Preemptive analgesic effects of ketorolac in ankle fracture surgery.

BACKGROUND: Preemptive analgesia has been difficult to show in human experiments. If ketorolac has preemptive effects, then there may be an advantage to administering it at the beginning of surgery despite the potential for increased blood loss. METHODS: The authors performed a randomized, double-blind, controlled trial of 48 patients scheduled for ankle fracture surgery in a county trauma hospital. Anesthesia management was standardized and included adequate opioid analgesia (5 microg/kg fentanyl and 0.1 mg/kg morphine). Intravenous 30 mg ketorolac was administered to 23 patients before tourniquet inflation and to 25 patients after tourniquet inflation. Visual analog scale pain scores, morphine patient-controlled analgesia consumption, nausea-vomiting, and postoperative bleeding were measured. RESULTS: The 23 patients given ketorolac before tourniquet inflation had no increase in pain postoperatively compared with their preoperative baseline (P = 0.280). The 25 patients who received ketorolac minutes later after tourniquet inflation had significant increases in their postoperative pain compared with their preoperative baseline (P = 0.00116). This effect was short-lived, and by 6 h the pain score in this group was not significantly more than it was preoperatively. Intergroup comparison showed a lower visual analog scale score at 2 (P = 0.0203) and 4 h (P = 0.00549) in the preemptive group and lower nausea scores at hour 6 (P = 0.00704). There was no difference in patient-controlled analgesia consumption between groups. CONCLUSIONS: Intravenous 30 mg ketorolac appears to have preemptive analgesic effects in patients undergoing ankle fracture repair. Ketorolac administered before tourniquet inflation prevents postoperative pain being perceived as more intense than preoperative pain.

Tracheal extubation of adult surgical patients while deeply anesthetized: a survey of United States anesthesiologists.

STUDY OBJECTIVE: To examine current practice regarding the performance of tracheal extubation of adult surgical patients while deeply anesthetized (deep extubation). DESIGN AND SETTING: Survey comprised of an anonymous written questionnaire mailed to 1,000 randomly selected active American Society of Anesthesiologists members. MEASUREMENTS AND MAIN RESULTS: Questionnaires were mailed between February and April 1998. Five hundred eighty-three completed forms were returned, 538 of which were suitable for data analysis. Responses from anesthesiologists who infrequently or never administer general anesthetics to adult surgical patients were excluded. The overall frequency of deep extubation of adults was "never" for 106 respondents (19.7%), "rarely" for 87 (16.2%), and "more frequently" for 345 (64.1%). The most common reasons for never performing deep extubations were lack of necessity and concern regarding potential laryngospasm and aspiration. The most frequent indications for deep extubations were unclipped intracranial aneurysm, reactive airway disease, and open-globe eye surgery. The most frequent contraindications to deep extubations for those who otherwise perform the technique were difficult airway, aspiration risk, and obesity. After performing a deep extubation, 44.0% of respondents remain with the patient in the operating room until he or she is awake. Deep extubations were perceived to have no consistent effect on operating room turnover time by 61.6% of anesthesiologists who perform them. CONCLUSIONS: Most anesthesiologists in this survey perform deep extubations in adult surgical patients. Lack of necessity and potential respiratory complications were the main reasons cited by those who do not use the technique. Future investigations are necessary to examine the risk-to-benefit ratio of the technique in adults. Our results may be used to determine which potential indications should be examined in such studies and to help delineate the standard of care followed in this country.

Postpartum plasma exchange for atypical preeclampsia-eclampsia as HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

OBJECTIVE: Our purpose was to investigate the postpartum use of plasma exchange in patients considered to have atypical preeclampsia-eclampsia manifested as persistent HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome with or without evidence of other organ injury. STUDY DESIGN: During a 10-year period, 18 patients with HELLP syndrome were treated post partum with single or multiple plasma exchange with fresh-frozen plasma. Each patient was entered into the clinical trial either because of persistent evidence of atypical preeclampsia-eclampsia as HELLP syndrome > 72 hours after delivery (group 1) or with evidence of worsening HELLP syndrome at any time post partum in association with single- or multiple-organ injury (group 2). All procedures were performed with the IBM 2997 Cell Separator (IBM, Cobe Laboratories, Inc., Lakewood, Colo.) system. Maternal and perinatal outcomes were the main outcomes studied. RESULTS: In the absence of other disease conditions, the 9 patients in group 1 with persistent postpartum HELLP syndrome complicated only by severe clinical expressions of preeclampsia-eclampsia responded rapidly to one or two plasma exchange procedures with few complications and no maternal deaths. In contrast, in the 9 patients of group 2 with HELLP syndrome presentations complicated by other organ disease, the response to plasma exchange was variable and there were two deaths in this group. CONCLUSION: The current series of patients details the successful postpartum application of plasma exchange therapy for unremitting HELLP syndrome but reveals that a uniformly positive response to this therapy will not always be observed when there is additional single or multiple organ injury.

Oxygenation and ventilation characteristics of thoracic surgical patients the night before surgery.

Studies of the respiratory effects of perioperative analgesic and anesthetic agents are complicated by evidence that healthy subjects and those with COPD may have abnormalities of oxygenation and ventilation during sleep. This report thus characterizes respiration during sleep preoperatively in a population frequently examined in postoperative analgesia studies. Sixty-two thoracic surgical patients were monitored by continuous respiratory inductive plethysmography, 49 of whom also had continuous pulse oximetry and bi-hourly blood gas measurements. The mean respiratory rate (RR) at each hour during sleep was similar to the awake RR (P > 0.06). The minimum RR during sleep was 7.6 +/- 2.1 (2.6-9.8; median 7.9). At least 1 apnea (tidal volume < 100 mL for > or = 15 sec) occurred in 77% of subjects, and 32% had > or = 1 slow respiratory rate (SRR; 5-min RR < 10 beats/min) episode. The mean SpO2 for hours 2 to 4 was significantly less than while awake (P < 0.0015), but the differences were < or = 1.1%. The minimum SpO2 was 88 +/- 7% (62-97; 89) and 40% of subjects had > or = 1 desaturation (DESAT90; SpO2 < 90% for > or = 15 sec) episode. The pH at hours 2 and 4 was significantly (P < 0.0009) less than while awake, but the differences were only 0.02. Other bi-hourly pH, PaCO2, and PaO2 values were similar to the awake values (P > 0.02). Interpatient variability was high, especially for episodic abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of postbypass bleeding with tranexamic acid and epsilon-aminocaproic acid.

In this institution, two antifibrinolytic agents have been in routine use before cardiopulmonary bypass (CPB) to prevent bleeding due to fibrinolysis; epsilon-aminocaproic acid (EACA) or tranexamic acid (TA) are administered as intravenous infusions over 2 hours, from the time of anesthetic induction until the onset of CPB. TA is 10 times more potent and binds more strongly to plasminogen than EACA. Data were collected retrospectively on 411 patients undergoing first-time coronary artery bypass grafting with cardiopulmonary bypass who had received one of four therapy regimens: 10 g of EACA (65 patients), 15 g of EACA (60 patients), 6 g of TA (100 patients), or 10 g of TA (75 patients). Patients who did not receive any drug (91) served as controls. Anesthetic technique and the heparin/protamine protocol did not differ. Blood collected by mediastinal and pleural tubes was autotransfused up to 6 hours postoperatively. Both TA and EACA reduced post-CPB bleeding in the first 24 hours. Ten grams of TA was the most effective, resulting in a 52% and 36% reduction in blood loss over controls at 6 and 24 hours, respectively. Although 10 g of TA was more effective than 6 g of TA in blood loss control for the first 6 hours, the difference was not significant at 24 hours. A significantly lower number of patients in the 10 g TA group received blood products than in control (28% v 49%) patients (P = 0.02). Pretreatment with 10 g of TA prevented excessive (over 750 mL in 6 hours) bleeding after CPB.

Hypoxaemia in adults in the post-anaesthesia care unit.

Continuous pulse oximetry was performed on 173 adults after general anaesthesia for elective inpatient surgery, throughout their post-anaesthesia care unit (PACU) stay. Supplemental oxygen was administered for greater than or equal to 30 min after arrival and subsequently discontinued before discharge to the ward. The mean and minimum oxyhaemoglobin saturation (SpO2) after discontinuing oxygen were lower than those values achieved during oxygen administration and preoperatively (P less than 0.001). At least one hypoxaemic episode (SpO2 less than or equal to 90% for greater than or equal to 15 sec) occurred in 70 subjects (41%) and 45 of these had a moderate-severe episode (SpO2 greater than or equal to 90% for less than or equal to 2 min or SpO2 less than or equal to 85%). The hypoxaemic episodes began 20 +/- 20 min (range 1-100; median 15) after discontinuing supplemental oxygen. Cyanosis was detected in only four of the 70 patients who desaturated. Factors associated with hypoxaemia were: ASA physical status class; surgical duration greater than or equal to 90 min; and preoperative mean SpO2 less than 95%. Factors not associated with hypoxaemia were: age, sex, % ideal body weight, smoking history, preoperative minimum SpO2, premedication and type of surgery. In conclusion, after discontinuing supplemental oxygen in the PACU, hypoxaemia was common, difficult to detect clinically, and associated with ASA class, surgical duration and preoperative mean SpO2.

Plasma exchange for preeclampsia. I. Postpartum use for persistently severe preeclampsia-eclampsia with HELLP syndrome.

The postpartum use of plasma exchange with fresh-frozen plasma was assessed in a group of seven women with severe preeclampsia-eclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) that persisted greater than 72 hours after delivery. During the study interval in which a total of 107 gravid women with HELLP syndrome were seen in our referral center, these seven patients (6.5%) demonstrated persistent thrombocytopenia (platelet count usually less than 30,000/mm3), rising lactic dehydrogenase (greater than 1000 IU/L) and evidence of multiorgan dysfunction. The seven case histories emphasize the variety of clinical and laboratory profiles that can be encountered in this small group of gravid women at risk for severe morbidity or mortality. Up to three 3 L plasma exchanges were required to effect permanent disease arrest and reversal. Utilization of the IBM 2997 Cell Separator system permitted bedside performance of procedures with enhanced convenience and optimal medical management. Successful plasma exchange was associated with (1) sustained increases in the mean platelet count at 24, 48, and 72 hours that were 2.2, 3.6, and 4.5 times the preexchange platelet counts and (2) a decreasing trend in lactic dehydrogenase concentrations below 1000 IU/L within 48 hours of exchange plasmapheresis. The current series of patients supports our recommendation that a trial of plasma exchange(s) with fresh-frozen plasma be considered for treatment of the infrequent postpartum case of HELLP syndrome that fails to abate within 72 hours of delivery and in which other evidence develops of an ongoing, widespread, and life-threatening thrombotic microangiopathy.