The effects of active warming on patient temperature and pain after total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is a procedure with associated risks of inadvertent perioperative hypothermia and significant postoperative pain. Hypothermia may affect patients' experience of postoperative pain, although the link is not well understood. OBJECTIVE: The aim of this prospective, randomized controlled trial was to determine the efficacy of a patient-controlled active warming gown in optimizing patients' perioperative body temperature and in diminishing postoperative pain after TKA. METHODS: Thirty patients who would be undergoing TKA received either a standard hospital gown and prewarmed standard cotton blanket (n = 15) or a patient-controlled, forced-air warming gown (n = 15). RESULTS: Although pain scores were not significantly different in the two groups (P = 0.08), patients who received warming gowns had higher temperatures (P < 0.001) in the postanesthesia care unit, used less opioid (P = 0.05) after surgery, and reported more satisfaction (P = 0.004) with their thermal comfort than did patients who received standard blankets. These findings indicate that patient-controlled, forced-air warming gowns can enhance perioperative body temperature and improve patient satisfaction. Patients who use warming gowns may also need less opioid to manage their postoperative pain. CONCLUSIONS: Nurses should ensure that effective patient warming methods are employed in all patients, particularly in patients with compromised thermoregulatory systems (such as older adults), and in surgeries considered to be exceptionally painful (such as TKA).

Hyperbaric spinal for elective Cesarean section--ropivacaine vs bupivacaine.

PURPOSE: To compare hyperbaric spinal ropivacaine to hyperbaric spinal bupivacaine for elective cesarean delivery in a prospective, randomized, double blinded study. METHODS: With the University Ethics Committee approval, 66 parturients for elective cesarean deliveries received either 15 mg of hyperbaric ropivacaine (N = 33) or 11.25 mg of hyperbaric bupivacaine (N - 33) with 0.1 mg of preservative-free morphine and 0.01 mg fentanyl. The sensory and motor blockades were assessed at 3, 6, and 9 min after injection. The APGAR scores, umbilical cord gases, intra-operative side effects and the total duration of motor and sensory blockade, were recorded. RESULTS: The two groups had similar demographics, and similar times for sensory block to T6 and Bromage score 3 motor blockade. The median levels of sensory blockade were T3 and T2 for the ropivacaine and bupivacaine groups respectively. Duration of sensory block was shorter in the ropivacaine group (174 +/- 24 min vs 217 +/- 46 min; P < 0.001). Duration of motor block was shorter in the ropivacaine group (85 +/- 26 vs 159 +/- 56 min; P < 0.001). The obstetricians rated intra-operative anesthesia as excellent in both groups. None of neonates had Apgar scores less than 7. There was no difference in cord gases between the two groups. Side effects did not differ between the two groups. The ropivacaine patients expressed significantly higher satisfaction levels (P < 0.016). DISCUSSION: 15 mg of hyperbaric ropivacaine with 0.1 mg morphine and 0.01 mg fentanyl provided excellent anesthesia for cesarean delivery. The advantages of hyperbaric ropivacaine consist of faster regression of the block and higher patient satisfaction.

Effects of anesthesia on pain after lower-limb amputation.

OBJECTIVE: To evaluate the effects of epidural, spinal, and general anesthesia on pain after lower-limb amputation. DESIGN: Cross-sectional survey. SETTING: Postamputation clinic. PATIENTS: 150 patients who were evaluated one to 24 months after their lower-limb amputation. INTERVENTIONS: Patients received epidural, spinal, or general anesthesia for their amputation. MEASUREMENTS: Standardized questions were used to assess stump pain, phantom sensation, or phantom limb pain preoperatively and postoperatively. Pain intensity was assessed on a verbal rating scale of 0 to 10. After the interview, each patient's medical history and anesthetic record were assessed. RESULTS: Patients who had received epidural anesthesia and those who had received spinal anesthesia recalled significantly less pain in the week after their surgery (P < 0.05). After an average of 14 months, there was no difference in stump pain, phantom limb sensation, or phantom limb pain between patients who received epidural anesthesia, those who received spinal anesthesia, and those who received general anesthesia for their amputation. Phantom limb pain continued to be frequent and severe despite patients' use of opioid analgesics, amitriptyline, and gabapentin. CONCLUSIONS: Patients who received epidural anesthesia and those who received spinal anesthesia recalled better analgesia in the first week after their amputation than did patients who received general anesthesia. Anesthetic technique had no effect on stump pain, phantom limb sensation, or phantom limb pain at 14 months after lower-limb amputation.

Severe fetal bradycardia in a pregnant surgical patient despite normal oxygenation and blood pressure.

PURPOSE: To report and discuss a case of fetal bradycardia in a parturient under anesthesia for cholecystectomy despite normal maternal oxygenation and arterial blood pressure. CLINICAL FEATURES: A 27-yr-old woman (gravida 2 para 1), with a fetus of 34 weeks gestation, received general anesthesia for cholecystectomy. After anesthesia induction and tracheal intubation, anesthesia was maintained with oxygen, sevoflurane and iv remifentanil infusion. While preparing for surgery, the fetal heart rate decreased within about half a minute to 70 beats x min(-1) and remained at that level. The maternal blood pressure, heart rate and oxygen saturation were normal. An emergency Cesarean delivery was performed. The infant had Apgar scores of 1 at one minute, 5 at five minutes, 7 at ten minutes and required resuscitation after birth. CONCLUSION: Ideally, women having non-obstetric surgery during the third trimester of pregnancy will have intraoperative fetal heart rate monitoring.