Application of low-dose etomidate combined with oxycodone and midazolam in endoscopic injection sclerotherapy.

OBJECTIVE: To evaluate the adverse effects and particularly the anesthetic effect of low-dose etomidate combined with oxycodone and midazolam in endoscopic injection sclerotherapy. MATERIALS AND METHODS: We herein report a prospective, double-blind, randomized controlled trial. It included patients with liver cirrhosis (age, 18 - 65 years; BMI, 18 - 25 kg/m2) who were treated with endoscopic injection sclerotherapy, and the patients were randomly assigned to the propofol group or the etomidate group. The incidence of respiratory depression was the primary outcome measure. The occurrence of various adverse effects and endoscopist satisfaction score were the secondary outcome measures. RESULTS: In this study, we enrolled a total of 96 patients. The incidence of respiratory depression in the propofol group was 19%, while that in the etomidate group was only 4% (9/47 vs. 2/49; p = 0.026). Regarding the secondary outcome measures, the incidence of hypoxia in the propofol group was 15%, while that in the etomidate group was only 2% (7/47 vs. 1/49; p = 0.029). Injection-site pain occurred in 0% and 23% of the patients in the etomidate group and propofol group, respectively (p < 0.001). Endoscopist satisfaction scores were classified as "poor", "fair", "good", and "very good". The scores were 17% higher (46/49 vs. 36/47; p = 0.026) for the "very good" level and 15% lower (3/49 vs. 10/47; p = 0.038) for the "good" level in the etomidate group than in the propofol group. CONCLUSION: Low-dose etomidate combined with oxycodone and midazolam for endoscopic injection sclerotherapy could reduce the incidence of hypoxia without increasing the incidence of complications.

Effect of side guide marks of ultrasound transducer on the success rate of ultrasound transducer-guided radial artery puncture: A randomized trial.

BACKGROUND: Compared with blind technique, ultrasound (US) transducer-guided technique for radial artery puncture can improve the success rate. However, difficulty in handling US transducer-guided technology is a key limitation to its wider use. The aim of the study was to explore the effect of guide marks on the side of US transducer on the success rate of US transducer-guided radial artery puncture. METHODS: In this parallel-group trial, 127 patients undergoing elective liver cancer resection and splenectomy under general anesthesia were randomly allocated to the traditional group or the Intervention group. The traditional group used the conventional US transducer-guided radial artery puncture technology, while the Intervention group used the US transducer-guided radial artery puncture technology with the guide marks on the side of the US transducer probe. The primary observation index was success rate of radial artery cannulation at the first attempt; the secondary observation indices were failure rate of cannulation, location time, and total time for successful cannulation. RESULTS: The successful rate of cannulation in the Intervention group (59 out of 63, 93.6%) was greater than that in the traditional group (50 out of 64, 78.1%, p = 0.01). The posterior wall puncture rate in the Intervention group was lower than that in the traditional group (11.1% vs 32.8%, p = 0.005). The location time in the Intervention group was longer than that in the traditional group (20.1 ± 3.8 vs 16.6 ± 4.0 s, p < .001), while the total cannulation time was significantly shorter (20.7 ± 4.3 vs 32.4 ± 7.4 s, p < 0.001). CONCLUSION: Using guide marks on the side of US transducer can help improve success rate of US transducer-guided radial artery puncture at the first attempt and reduce the risk of puncture-related complications.

Different Doses of Oxycodone for Endoscopic Injection Sclerotherapy of Esophageal Varices.

BACKGROUND The aim of the present study was to evaluate the effects of different doses of oxycodone during endoscopic injection sclerotherapy (EIS) for esophageal varices with painless sclerosing agents. MATERIAL AND METHODS A total of 119 patients were randomly divided into 3 groups: Group A, midazolam and 0.075 mg/kg oxycodone (n=40); Group B, midazolam and 0.1 mg/kg oxycodone (n=40); and Group C, midazolam and 0.125 mg/kg oxycodone (n=39). The main observation index was the incidence of body movement during the perioperative period. The secondary indices were additional propofol usage; postoperative analgesic usage; other adverse effects, such as hypoxia, myoclonus, and cough; and satisfaction scores for surgeons and patients. RESULTS The incidence rates for body movement during the perioperative period in groups A, B, and C were 33%, 13%, and 0, respectively (P<0.001). The satisfaction scores for surgeons and patients were highest in Group C (0.125 mg/kg oxycodone). The incidence rates for hypoxia before EIS were 15%, 8%, and 33% (P=0.026) and during EIS were 23%, 3%, and 0% (P<0.001), respectively. There were no significant between-group differences with respect to other adverse effects. CONCLUSIONS The ideal dose of oxycodone for perioperative analgesia during EIS for esophageal varices is 0.125 mg/kg.

Acoustic Shadowing Facilitates Ultrasound-guided Radial Artery Cannulation in Young Children.

BACKGROUND: Arterial cannulation in young children can be challenging. Ultrasound guidance using focused acoustic shadowing may be suitable for guiding radial artery puncture in young children. The present research tested the hypothesis that ultrasound guidance using focused acoustic shadowing helps increase the success rate of radial artery cannulation in this population. METHODS: In a double-blinded, parallel-group trial, 79 young children undergoing surgery under general anesthesia were randomly assigned to two groups (1:1 ratio): the traditional ultrasound group and the novel ultrasound group. Young children in the traditional group underwent conventional ultrasound-guided radial artery puncture, whereas those in the novel ultrasound group underwent radial artery puncture guided by acoustic shadowing ultrasound with double developing lines. All radial artery punctures were performed using the short-axis out-of-plane approach. The primary endpoint was the success rate of cannulation at the first attempt. The secondary endpoints included cannulation failure rate, ultrasound location time, and puncture time. RESULTS: The success rate of cannulation at the first attempt in the novel ultrasound group (35 of 39 [90%]) was significantly higher than that in the traditional ultrasound group (24 of 40 [60%]; difference: 30% [95% CI, 12 to 48%], P =0.002). None of the patients in the ultrasound with acoustic shadowing group experienced failure of radial artery puncture and cannulation. The ultrasound location time and puncture time in the ultrasound acoustic shadowing group were significantly lower than that in the traditional ultrasound group (location time: median [interquartile range]: 6 [5, 8] vs. 18 [15, 21] s; puncture time: 24 [15, 41] vs. 40 [23, 56] s). CONCLUSIONS: Acoustic shadowing via the use of double developing lines significantly improved the success rate of radial artery puncture in young children, compared with that achieved with the use of traditional ultrasound guidance.

Analgesic Effects of Oxycodone Relative to Those of Sufentanil, in the Presence of Midazolam, During Endoscopic Injection Sclerotherapy for Patients With Cirrhosis and Esophageal Varices.

BACKGROUND: We evaluated the efficacy and gastroenterologist/patient satisfaction of midazolam combined with oxycodone, relative to that of midazolam combined with sufentanil, for anesthesia during endoscopic injection sclerotherapy (EIS) in patients with cirrhosis and esophageal varices. METHODS: Patients with cirrhosis (20-69 years of age), body mass index, 18-25 kg/m, American Society of Anesthesiology patient classification physical status I-II who underwent elective EIS were randomly assigned to 1 of 2 groups. In this prospective, double-blinded, randomized controlled trial, 1 group received midazolam and oxycodone (n = 64), and the other group received midazolam and sufentanil (n = 63). Primary and secondary outcome measures were compared between groups. The primary outcome measure was the incidence of hypoxia. Secondary outcome measures included perioperative limb movement, need for rescue analgesics, need for additional sedative propofol, specified adverse reactions (postoperative myoclonus, nausea, vomiting, dizziness, and drowsiness), gastroenterologist satisfaction, and patient satisfaction with postoperative analgesia. RESULTS: Patients in the midazolam-oxycodone group had 32% fewer episodes of hypoxia than did those in the midazolam-sufentanil group (95% confidence interval [CI], -45% to -18%; P < .001), 36.73% fewer perioperative limb movements (95% CI, -51.73% to -21.73%; P < .001), 19.12% fewer required rescue analgesics (95% CI, -30.85% to -7.40%; P = .002), and less propofol requirement in the perioperative period (before EIS, -17.83%; 95% CI, -33.82% to -1.85%; P = .003; throughout EIS, -36.73%; 95% CI, -51.73% to -21.73%; P < .001). The incidence rates for adverse reactions were similar between groups. Both the gastroenterologist and patients reported higher degrees of satisfaction with oxycodone than with sufentanil. CONCLUSIONS: Oxycodone in combination with midazolam may provide an anesthetic technique that results in fewer episodes of hypoxia and other adverse conditions during EIS.

Large doses of uterotonic drugs caused type II second degree sinoatrial block during cesarean section.

In China, it is a routine procedure to inject 250 µg of hemabate (sterile solution, an oxytocic, contains the tromethamine salt of the (I5S)-15 methyl analogue of naturally occurring prostaglandin F2α in a solution suitable for intramuscular injection) into the myometrium of patients experiencing uterine inertia after delivery, with an additional dose given in the event that the efficacy is not obvious. Although hemabate is prohibited from being used in patients with active liver disease, there are no restrictions regarding the application of hemabate in positive hepatitis B surface antigen (HbsAg)-positive subjects with normal liver function. Here we report adverse effects of hemabate in 1 HbsAg-positive subject with normal liver function. This subject experienced increased blood pressure, chest tightness, and type II second degree sinoatrial block 25 minutes after an additional injection of hemabate. Thus, special attention should be paid when applying hemabate in HbsAgpositive subjects with normal liver function.

Combined use of hyperbaric and hypobaric ropivacaine significantly improves hemodynamic characteristics in spinal anesthesia for caesarean section: a prospective, double-blind, randomized, controlled study.

PURPOSE: To observe the hemodynamic changes of parturients in the combined use of hyperbaric (4 mg) and hypobaric (6 mg) ropivacaine during spinal anesthesia for caesarean section in this randomized double-blind study. METHODS: Parturients (n = 136) undergoing elective cesarean delivery were randomly and equally allocated to receive either combined hyperbaric and hypobaric ropivacaine (Group A) or hyperbaric ropivacaine (Group B). Outcome measures were: hemodynamic characteristics, maximum height of sensory block, time to achieve T8 sensory blockade level, incidence of complications, Apgar scores at 1 and 5 min, and neonatal blood gas analysis. RESULTS: Group A had a lower level of sensory blockade (T6 [T6-T7]) and longer time to achieve T8 sensory blockade level (8 ± 1.3 min) than did patients in Group B (T3 [T2-T4] and 5 ± 1.0 min, respectively; P < 0.001, both). The incidence rates for hypotension, nausea, and vomiting were significantly lower in Group A (13%, 10%, and 3%, respectively) than Group B (66%, 31%, and 13%; P < 0.001, P = 0.003, P = 0.028). CONCLUSIONS: Combined use of hyperbaric (4 mg) and hypobaric (6 mg) ropivacaine significantly decreased the incidences of hypotension and complications in spinal anesthesia for caesarean section by extending induction time and decreasing the level of sensory blockade. TRIAL REGISTRATION: Chinese Clinical Trial Register ChiCTR-TRC-13004622.

Effective analgesic dose of dexamethasone after painless abortion.

BACKGROUND AND PURPOSE: Dexamethasone is known to produce analgesic effects, but the optimal analgesic dosage of dexamethasone remains unclear, especially in patients without postoperative use of other analgesics. The purpose of this study was to explore the effective analgesic dose of dexamethasone in day surgery patients undergoing painless abortion. METHODS: 287 patients undergoing painless abortion were randomly assigned to one of four groups: control group receiving saline and dexamethasone groups receiving 0.1, 0.15, or 0.2 mg/kg dexamethasone. Drugs were intravenously injected 30 min before induction of anesthesia. All patients underwent the same anesthesia procedure using propofol and remifentan. The visual analogue scale (VAS) scores and occurrence of nausea, vomiting and drug-induced side effects were recorded at 1, 2 and 24 h after operation. RESULTS: There were no significant differences in patient's clinical characteristics, surgical features and frequency of occurrence of nausea and vomiting among the four groups (P > 0.05). The VAS scores at rest and during coughing at 2 h after operation (time of discharge from the hospital) were significantly lower in patients receiving 0.2 mg/kg dexamethasone compared with control patients (P < 0.05). CONCLUSION: Intravenous injection of 0.2 mg/kg dexamethasone before induction of anesthesia can significantly reduce the VAS scores at 2 h after painless abortion.

Modified short-axis out-of-plane ultrasound versus conventional long-axis in-plane ultrasound to guide radial artery cannulation: a randomized controlled trial.

BACKGROUND: Currently, short-axis out-of-plane (SA-OOP) and long-axis in-plane (LA-IP) ultrasound techniques are used to guide radial artery cannulation. In this study, we compared the success rate of a modified SA-OOP technique with that of traditional LA-IP. METHODS: One hundred sixty-four patients who were to undergo liver surgery or splenic resection under general anesthesia were included. Using a sealed envelope method, patients were randomly divided into 2 groups: the modified SA-OOP or the LA-IP ultrasound guidance approaches. The number of cannula insertion attempts until success was recorded in both groups. The primary end point to compare the groups was the rate of cannula insertion successes on the first attempt. The secondary end points were also recorded and compared: insertion failure rate, inner diameter of the radial artery, depth of artery from the skin, ultrasonic location time, cannulation time, and vascular complications including thrombosis, hematoma, edema, and vasospasm. RESULTS: The cannula insertion success rate on the first attempt was significantly higher in the modified SA-OOP group compared with the LA-IP group (proportion difference 15.7%, 95% confidence interval [CI], 0.6%-30.7%, P = 0.0158). However, the insertion failure rate was not different between groups (95% CI, -17.7% to 12.8%, P = 0.4969). The ultrasonic location time was significantly decreased in the modified SA-OOP group compared with the LA-IP group (mean difference -9.5 seconds, 95% CI, -10.6 to -8.5 seconds, P < 0.0001). However, there was no significant difference between groups for cannulation time (95% CI, -0.6 to 7.6 seconds, P = 0.1152), depth of artery (95% CI, -0.07 to 0.57 mm, P = 0.1050), and the diameter of the radial artery (95% CI, -0.30 to 0.03 mm, P = 0.1153). CONCLUSION: The modified SA-OOP technique may improve the success rate of cannula insertion into the radial artery on the first attempt.

Influence of lateral decubitus positioning after combined use of hyperbaric and hypobaric ropivacaine on hemodynamic characteristics in spinal anesthesia for caesarean section.

PURPOSE: Positioning of the patient during and after surgery can have significant implications on recovery. Therefore, the purpose of the present study was to determine the influence of placing patients in a lateral decubitus position for 15 min after combined use of hyperbaric and hypobaric ropivacaine and assess hemodynamic characteristics during spinal anesthesia for caesarean section. METHODS: One hundred-forty patients undergoing elective cesarean delivery with combined use of hyperbaric and hypobaric ropivacaine were included in the present study. Patients meeting inclusion criteria (134) were randomly allocated into Group A: immediately turned to the supine position after induction of spinal anesthesia (n = 67) or Group B: maintained in a lateral decubitus position for 15 min before being turned to the supine position (n = 67). Primary endpoints of the study were to compare hemodynamic characteristics and sensory blockade levels in the two groups, while a secondary endpoint was to observe the incidence of complications. RESULTS: Both groups showed similar effects of the combined anesthetic treatment. Incidence of hypotension (43% vs 18%, P = 0.001), systolic AP < 90 mmHg (36% vs. 16%, P = 0.011), usage of ephedrine (43% vs. 18%, P = 0.001) and the total dose of ephedrine [0 (0-24) vs 0 (0-18), P = 0.001] were significantly higher in Group A compared to Group B. Group A had a higher incidence of nausea compared to Group B (25% vs 7%, P = 0.005). CONCLUSIONS: Combined use of hyperbaric and hypobaric ropivacaine had satisfactory anesthetic effects and a more stable hemodynamic characteristic than either drug used alone. Maintaining the patient in a lateral decubitus position for 15 min can significantly decrease the incidence of hypotension.

Influence of phenylephrine or ephedrine on maternal hemodynamics upon umbilical cord clamping during cesarean delivery.

BACKGROUND AND OBJECTIVE: Vasopressors ephedrine and phenylephrine are commonly used with spinal anesthesia during cesarean delivery. Studies on them have focused on the period before the umbilical cord is clamped, although anesthesia is continuously administered throughout and after this event. This study aimed to compare the effects of these drugs on maternal hemodynamics at and after clamping of the umbilical cord. STUDY DESIGN: Prospective, randomized, double-blind study. SETTING: Parturients (n = 60) scheduled for elective cesarean delivery were randomly divided into an ephedrine group and a phenylephrine group. Each woman received an intrathecal injection of bupivacaine (7.5 mg). MEASUREMENTS: Patients in the ephedrine and phenylephrine groups were infused continuously with ephedrine (0.02 mg×kg-1×min-1) or phenylephrine (0.25 µg×kg-1×min-1), respectively, from immediately after the injection of bupivacaine until termination 10 minutes after the umbilical cord was clamped (the endpoint). Hemodynamic changes were recorded. RESULTS: After clamping the umbilical cord, the patients who were administered ephedrine experienced significant increases in heart rate (89 ± 11 beats/min to 106 ± 15 beats/min), cardiac output (6.4 ± 0.9 l/min to 7.6 ± 1.2 l/min) and cardiac index (3.5 ± 0.39 l×min-1×m-2 to 4.3 ± 0.48 l×min-1×m-2), while the systemic vascular resistance decreased (908 ± 296 dyne·s/cm5 to 711 ± 285 dyne·s/cm5). Such differences were not observed in the patients who received phenylephrine. Moreover, the heart rate of patients administered ephedrine was higher than that of patients given phenylephrine after clamping the umbilical cord. CONCLUSION: Continuous infusion of phenylephrine during cesarean delivery maintains a stable maternal hemodynamic status better than ephedrine.