 0.001) were all higher amongst Group DEX patients compared with Group TRA. There was no difference between discharge times of patients in Group DEX compared with those in Group TRA [85 (60,115) min vs 65 (40,95) min, P = 0.069]. CONCLUSION: Dexmedetomidine in combination with morphine PCA provided better analgesia for ESWL and was associated with higher patients' and urologist's satisfaction when compared with a tramadol/midazolam PCA combination.