[Simulation of difficult airway management for residents: prospective comparative study]. / Simulação de manejo de via aérea difícil para residentes: estudo comparativo prospectivo.

BACKGROUND AND OBJECTIVES: Procedural simulation training for difficult airway management offers acquisition opportunities. The hypothesis was that 3 hours of procedural simulation training for difficult airway management improves: acquisition, behavior, and patient outcomes as reported 6 months later. METHODS: This prospective comparative study took place in two medical universities. Second-year residents of anesthesiology and intensive care from one region participated in 3h procedural simulation (intervention group). No intervention was scheduled for their peers from the other region (control). Prior to simulation and 6 months later, residents filled-out the same self-assessment form collecting experience with different devices. The control group filled-out the same forms simultaneously. The primary endpoint was the frequency of use of each difficult airway management device within groups at 6 months. Secondary endpoints included modifications of knowledge, skills, and patient outcomes with each device at 6 months. Intervention cost assessment was provided. RESULTS: 44 residents were included in the intervention group and 16 in the control group. No significant difference was observed for the primary endpoint. In the intervention group, improvement of knowledge and skills was observed at 6 months for each device, and improvement of patient outcomes was observed with the use of malleable intubation stylet and Eschmann introducer. No such improvement was observed in the control group. Estimated intervention cost was 406€ per resident. CONCLUSIONS: A 3h procedural simulation training for difficult airway management did not improve the frequency of use of devices at 6 months by residents. However, other positive effects suggest exploring the best ratio of time/acquisition efficiency with difficult airway management simulation. CLINICALTRIALS. GOV IDENTIFIER: NCT02470195.

Simulation of difficult airway management for residents: prospective comparative study / Simulação de manejo de via aérea difícil para residentes: estudo comparativo prospectivo

Abstract Background and objectives Procedural simulation training for difficult airway management offers acquisition opportunities. The hypothesis was that 3 hours of procedural simulation training for difficult airway management improves: acquisition, behavior, and patient outcomes as reported 6 months later. Methods This prospective comparative study took place in two medical universities. Second-year residents of anesthesiology and intensive care from one region participated in 3 h procedural simulation (intervention group). No intervention was scheduled for their peers from the other region (control). Prior to simulation and 6 months later, residents filled-out the same self-assessment form collecting experience with different devices. The control group filled-out the same forms simultaneously. The primary endpoint was the frequency of use of each difficult airway management device within groups at 6 months. Secondary endpoints included modifications of knowledge, skills, and patient outcomes with each device at 6 months. Intervention cost assessment was provided. Results 44 residents were included in the intervention group and 16 in the control group. No significant difference was observed for the primary endpoint. In the intervention group, improvement of knowledge and skills was observed at 6 months for each device, and improvement of patient outcomes was observed with the use of malleable intubation stylet and Eschmann introducer. No such improvement was observed in the control group. Estimated intervention cost was 406€ per resident. Conclusions A 3 h procedural simulation training for difficult airway management did not improve the frequency of use of devices at 6 months by residents. However, other positive effects suggest exploring the best ratio of time/acquisition efficiency with difficult airway management simulation. ClinicalTrials.gov Identifier NCT02470195.

Resumo Justificativa e objetivos O treinamento em simulação para o manejo de via aérea difícil oferece oportunidades de aprendizagem. A hipótese foi que um treinamento em simulação de procedimentos de três horas, para o manejo de via aérea difícil, melhoraria o aprendizado, o comportamento e os resultados dos pacientes, conforme relatado seis meses após o treinamento. Métodos Este estudo comparativo prospectivo foi realizado em duas universidades médicas. Residentes do segundo ano de anestesiologia e terapia intensiva de uma região participaram de um curso de três horas em simulação de procedimentos (grupo intervenção). Nenhuma intervenção foi programada para seus pares da outra região (grupo controle). Antes da simulação e seis meses após, os residentes preencheram a mesma ficha de autoavaliação sobre sua experiência com diferentes dispositivos. O grupo controle preencheu os mesmos formulários simultaneamente. O desfecho primário foi a frequência de uso de cada dispositivo para o manejo de via aérea difícil dentro dos grupos aos seis meses. Os pontos de corte secundários incluíram modificações em relação ao conhecimento, às habilidades e aos resultados dos pacientes com cada dispositivo aos seis meses. A avaliação do custo da intervenção foi registrada. Resultados Foram incluídos no grupo intervenção 44 residentes e 16 no grupo controle. Nenhuma diferença significativa foi observada para o ponto de corte primário. No grupo intervenção, a melhoria do conhecimento e das habilidades foi observada aos seis meses para cada dispositivo e a melhoria dos desfechos dos pacientes foi analisada com o uso de estilete maleável e do introdutor de Eschmann para intubação. Nenhuma melhoria foi observada no grupo controle. O custo da intervenção estimado foi de 406€ por residente. Conclusões Um treinamento simulado de três horas para o manejo de via aérea difícil não melhorou a frequência do uso de dispositivos pelos residentes aos seis meses. No entanto, outros efeitos positivos sugerem a exploração da melhor relação tempo/eficiência de aquisição de conhecimento com a simulação do manejo de via aérea difícil. ClinicalTrials.gov Identifier NCT02470195.

Comparison of axillary nerve block duration using mepivacaine in non-insulin diabetic or renal insufficiency patients: a controlled observational matched multicenter trial.

BACKGROUND: Although studies in diabetic patients demonstrated delayed recovery after long-acting local anesthetic, its effects with short-acting LA remains to be determined. Using mepivacaine, the authors evaluated the duration of axillary nerve blocks in diabetic (DP), renal failure (creatinine clearance <30 mL.min-1) (RP) and healthy patients (HP). METHODS: We prospectively included consecutive patients aged 18-80 years, with DP (N.=37), RP (N.=32) and HP (N.=48) scheduled for distal upper limb surgery. Before surgery, an axillary nerve block (20 mL mepivacaine 15 mg.mL-1) was performed with an ultrasound approach combined with nerve stimulation. Five mL was injected for each nerve: median, ulnar, radial, musculocutaneous nerves. The primary endpoint measured was the duration of sensory block. For statistical analysis, each HP patient was matched with RP and DP patient (1:1), with regards to age (range±5 years) and sex. RESULTS: Patient characteristics were similar between groups. Creatinine clearance was 14±8 mL.min-1 in RP group and HbA1c (%) was 7.5±1.5 in DP group. Mean duration of diabetic or renal insufficiency illness were respectively eight and 12 years. Onset time for sensory and motor blocks were similar between groups. Average time for sensory block duration was similar between DP vs. HP (235±52 vs. 230±54 min, P=0.71); and between RP vs. HP (234±51 vs. 229±57 min, P=0.65). CONCLUSIONS: The short-acting LA (mepivacaine) are associated with similar pharmacodynamic effects in diabetic and renal failure patients as compared with healthy patients.

Incidence of postoperative delirium in elderly ambulatory patients: A prospective evaluation using the FAM-CAM instrument.

BACKGROUND: While the incidence of postoperative delirium is high in aged hospitalized patients undergoing major surgery, little is known concerning patients undergoing ambulatory surgery. OBJECTIVE: To determine the incidence of postoperative delirium in aged patients after hospital discharge from an ambulatory surgery unit. DESIGN: Prospective observational study. PATIENTS: Elderly patients (≥75 years) scheduled for a surgical procedure on an ambulatory basis. INTERVENTIONS: Filling of the Family Confusion Assessment Method (FAM-CAM) questionnaire (11 items) during a phone interview of family caregivers on two separate occasions: five to three days before surgery, and three to five days after surgery. MAIN OUTCOME MEASURES: The detection of acute onset and fluctuating course inattention, disorganized thinking, altered level of consciousness, disorientation, perceptual disturbances, and psychomotor agitation from the observations of family caregivers. RESULTS: Signs of delirium appeared de novo in 2 of 141 patients (incidence 1.4%) in the postoperative period: a 80-years old man who was disoriented and had incoherent and illogical speech on postoperative day 1 of resection of a cephalic cutaneous melanoma under local anesthesia and sedation (midazolam, sufentanil, and propofol), and a 83-years old woman with a pre-existing mental confusion, who experienced visual and hearing hallucinations and had inappropriate behaviour on postoperative day 2 of cataract surgery performed under episcleral block. Both patients returned to their preoperative states within a few days. CONCLUSIONS: Using the FAM-CAM instrument for the detection of postoperative delirium in ambulatory patients, the study showed that the incidence of cognitive changes in the ambulatory setting is very low. Among several putative factors, the lightness of the surgical procedure, the wide use of regional anesthesia, and the short hospital stay may be contributing factors to this result. The findings of this study need to be confirmed in a larger sample of patients.

Tracheal extubation with suction vs. positive pressure during emergence from general anaesthesia in adults: A randomised controlled trial.

BACKGROUND: After general anaesthesia (GA) in adults, the optimal tracheal extubation technique (positive pressure or suctioning) remains debated. The primary endpoint of this study was to assess the effects of these techniques on onset time of desaturation (SpO2<92%). METHODS: Sixty-nine patients with a body mass index<30 scheduled for elective orthopaedic surgery were allocated to positive pressure (PP) or suctioning (SUC) group. GA was standardised with propofol and remifentanil via target-controlled infusion. A morphine bolus of 0.15mg/kg was administered 20-30mins before the end of surgery. The effect of extubation technique on onset time of desaturation (T92) was assessed during the first 10mins after extubation during the spontaneous air breathing. Secondary endpoints included: frequency of desaturation, respiratory complications, need to use oxygen therapy and SpO2 at the end of the first hour while breathing in air (ClinicalTrials.gov identifier: NCT01323049). RESULTS: Baseline patient characteristics and intraoperative management data for the 68 patients included had no relevant clinical difference between groups. T92 (sec) after tracheal extubation was 214 (168) vs. 248 (148) in the PP and SUC groups, respectively (P=0.44). In the PP and SUC groups, 50 and 43% reached a SpO2<92% within the first 10mins after extubation respectively (P=0.73). There were no statistically significant differences between groups for any secondary endpoints. CONCLUSIONS: Positive pressure extubation as compared with suctioning extubation did not seem to delay onset time of desaturation after GA in standard weight adult patients.

Opioid-sparing effect of nefopam in combination with paracetamol after major abdominal surgery: a randomized double-blind study.

BACKGROUND: Because nefopam's morphine-sparing is debated when combined with paracetamol, this study aimed to assess pain relief by IV nefopam in combination with paracetamol after major abdominal surgery. METHODS: This was a prospective, double-blinded randomized controlled study including patients (ASA I-III, >18 years) scheduled for elective colectomy surgery by laparotomy. Patients were randomized into the nefopam group (N.=37, continuous IV 120 mg nefopam) or control group (N.=32, placebo, same infusion) for 48 hours after surgery (both groups: IV paracetamol 1 g/6 h + IV PCA morphine rescue). The primary endpoint was the total morphine consumption from the potential titration in the postoperative care unit to 48 hours (20% reduction in nefopam group). The secondary endpoints were adverse events and clinical outcomes. RESULTS: Both groups were similar for demographic characteristic, surgery, and anesthesia (including IV sufentanil 20 [20-25] µg for nefopam vs. 22.5 [20-25] µg for the control, P=0.6). Time in PACU and hospital stay were not statistically different. The number of patients requiring titration in PACU and the amount of IV morphine titration were similar. As the main endpoint, morphine consumption over the study period was similar between nefopam and the control group (respectively, 53±37 and 54±34 mg, P=0.86). No difference was observed for pain relief satisfaction between groups or total adverse events like PONV, ileus, desaturation, or confusion (nefopam 14±38 vs. control group 11±34, P=0.77). CONCLUSIONS: This prospective randomized study suggested that nefopam in combination with paracetamol has no benefit after open abdominal surgery.

Sore throat following three adult supraglottic airway devices: A randomised controlled trial.

BACKGROUND: Sore throat is a common complaint after surgery. It affects patient satisfaction and can affect activity after discharge. The supraglottic airway device (SAD) offers an alternative to traditional tracheal intubation with potential benefit in preventing sore throat. OBJECTIVE: The aim of this study was to compare the incidence of sore throat following three different SADs, the laryngeal mask airway Unique (LMA-U) and the more recent LMA Supreme (LMA-S) and the I-gel. DESIGN: A randomised single-blind controlled three parallel-group trial. SETTING: University Hospital of Nîmes, Division of Anaesthesia Intensive Care Pain and Emergency, Nîmes, France, from April 2009 to September 2012. PATIENTS: A total of 546 patients scheduled to undergo elective surgery of less than 2 h under general anaesthesia were randomly allocated to receive the LMA-U, the LMA-S or the I-gel. INTERVENTIONS: Anaesthesia was induced with propofol and sufentanil and maintained with propofol or with sevoflurane in air-oxygen. After airway device insertion, intra-cuff pressure was adjusted to less than 60 mmHg (LMA-U, LMA-S) and pressure-controlled ventilation initiated. MAIN OUTCOMES: The primary study endpoint was to compare incidence of sore throat 24 h postoperatively (H+24) following placement of the LMA-U, LMA-S and the I-gel. Secondary endpoints were clinical performance (airway leak pressure, dynamic airway compliance, complications during maintenance), ease of use (device insertion time, success on first attempt, ease of insertion and removal) and other adverse events (neck or jaw pain, dysphonia, dysphagia, nausea and vomiting). RESULTS: The authors analysed 177, 174 and 173 patients who received LMA-U, the LMA-S and the I-gel, respectively. The primary endpoint was assessed in 436 patients. In total, 104 patients (23.9%) patients reported a H+24 sore throat, with no difference between groups (P = 0.34). H+24 dysphagia with liquids was higher (P = 0.0065) with the LMA-S (12.1%) compared with LMA-U (5.3%) and I-gel (2.9%). Airway leak pressure (cmH2O) was lower (P < 0.0001) with LMA-U [21 (18 to 27)] compared with I-gel [26 (20 to 30)] and LMA-S [25 (21 to 30)]. Device insertion time (sec) was shorter (P < 0.0167) with the I-gel [30 (20 to 40)] compared with the LMA-U [34 (23 to 48)] and LMA-S [32 (22 to 50)]. CONCLUSION: The incidence of postoperative sore throat was not significantly different between the three SADs studied.

Residual anxiety after high fidelity simulation in anaesthesiology: An observational, prospective, pilot study.

BACKGROUND: High fidelity simulation (HFS) in anaesthesiology intentionally provides stress on students, but anxiety may be detrimental if it goes on through debriefing. The primary goal of this study was to estimate the proportion of students with significant anxiety remaining after debriefing (residual anxiety [RA]). Secondary goals were to evaluate the instructors' ability to estimate students' RA and to identify potential risk factors for high RA. SUBJECTS AND METHODS: Following IRB approval and informed consent, data from a cohort of subjects were prospectively collected by an independent expert. State-anxiety after debriefing (RA) was prospectively measured using the State-Trait Anxiety Inventory (a score varying from 20 to 80/80). RA was considered significant when≥36/80. Instructors simultaneously estimated the levels of subjects' RA via a visual analogue scale. Data about subjects, stress during scenarios (including continuous heart rate monitoring), and debriefings (including DASH© quality scores) were also collected. RESULTS: Seventy study subjects (30 residents, 26 nurses and 14 anaesthetists) were enrolled during 52 HFS sessions. As concerns the primary endpoint, RA was≥36/80 in 15 subjects (21%; 95% CI: 13-32). The median RA was 30/80 [25-35]. For secondary endpoints, the instructors' estimations poorly correlated with measurements: rho=0.36 (P<0.01); limits of agreement: -16 and 22. Subjects with RA≥36/80 had significantly higher trait-anxiety (P<0.01). An easy scenario (P=0.04) and low quality debriefing (P=0.04) were associated with higher RAs. CONCLUSION: Most students experienced low anxiety after debriefing. Instructors seem to be unable to reliably estimate students' RA. Students with an anxious personality are more likely to be anxious after debriefing.

The Influence of Arm Positioning on Ultrasonic Visualization of the Subclavian Vein: An Anatomical Ultrasound Study in Healthy Volunteers.

We hypothesized that placing the arm in 90° abduction, through 90° flexion and 90° external rotation, could improve ultrasound visualization of the subclavian vein. In 49 healthy volunteers, a single operator performed a view of the subclavian vein in neutral position and abduction position. A second blinded operator measured the cross-sectional area of the subclavian vein. Abduction position increased the cross-sectional area of the subclavian vein from 124 ± 46 (mean ± SD) to 162 ± 58 mm (P = 0.001). An increase of the cross-sectional area of ≥50% was observed in 41% volunteers (95% confidence interval, 27%-56%, n = 20); this technique offers an alternative approach (maybe safer) for ultrasound-guided catheterization of the subclavian vein.

Spontaneous uterine rupture at 14 weeks gestation during a pregnancy consecutive to an oocyte donation in a woman with Turner's syndrome.

We describe a spontaneous uterine rupture at 14 weeks gestation in a Turner patient. A 39 year-old patient was admitted for abdominal pain and hypotension at 14 weeks of pregnancy. The pregnancy had been obtained by oocyte donation and in vitro fertilization (IVF) because of Turner's syndrome. The abdominal ultrasound scan showed a normal pregnancy and a conserved foetal cardiac activity. It also showed a large amount of free fluid in the perihepatic space. Haemoglobin was 11.2 g/dL. After hemodynamic degradation, urgent laparoscopy showed an unrepairable uterine rupture with partial exteriorisation of the pregnancy, and placenta percreta. Urgent conversion to laparotomy allowed haemostatic hysterectomy. Uterine rupture during pregnancy obtained by oocyte donation in Turner's syndrome may be life threatening. The possibility of such a complication should be considered before oocyte donation for IVF in Turner's patients. Early spontaneous uterine rupture (second trimester) is a challenging diagnostic that should be evoked in case of non-specific abdominal pain in the presence of risk factors.

Effect of sedative premedication on patient experience after general anesthesia: a randomized clinical trial.

IMPORTANCE: Sedative premedication is widely administered before surgery, but little clinical evidence supports its use. OBJECTIVE: To assess the efficacy of sedative premedication on perioperative patient experience. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial, the PremedX study, enrolled 1062 adult patients who were younger than 70 years and had been scheduled for various elective surgeries under general anesthesia at 5 French teaching hospitals (in Marseille, Montpellier, Nimes, and Nice) between January 2013 and June 2014. Neurosurgery, obstetrical, cardiac, and outpatient surgery were excluded. INTERVENTIONS: Patients were randomized to 3 groups of 354 participants each to receive 2.5 mg of lorazepam, no premedication, or placebo. MAIN OUTCOMES AND MEASURES: The primary outcome was perioperative patient experience assessed 24 hours after surgery with a validated questionnaire (Evaluation du Vécu de l'Anesthésie Generale; EVAN-G) describing 6 domains of satisfaction and a global index (score range, 0-100; high scores represent high satisfaction); secondary outcomes included time to extubation and early cognitive recovery. A subgroup analysis was planned a priori in patients with a high level of preoperative anxiety. RESULTS: Premedication with lorazepam did not improve the EVAN-G mean global index for overall level of patient satisfaction (72 [95% CI, 70-73]; n = 330) compared with no premedication (73 [95% CI, 71-74]; n = 319) or placebo (71 [95% CI, 70-73]; n = 322) (P = .38). Among patients with heightened preoperative anxiety, there were no significant differences found in the EVAN-G mean global index between the lorazepam group (68 [95% CI, 65-72]; n = 87) and the no premedication group (73 [95% CI, 69-77]; n = 57) or the placebo group (70 [95% CI, 67-72]; n = 87) (P = .18). Time to extubation was 17 minutes (95% CI, 14-20 minutes) in the lorazepam group, 12 minutes (95% CI, 11-13 minutes) for the no premedication group, and 13 minutes (95% CI, 12-14 minutes) for the placebo group (P < .001) and the rate of early cognitive recovery was 51% (95% CI, 45%-56%), 71% (95% CI, 66%-76%), and 64% (95% CI, 59%-69%), respectively (P < .001). CONCLUSIONS AND RELEVANCE: Among patients undergoing elective surgery under general anesthesia, sedative premedication with lorazepam compared with placebo or no premedication did not improve the self-reported patient experience the day after surgery, but was associated with modestly prolonged time to extubation and a lower rate of early cognitive recovery. The findings suggest a lack of benefit with routine use of lorazepam as sedative premedication in patients undergoing general anesthesia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01901003.

Reversal of a rocuronium-induced grade IV anaphylaxis via early injection of a large dose of sugammadex.

AIM: To report rapid recovery from grade IV rocuronium-induced anaphylaxis with a large dose of sugammadex administered early after the onset of symptoms. CLINICAL FEATURES: A 22-yr-old female without relevant medical history developed an anaphylactic reaction within three minutes of rocuronium injection at induction of anesthesia for a routine cholecystectomy. During the first six minutes, she was unresponsive to usual treatment and her condition evolved to a grade IV anaphylaxis reaction despite a cumulated dose of epinephrine 0.7 mg. Sugammadex 14 mg·kg(-1), injected six minutes after rocuronium, resulted in total resolution of all manifestations of anaphylaxis within three minutes. The patient was discharged from hospital the next day. Allergy investigations confirmed rocuronium as the cause of anaphylaxis. CONCLUSION: Very early administration of a large dose of sugammadex may be an effective treatment for rocuronium-induced anaphylaxis.

Blood wastage reduction: a 10-year observational evaluation in a large teaching institution in France.

CONTEXT: Blood transfusion has increased significantly during the last decade and blood wastage reduction is a medical and economic challenge in hospital practice and for institutional quality, particularly in the ICU and operating theatre. OBJECTIVE: To evaluate the impact of multiple strategies in one hospital to reduce red blood cell wastage. DESIGN: Multicentre, prospective, comparative, observational study. SETTING: Over 10 years, the study was conducted over two time periods. During the first period (2000 to 2003), information was given to medical professionals about blood wastage, and audits (reasons for wastage) were performed, in a large teaching institution (more than 4% wastage in 1999). The second period (2004 to 2010) was designed to analyse the impact of seven strategies intended to minimise blood wastage. Blood wastage reduction in the local centre was compared with regional (64 institutions) and national centres (1470 institutions). Reduction was compared using the Mann-Kendall non-parametric trend test. PATIENTS: Local centre (22,572 transfused patients, Nîmes, France), regional centre (South France, 64 institutions, 208,525 transfused patients) and national centres (France, 1470 institutions). INTERVENTIONS: Medical and surgical procedures. MAIN OUTCOME MEASURES: The primary end-point was to describe the percentage of blood wastage for two periods in a local centre. The secondary objective was to compare the percentage of blood wastage in the local centre with wastage at regional and national centres. RESULTS: Over the 10 year study period the percentage of blood wastage in the local centre decreased, with a significant reduction in the second period, from more than 4% (1999) to less than 1% (2010; P < 0.05). Blood wastage at regional and national centres was never less than 1%. Inadequate containers for transport, absence of a temperature analyser in the ICU and inadequate intraoperative blood strategies (excessive orders of blood) were the main causes of wastage. Correction of these points affected the outcome favourably in the second period, but transfusion information was poor in the first period. CONCLUSION: Seven simple strategies (including transport containers with an effective temperature analyser and audits) decreased blood wastage, especially in the ICU and operating theatre.

American Society of Anesthesiologists' physical status system: a multicentre Francophone study to analyse reasons for classification disagreement.

CONTEXT: Variability of American Society of Anesthesiologists' (ASA) physical status scores attributed to the same patient by multiple physicians has been reported in several studies. In these studies, the population was limited and diseases that induced disagreement were not analysed. OBJECTIVES: To evaluate the reproducibility of ASA physical status assessment on a large population, as used in current practice before scheduled surgery. DESIGN: Multicentre, randomised, blinded cross-over observational study. METHODS: During a 2-week period in nine institutions, ASA physical status and details of assessment performed routinely by anaesthesiologists for patients who underwent elective surgery were recorded. Records were blinded (including ASA physical status) by an independent statistical division and returned randomly to one of the nine centres for reassessment by accredited specialist anaesthesiologists. MAIN OUTCOME MEASURES: The level of agreement between the two measurements of the ASA physical status was calculated by using the weighted Kappa coefficient. RESULTS: During the study period, 1554 anaesthesia records were collected and 197 were excluded from analysis because of missing data. After the initial evaluation, the distribution of ASA physical status grades was as follows: ASA 1, 571; ASA 2, 591; ASA 3, 177; and ASA 4, 18. After the final evaluation, the distribution of ASA grades was as follows: ASA 1, 583; ASA 2, 520; ASA 3, 223; and ASA 4, 31. Two per cent of the patients had an underestimation of their physical status. The degree of agreement between the two measures evaluated by the weighted Kappa coefficient was 0.53 (0.49-0.56). No difference was observed between public and private institutions. Patients with co-existing diseases, obesity, allergy, sleep apnoea, obstructive lung disease, renal insufficiency and hypertension were least likely to have been graded correctly. CONCLUSION: The degree of agreement between two measures of the ASA physical status grade is moderate and influenced by staff characteristics and the complexity of diseases.

Reversal of bupivacaine-induced cardiac electrophysiologic changes by two lipid emulsions in anesthetized and mechanically ventilated piglets.

BACKGROUND: Accidental IV administration of bupivacaine can compromise cardiovascular function by inducing lethal arrhythmias whose hemodynamic consequences may be alleviated by lipid emulsions. However, little is known about the electrophysiologic effects of lipid emulsions. In this study, we assessed whether 2 different lipid emulsions can reverse cardiac electrophysiologic impairment induced by the IV administration of bupivacaine in anesthetized and mechanically ventilated piglets. METHODS: Bupivacaine (4 mg . kg(-1)) was injected over a 30-second period in 26 piglets. Thirty seconds after the end of bupivacaine injection, 1.5 mL . kg(-1) saline solution for the control group, and long-chain triglyceride emulsion (LCT group) or a mixture of long-chain and medium-chain triglyceride emulsion (LCT/MCT group) were infused over 1 minute. Cardiac conduction variables and hemodynamic variables were monitored for 30 minutes after injection. RESULTS: Bupivacaine induced similar electrophysiologic and hemodynamic changes. After 3 minutes, His ventricle intervals (median and interquartiles) were 100 (85-105), 45 (35-55), and 53 (48-73) milliseconds in the control, LCT, and LCT/MCT groups, respectively (P < 0.001 between control and both lipid emulsion groups). Lipid emulsions also reversed the effects on QRS duration, atrial-His, and PQ (the onset of the P wave to the Q wave of the QRS complex) intervals. LCT/MCT emulsion restored the decrease in maximal first derivative of left ventricular pressure (P < 0.01 after 3 minutes versus control group). CONCLUSIONS: LCT and LCT/MCT emulsions reversed the lengthening of His ventricle, QRS, atrial-His, and PQ intervals induced by the IV injection of 4 mg . kg(-1) bupivacaine.