Postoperative anemia does not impede functional outcome and quality of life early after hip and knee arthroplasties.

BACKGROUND: Clinicians have adopted a restrictive transfusion threshold (75-80 g/L) after major orthopedic surgery. Anemia may be associated with a decrease in postoperative vigor. We hypothesize that, in these patients, a threshold hemoglobin (Hb) concentration exists below which functional recovery and quality of life (QoL) become difficult. STUDY DESIGN AND METHODS: A prospective, observational cohort study in 305 patients 60 years or older undergoing a total hip or knee arthroplasty was conducted. Major outcome variables were distance walked in 6 minutes (6MWT), score on the Borg Scale for perception of effort, maximal dominant hand strength, and Short Form 36 (SF-36) QoL assessment in the preoperative and early postoperative periods. Patients were categorized according to their Hb level the day of the postoperative 6MWT (≤ 80, 81-90, 91-100, and >100 g/L). RESULTS: There was no difference between Hb groups in the decrease of the distance walked preoperatively versus postoperatively. For both moments of observation, the 6MWT was not significantly different between Hb groups (p = 0.190). Similar results were found with perception of effort, maximal dominant hand strength, and SF-36 QoL assessment scores. In a regression model, the decrease in Hb concentration could explain only 1.9% of the total variation observed in the 6MWT (p = 0.008). CONCLUSION: Moderate anemia is not associated with an impaired functional recovery or QoL in the immediate postoperative period after major arthroplasties. Further studies will be required to determine the long-term consequences of a restrictive transfusion strategy in these patients.

Tracheal intubation through the I-gel™ supraglottic airway versus the LMA Fastrach™: a randomized controlled trial.

BACKGROUND: The i-gel™ is a supraglottic airway device not requiring inflation of a cuff for lung ventilation. Its design allows for unobstructed passage of a tracheal tube and previous studies have demonstrated a favorable alignment with the glottic inlet. In this prospective randomized study, we compared the success rate of blind tracheal intubation using the i-gel and the laryngeal mask airway (LMA) Fastrach™. METHODS: One hundred sixty patients requiring general anesthesia and airway management were randomized to tracheal intubation using the i-gel or the LMA Fastrach. After induction of general anesthesia, the allocated device was inserted and adequate lung ventilation was confirmed. Blind tracheal intubation was then attempted. First attempt and overall tracheal intubation success rates were evaluated and tracheal intubation times were measured. RESULTS: Eighty patients were recruited in each study group. Successful tracheal intubation was obtained on the first attempt in 69% of patients with the i-gel and 74% of patients with the LMA Fastrach (95% confidence interval [CI] of difference, -9% to 19%, P = 0.60). The overall intubation success rate was lower using the i-gel than it was using the LMA Fastrach (73% vs 91%, 95% CI of difference, 7% to 31%, P < 0.0001). CONCLUSIONS: On first attempts, successful blind tracheal intubation was obtained at comparable rates using the i-gel and the LMA Fastrach. However, when the first attempt was unsuccessful, subsequent attempts through the i-gel did not significantly increase tracheal intubation success rate. The LMA Fastrach yielded a higher overall intubation success rate.

Superficial cervical plexus block for transitional analgesia in infratentorial and occipital craniotomy: a randomized trial.

BACKGROUND: In this study, we compared the quality of transitional analgesia provided by bilateral superficial cervical plexus block (SCPB) or morphine following a remifentanil-based anesthesia for infratentorial or occipital craniotomy. METHODS: In this randomized controlled and double-blind study, 30 patients scheduled for infratentorial or occipital craniotomy were divided randomly into two groups: group morphine (morphine 0.1 mg·kg⁻¹ iv after dural closure and a SCPB performed with 20 mL of 0.9% saline at the end of the surgery) or group block (10 mL of 0.9% saline iv instead of morphine after dural closure and a SCPB performed with 20 mL of a 1:1 mixture of 0.5% bupivacaine and 2% lidocaine at the end of the surgery). Postoperative pain was assessed at one, two, four, eight, 12, 16, and 24 hr using an 11-point (0-10) numerical rating scale (NRS). Analgesia was provided with subcutaneous codeine. RESULTS: Average NRS scores were similar between the two groups at each time interval over the study period. The average scores (with 95% confidence interval) were 3.9 (3.4-4.4) and 4.3 (3.8-4.9) for the block and morphine groups, respectively (P = 0.25). The delay before administration of the first dose of codeine was not statistically different between the two groups: 25 min (5-2,880) vs 21.5 min (5-90), median and range for the block and morphine groups, respectively. The incidence of nausea and vomiting was similar between the two groups. CONCLUSION: Bilateral superficial cervical plexus block provides transitional analgesia that is clinically equivalent to morphine following remifentanil-based anesthesia in patients undergoing occipital or infratentorial craniotomies.

Red blood cell transfusion practice in elective orthopedic surgery: a multicenter cohort study.

BACKGROUND: The indications for red blood cell (RBC) transfusions remain unclear despite published guidelines. Our hypothesis was that the transfusion practice varies inside the Centre hospitalier de l'Université de Montréal (CHUM). STUDY DESIGN AND METHODS: A total of 701 charts of patients who underwent a knee or hip arthroplasty or prosthesis revision in three hospitals of the CHUM were reviewed. Demography, hemoglobin (Hb) concentrations, details on transfusions, and postoperative adverse events (AEs) were collected up until discharge. The primary outcome was the presence or absence of RBC transfusion. Secondary outcomes were the nadir Hb, number of units transfused, discharge Hb, blood losses, and postoperative AEs. RESULTS: The rate of postoperative transfusion was 29%. We found no significant difference between odds ratios of each site for sex, coronary artery disease, chronic heart failure, type of procedure, American Society of Anesthesiologists physical status, weight, height, body mass index, body surface area, and estimated blood volume. Overall, patients were transfused at a Hb between 75 and 80g/L. Eighty-five percent of postoperative transfusions could be predicted using only nadir Hb and adding patient characteristics did not substantially improve the model (86.1%). Discharge Hb was below 100g/L in 66% of patients. CONCLUSIONS: There was no difference among hospitals regarding the way RBC transfusions are used. Our data suggest that physicians mainly based their decision to transfuse on a single variable, the Hb concentration, with the use of a restrictive strategy. Future trials should focus on the optimal transfusion trigger to adopt in major orthopedic surgery.

The effect of sedation on intracranial pressure in patients with an intracranial space-occupying lesion: remifentanil versus propofol.

BACKGROUND: In this study, we compared the effect of light sedation with remifentanil versus propofol on intracranial (ICP) and cerebral perfusion pressure (CPP) of patients undergoing stereotactic brain tumor biopsy under regional anesthesia. METHODS: This was a prospective, open-label, randomized, and controlled study. Forty patients undergoing stereotactic brain tumor biopsy under regional anesthesia were randomized into two groups to receive remifentanil or propofol titrated to a level of four on the modified Assessment of Alertness/Sedation Scale. ICP was measured via the biopsy needle. RESULTS: At the targeted level of sedation, the rates of infusion for remifentanil and propofol were, respectively, 4.2 +/- 1.8 microg x kg(-1) x h(-1) and 4.3 +/- 2.5 mg x kg(-1) x h(-1). At the time of ICP measurement, patients in the remifentanil group had a slower respiratory rate (11/min +/- 3 vs 15 per min +/- 3, P = 0.0001) and a higher PCO2 (48.3 +/- 6.2 mm Hg vs 43.1 +/- 5.5 mm Hg, P = 0.009) than patients in the propofol group. The mean was similar for both groups, 19.0 +/- 11.9 mm Hg vs 16.4 +/- 11.1 mm Hg for remifentanil and propofol, respectively (P = 0.48). Higher mean arterial blood pressure in the remifentanil group (101.1 +/- 13.7 mm Hg vs 85.8 +/- 12.7 mm Hg, P = 0.0008) resulted in a higher CPP than the propofol group: 82.0 +/- 19.0 mm Hg vs 69.5 +/- 17.0 +/- 19.0 mm Hg (P = 0.03). CONCLUSION: Light sedation with remifentanil does not result in a higher ICP than propofol in patients undergoing stereotactic brain tumor biopsy. CPP might be better preserved with remifentanil.

Clopidogrel induces an acute hemostatic deficit and increases intra abdominal bleeding in rabbits.

PURPOSE: Clopidogrel, a potent antiplatelet drug, increases hemorrhagic adverse events when its use is continued up to five days before cardiac surgery but data are lacking in non-cardiac surgery. We sought to determine the dose of clopidogrel which has a maximal antiplatelet and hemorrhagic effect in a rabbit model of non-cardiac surgery. METHODS: Twenty-four rabbits were divided into three groups according to the dose of clopidogrel administered (5, 10 and 20 mg.kg(-1)). Baseline measurement of platelet aggregation induced with ADP, platelet reactivity index (PRI) of the VASP-phosphorylation assay and hematologic variables were obtained the day before the experiment. Two hours after clopidogrel administration, the same variables were measured, along with intra abdominal bleeding following standardized hepato-splenic lesions. RESULTS: Platelet aggregation was inhibited in a dose-dependent manner: 46%+/-16% with 5 mg.kg(-1) and 93%+/-7% with 20 mg.kg(-1) of clopidogrel. PRI was reduced by 61%+/-25% with 5 mg.kg(-1) of clopidogrel and by 92%+/-11% and 94%+/-10% with 10 mg.kg(-1) and 20 mg.kg(-1) respectively (p=0.01). Percentage reduction of platelet aggregation was positively correlated with the percentage reduction of PRI (r=0.69; CI(95), 0.40 to 0.86). Bleeding from hepato-splenic lesions was more important in the 10 and 20 mg.kg(-1) groups compared to the 5 mg.kg(-1) group (p<0.05). CONCLUSION: Higher doses of clopidogrel are associated with a more profound inhibition of platelet aggregation and PRI and increased blood losses following standardized hepato-splenic lesions. We conclude that our animal model demonstrates clopidogrel's propensity to increase intra abdominal bleeding after standardized hepato-splenic lesions and may help develop blood sparing strategies for patients undergoing surgery while on clopidogrel.

Preliminary evaluation of infraclavicular catheters inserted using ultrasound guidance: through-the-catheter anesthesia is not inferior to through-the-needle blocks.

BACKGROUND AND OBJECTIVES: This prospective study compared the initial block quality and surgical anesthesia rates of ultrasound-guided infraclavicular blocks with local-anesthetic injected through a catheter versus through a needle. We hypothesized that positioning of the catheter immediately posterior to the axillary artery would produce through-the-catheter (TTC) anesthesia with rates of complete block not inferior to through-the-needle (TTN) injection. METHODS: Eighty patients undergoing hand or forearm surgery extensive enough to require regional anesthesia were randomized into 2 groups of 40. In group TTN, local anesthetic was deposited posterior, lateral, and medial to the axillary artery using as few injections as necessary. In group TTC, a 20-gauge, multiorifice catheter was positioned between the posterior wall of the axillary artery and the posterior cord of the brachial plexus. All blocks were performed by use of ultrasound visualization with a 6-MHz to 10-MHz 38-mm linear probe. Local-anesthetic solution consisted of 0.5 mL/kg lidocaine 2% with epinephrine. Sensory and motor blocks, as well as supplementation rates, were evaluated for the musculocutaneous, median, radial, and ulnar nerves. RESULTS: Complete sensory block of all nerve territories was achieved in 92% of patients in group TTN and 90% in group TTC (P = .51). In group TTN, 90% of patients had satisfactory anesthesia for surgery (no discomfort and no need for anesthetic supplementation of any type) compared with 92% in group TTC (P = .51). CONCLUSION: Ultrasound-guided TTC infraclavicular block produced perioperative anesthesia that was not inferior to a TTN technique.

Craniotomy site influences postoperative pain following neurosurgical procedures: a retrospective study.

OBJECTIVE: This retrospective study was designed to assess the intensity of postoperative pain in relation to the location of craniotomy. METHODS: After Research Ethics Board approval, data were collected from the charts of all patients who underwent a craniotomy at our institution between January 2004 and December 2005. The severity of post-craniotomy pain was assessed by collecting scores obtained using an 11-point verbal rating scale and calculating the cumulative analgesic requirements for the first 48 hr postoperatively. Data were compared according to the craniotomy location. RESULTS: Data from 299 patients was available for analysis. On average, 76% of patients experienced moderate to severe postoperative pain. Frontal craniotomy was associated with lower pain scores than four of six craniotomy sites analyzed, with 49% of patients reporting mild pain, a significant difference (P < 0.05) compared with all other groups except for parietal craniotomies. Frontal craniotomy patients also had lower opioid analgesic requirements compared to patients who underwent posterior fossa craniotomy (P < 0.05). Logistic regression analysis showed that craniotomy location (P < 0.0001) and age (P = 0.004) were both independent predictors of the intensity of postoperative pain, with lower pain scores as age increased. Postoperative use of steroids, gender and presence of preoperative pain were not statistically linked to postoperative pain intensity. The prevalence of postoperative nausea and vomiting was 56% and it did not vary according to the location of craniotomy. CONCLUSION: This study shows that the intensity of postoperative pain in neurosurgery is affected by the site of craniotomy. Frontal craniotomy patients experienced the lowest pain scores, and required significantly less opioid than patients undergoing posterior fossa interventions.

Anesthetic technique does not affect the performance of a rabbit model of arterial cyclic flow reductions: a pilot study.

PURPOSE: Pentobarbital anesthesia is, typically, used in an experimental model of cyclic flow reductions (CFR) in rabbits. Our initial observations, using a more complete and effective isoflurane-based anesthetic technique, failed to reproduce findings reported previously. Consequently, we compared the effects of these two anesthetic techniques in the model. METHODS: A modified Folts' model of carotid artery lesion and stenosis was used. Twelve rabbits completed the experimental protocol: five in the pentobarbital group (P) and seven in the isoflurane group (I). The carotid artery was exposed and flow was reduced by application of a clamp. A standardized injury was performed by cross clamping the artery with a needle forceps and this produced CFR. The number of CFR and the duration of their occurrence were noted. The incidence of thrombosis was compared in each group as well as hemodynamic, hematologic and bleeding time values. RESULTS: The hematocrit value, platelet count and bleeding time were similar in both groups. The median number and range of CFR [group P: 9 (4-16) ; group I: 9 (5-14)] and the time span of effective CFR formation (group P: 39 +/- 17; group I: 38 +/- 25 min) were comparable in both groups. The incidence of complete thrombosis of the carotid artery was similar in both groups. CONCLUSIONS: The stability of the model is of short duration, but the occurrence of CFR is not affected by the type of anesthesia. Our findings suggest that the ideal duration of the experimental protocol should be between 30 and 45 min in order to maximize the number of animals still developing CFR.

Recombinant human activated factor VII is thrombogenic in a rabbit model of cyclic flow reduction and does not reduce intra-abdominal bleeding.

Recombinant human activated factor VII (rHuFVIIa) can reduce bleeding but may be associated with arterial thrombosis. We hypothesized that rHuFVIIa would increase the occurrence of cyclic flow reductions (CFR) and reduce intra-abdominal bleeding in an experimental model. An adapted Folts' model of carotid artery lesion and stenosis was used. Twenty four rabbits were randomized to receive rHuFVIIa (group F) or placebo (group P) in a double-blind fashion. A standardized injury to the common carotid artery resulted in CFR and/or thrombosis. Hematological values, coagulation and thromboelastographic (TEG) variables were compared. Intra-abdominal bleeding was evaluated by measuring blood loss from standardized hepatosplenic lesions. The median number (range) of spontaneous CFR [group P: 6 (0-15); group F: 8 (0-16)] was comparable between groups. The number of induced CFR (by "shaking" of the artery) needed to avert thrombosis (group F: 2; group P: 0; p < 0.05) and the incidence of complete carotid artery thrombosis (group F: 3; group P: 0; p < 0.05) were higher in group F. Intra-abdominal bleeding was similar in both groups. TEG analysis demonstrated a hypercoagulable state in both groups but the magnitude of the change was statistically more important in group F. rHuFVIIa increases thrombosis in a rabbit model of carotid artery injury. The bleeding from hepatic and splenic lesions is not reduced by administration of rHuFVIIa despite a hypercoagulable state confirmed by standard TEG analysis.

Prevalence and impact of pain on the quality of life of lung transplant recipients: a prospective observational study.

STUDY OBJECTIVE: To study the prevalence and impact of pain on the quality of life (QOL) of lung transplant recipients. DESIGN AND PATIENTS: Prospective, observational, cross-sectional study. Ninety-six lung transplant recipients (> 3 months after transplantation) completed questionnaires measuring the severity and impact of pain (Brief Pain Inventory), anxiety (State Trait Anxiety Inventory), QOL (Short Form-36 version 2 [SF-36v2]), and depression (Beck Depression Inventory [BDI]). SETTING: University medical center lung transplant outpatient clinic. RESULTS: The prevalence of pain in lung transplant recipients was 49%. Patients with pain were older, more likely to have undergone unilateral lung transplantation (64% vs 40%, p = 0.03), and were more likely to have lung emphysema (55% vs 38%, p = 0.004). Only a pulmonary diagnosis of lung emphysema remained an independent predictor for postoperative pain in a logistic regression model. Average (+/- SD) score of the BDI was 9.6 +/- 7.8 and 5.8 +/- 5.8 (p = 0.005) for patients with and without pain, respectively. Patients with and without pain did not significantly differ in terms of anxiety. Pain-free patients had a significantly higher physical component score than patients with pain in the SF-36v2 (mean, 48.7 +/- 8.6 vs 38.6 +/- 9.8, p < 0.0001, respectively), while the mental component scores were not statistically different between the two groups. CONCLUSIONS: Lung transplant recipients have a high prevalence of pain. Patients with lung emphysema as their preoperative diagnosis are more likely to have pain. The occurrence of pain is associated with a decreased QOL in lung transplant recipients.

A comparison between scalp nerve block and morphine for transitional analgesia after remifentanil-based anesthesia in neurosurgery.

We compared transitional analgesia provided by scalp nerve block (SNB) or morphine after remifentanil-based anesthesia in neurosurgery. Fifty craniotomy patients were randomly divided into two groups: morphine (morphine 0.1 mg x kg(-1) IV after dural closure and an SNB performed with 20 mL of 0.9% saline at the end of surgery) and block (10 mL of 0.9% saline instead of morphine after dural closure and an SNB performed with a 1:1 mixture of bupivacaine 0.5% and lidocaine 2% at the end of surgery). Postoperative pain was assessed at 1, 2, 4, 8, 12, 16, and 24 h using a 10-point numerical rating scale. Analgesia consisted of subcutaneous codeine. Average numerical rating scale scores were similar between the two groups at each time interval. Total codeine dosage was also similar, except at 4 h postoperatively when it was higher in the block group. The delay before administration of the first dose of codeine was not statistically different between groups: 45 min (20-2880) vs 30 min (10-2880), median and range for the block and morphine group, respectively. Postoperative hemodynamics were similar for both groups. The incidence of nausea and vomiting was slightly more frequent in the morphine group, but the occurrence of confusion did not differ between groups. In conclusion, SNB provides a quality of transitional analgesia that is similar to that of morphine with the same postoperative hemodynamic profile.

Esophageal Doppler and thermodilution are not interchangeable for determination of cardiac output.

PURPOSE: This study compares thermodilution cardiac output (TD-CO) and esophageal Doppler cardiac output (ED-CO) during periods of hemodynamic stability and after heart stabilization during off-pump coronary artery bypass (OPCAB) surgery. METHODS: After Institutional Review Board approval, 58 patients undergoing OPCAB had simultaneous comparison of TD-CO and ED-CO at three time periods. Measurements were recorded, in a blinded manner, after probe insertion (T0), immediately before and after (T1,T2) heart displacement and before starting any pharmacological treatment (if needed) to maintain systolic blood pressure to its value before heart mobilization. Measurements were also taken before sternal closure (Tfinal). RESULTS: Three hundred and two pairs of data were analyzed using the Bland and Altman method. Bias, standard deviation (SD) of the bias (precision), and degree of agreement (bias +/- 2 SD) were calculated. Based on published literature, we considered that the highest degree of agreement should be < 0.5 L.min(-1) to consider both methods as interchangeable. At T0, bias and SD of bias between TD-CO and ED-CO were -0.1 +/- 1.0 L.min(-1). Immediately before heart stabilization, bias +/- SD was 0.6 +/- 1.0 L.min(-1) and after heart displacement, 0.5 +/- 0.8 L.min(-1). At Tfinal, bias +/- SD was 0.7+/- 0.7 L.min(-1). CONCLUSION: Because the degree of agreement was > 0.5 L.min(-1) at all measurement periods except T0, we conclude that TD and ED are not interchangeable at any time during OPCAB surgery.

Acetaminophen decreases early post-thoracotomy ipsilateral shoulder pain in patients with thoracic epidural analgesia: a double-blind placebo-controlled study.

OBJECTIVE: Despite effective epidural analgesia, up to 85% of post-thoracotomy patients complain of moderate-to-severe ipsilateral shoulder pain. This study assessed the efficacy of acetaminophen in decreasing postoperative shoulder pain after a thoracotomy. DESIGN: Double-blind randomized and placebo-controlled study. SETTING: University medical center. PARTICIPANTS: 65 patients. INTERVENTION: Patients were randomized into 2 groups; 31 patients received acetaminophen (group A), and 34 patients received a placebo (group P). After induction of anesthesia, patients received either a loading dose of acetaminophen, 1000 mg intrarectally, or a placebo suppository. Thereafter, acetaminophen, 650 mg, or a placebo, was administered intrarectally every 4 hours for 48 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Postoperative pain at the surgical site and shoulder pain were assessed separately every 4 hours for 48 hours using a numerical rating scale (NRS). Rescue analgesia for severe shoulder pain (NRS > 7) consisted of subcutaneous hydromorphone. Sixty-three patients experienced shoulder pain (97% prevalence). Demographic and intraoperative data were similar between the 2 groups. Average NRS for shoulder pain was higher in group P compared with group A at 8, 12, and 16 hours postoperatively (3.1 +/- 2.9, 2.6 +/- 2.6, 2.3 +/- 2.4 vs 1.8 +/- 2.6, 1.2 +/- 1.5, 1.3 +/- 1.8; P < 0.05). The total dose of hydromorphone did not differ between the 2 groups at 16, 24, and 48 hours. CONCLUSION: Acetaminophen decreases post-thoracotomy ipsilateral shoulder pain when given preemptively and regularly during the first 48 hours postoperatively in patients who received thoracic epidural analgesia.

Ultrasound-guided infraclavicular versus supraclavicular block.

In this prospective study we compared ultrasound-guided (USG) infraclavicular and supraclavicular blocks for performance time and quality of block. We hypothesized that the infraclavicular approach would result in shorter performance times with a quality of block similar to that of the supraclavicular approach. Eighty patients were randomized into two equal groups: Group I (infraclavicular) and Group S (supraclavicular). All blocks were performed using ultrasound visualization with a 7.5-MHz linear probe and neurostimulation. The anesthetic mixture consisted of 0.5 mL/kg of bupivacaine 0.5% and lidocaine hydrocarbonate 2% (1:3 vol.) with epinephrine 1:200,000. Sensory block, motor block, and supplementation rates were evaluated for the musculocutaneous, median, radial, and ulnar nerves. Surgical anesthesia without supplementation was achieved in 80% of patients in group I compared with 87% in Group S (P = 0.39). Supplementation rates were significantly different only for the radial territory: 18% in Group I versus 0% in group S (P = 0.006). Block performance times were not different between groups (4.0 min in Group I versus 4.65 min in Group S; P = 0.43). Technique-related pain scores were not different between groups (I: 2.0; S: 2.0; P = 1.00). We conclude that USG infraclavicular block is at least as rapidly executed as USG supraclavicular block and produces a similar degree of surgical anesthesia without supplementation.

Cisatracurium pharmacodynamics in patients with oculopharyngeal muscular dystrophy.

The pharmacodynamics of muscle relaxants in patients with oculopharyngeal muscular dystrophy (OPMD) have never been studied. We designed this study to compare the pharmacodynamics of cisatracurium in OPMD patients versus a control group. Forty patients were enrolled: 20 OPMD patients requiring general anesthesia for cricopharyngeal myotomy and 20 age-matched controls undergoing an operation of similar duration and expected blood loss. Anesthesia was standardized, and both groups received a bolus of cisatracurium 0.1 mg/kg. Onset time, time to 10% T1 recovery, and the intervals 10%-25% and 25%-75% were calculated for both groups. A subgroup analysis was performed in patients with a more severe form of OPMD. Demographic and intraoperative data were similar. Onset time was significantly longer in OPMD patients compared with the control group (4.6 +/- 1.5 min versus 3.4 +/- 1.0 min; P = 0.001). There was no difference in recovery times or indices between groups, regardless of the severity of the disease. In conclusion, there was no difference in the duration of a cisatracurium-induced neuromuscular block between OPMD patients and a control group. A delayed onset of action of the drug may occur.

Cisatracurium-induced neuromuscular blockade is affected by chronic phenytoin or carbamazepine treatment in neurosurgical patients.

The effect of chronic anticonvulsant therapy (CAT) on the maintenance and recovery profiles of cisatracurium-induced neuromuscular blockade has not been adequately studied. In this study, we compared the pharmacokinetics and pharmacodynamics of cisatracurium after a prolonged infusion in patients with or without CAT. Thirty patients undergoing intracranial surgery were enrolled in the study: 15 patients under CAT (carbamazepine and phenytoin, Group A) and 15 controls receiving no anticonvulsant therapy (Group C). Anesthesia was standardized and both groups received a bolus of cisatracurium followed by an infusion to maintain a 95% twitch depression. A steady-state was obtained and the infusion was kept constant for 2 additional hours. Neuromuscular blockade was then allowed to spontaneously recover. Blood samples were taken for measurement of cisatracurium plasma concentration during the steady-state period (Cp(ss)95) and at various times during recovery. Demographic and intraoperative data were similar. CAT resulted in faster 25% and 75% recovery of the first twitch. The rate of infusion of cisatracurium needed to maintain a 95% twitch depression at steady-state was 44% faster in Group A (P < 0.001). The clearance of cisatracurium was significantly faster in Group A when compared with Group C (7.12 +/- 1.87 versus 5.72 +/- 0.70 L . kg(-1) . min(-1), P = 0.01). The Cp(ss)95 was also significantly larger in Group A (191 +/- 45 versus 159 +/- 36 ng/mL, P = 0.04). In addition, patients receiving CAT had a 20% increase in the clearance of cisatracurium that, in turn, resulted in a faster recovery of neuromuscular blockade after an infusion of the drug. Also, patients under CAT had a 20% increase in their Cp(ss)95, indicating an increased resistance to the effect of cisatracurium.

Bilateral sixth cranial nerve palsy after unintentional dural puncture.

PURPOSE: Bilateral sixth nerve palsy is a known though uncommon complication following dural puncture. The recommended treatment consists of hydration and alternate monocular occlusion. The value and the timing of an epidural blood patch (EBP) for sixth nerve palsy remains controversial as some authors have demonstrated benefits in performing an EBP early in course of the nerve palsy whereas others have not found any advantage when an EBP was performed later. CLINICAL FEATURES: A 40-yr-old woman developed bilateral sixth nerve palsy ten days after an unintentional dural puncture. An EBP was done within 24 hr after the onset of the symptoms and immediate improvement of the diplopia was noted by the patient and confirmed by an ophthalmologist. Complete resolution of the diplopia occurred 36 days after the dural puncture. CONCLUSION: Blood patching within 24 hr of the onset of diplopia may be a reasonable treatment for ocular nerve palsy as it relieved the postdural puncture headache and produced partial improvement of the diplopia.

The effect of propofol sedation on the intracranial pressure of patients with an intracranial space-occupying lesion.

The fear of producing CO(2) retention and a secondary increase of intracranial pressure (ICP) sometimes precludes the use of sedation for the spontaneously breathing patient in the presence of an intracranial space-occupying lesion. In this study we assessed the effect of moderately deep propofol sedation on the ICP of patients undergoing stereotactic brain tumor biopsy under regional anesthesia. Thirty patients were randomized into 2 groups to receive propofol titrated to a level of 2 on the Observer's Assessment of Alertness/Sedation Scale or no sedation. ICP was measured via the biopsy needle. Preoperative data were similar in both groups. During surgery, patients receiving propofol had a higher arterial Pco(2) (48 +/- 8 mm Hg versus 41 +/- 3 mm Hg; P = 0.005) (95% confidence interval, 43-53 mm Hg and 39-43 mm Hg, respectively), resulting in a lower arterial pH (P = 0.002) than patients in the no-sedation group. The median ICP (95% confidence interval) for both groups was similar-13 mm Hg (8.2-16.2 mm Hg) and 15 mm Hg (8.3-21.7 mm Hg)-for the propofol and no-sedation groups, respectively (P = 0.66). Cerebral perfusion pressure was lower in the propofol group (76 +/- 18 mm Hg versus 89 +/- 18 mm Hg; P = 0.003). Moderately deep propofol sedation does not result in a higher ICP than no sedation in patients undergoing stereotactic brain tumor biopsy. Further studies are needed to assess the effect on ICP of other sedative medications.

Acute postoperative pain in lung transplant recipients.

BACKGROUND: This retrospective study was designed to assess the quality of postoperative pain control and the facility of transition from epidural to oral analgesia in lung transplant recipients. METHODS: After institutional review board approval, data were collected from the charts of all patients who underwent lung transplantation at our institution between 1998 and 2002. The study group consisted of the patients for whom an epidural was the first postoperative pain management modality. To serve as a control group we reviewed the charts of 30 patients, randomly selected over the same period, who underwent a thoracotomy for indications other than transplantation and who received postoperative epidural analgesia. RESULTS: Eighty-three patients were available for analysis. Unilateral and bilateral lung transplant recipients had equivalent quality of pain control. However, lung transplant recipients had a lower incidence of adequate pain relief than patients undergoing thoracotomy for other indications (73% vs 87%, p < 0.05). Lung transplant recipients also had a higher incidence of epidural to oral analgesia transition failure (47% vs 20%, p < 0.01). CONCLUSIONS: This is the first study to assess the quality of postoperative pain control and success of transition from epidural to oral analgesia in lung transplant recipients. Prospective studies are needed to assess the impact of our findings on patients' outcome.