A systematic review and meta-regression analysis of mivacurium for tracheal intubation.

We systematically reviewed factors associated with intubation conditions in randomised controlled trials of mivacurium, using random-effects meta-regression analysis. We included 29 studies of 1050 healthy participants. Four factors explained 72.9% of the variation in the probability of excellent intubation conditions: mivacurium dose, 24.4%; opioid use, 29.9%; time to intubation and age together, 18.6%. The odds ratio (95% CI) for excellent intubation was 3.14 (1.65-5.73) for doubling the mivacurium dose, 5.99 (2.14-15.18) for adding opioids to the intubation sequence, and 6.55 (6.01-7.74) for increasing the delay between mivacurium injection and airway insertion from 1 to 2 min in subjects aged 25 years and 2.17 (2.01-2.69) for subjects aged 70 years, p < 0.001 for all. We conclude that good conditions for tracheal intubation are more likely by delaying laryngoscopy after injecting a higher dose of mivacurium with an opioid, particularly in older people.

A randomized study of the efficacy and recovery of remifentanil-based and alfentanil anaesthesia with desflurane or sevoflurane for gynecological surgery.

We performed a prospective, randomized study comparing the efficacy and safety of the combination of remifentanil and the newer volatile anaesthetics desflurane and sevoflurane with a conventional anaesthetic technique using alfentanil and desflurane. Forty five ASA class I or II female patients were randomly assigned to one of three groups. Following induction with propofol patients received a continuous infusion of remifentanil in combination with either 0.5 MAC desflurane (n = 15) or sevoflurane (n = 15), a third group (n = 15) received 1 MAC of desflurane with bolus doses of alfentanil for maintenance of anaesthesia. Remifentanil infusion and alfentanil (bolus) were titrated to responses to surgical stimuli while the concentration of volatile agents was kept unchanged. The number of responses to surgical stimuli was similar in the two remifentanil groups and higher in the alfentanil-desflurane group. Recovery times were similar in all groups. The incidence of postoperative side effects was high in the three groups. No awareness occurred and patient satisfaction in the two remifentanil groups was comparable to the conventional anaesthetic technique.

The impact of nitrous oxide on postoperative nausea and vomiting after desflurane anesthesia for breast surgery.

A recent meta-analysis showed that omitting N2O significantly reduced postoperative vomiting (POV) compared with a N2O regime. Our study was designed to evaluate the effect of the combination of desflurane with N2O versus desflurane alone on postoperative nausea and vomiting (PONV) in a subgroup of female patients and PONV was considered as the primary endpoint. After approval of the local Ethics Committee and informed consent 60 female in-patients (ASA I & II), aged 18-65 y, scheduled for breast surgery with a duration of 1-3 h were included. Obese patients or patients with a history of PONV and motion sickness were excluded. No prophylactic anti-emetic therapy was allowed during the study. Patients received a standardized anesthetic technique consisting of propofol for induction, vecuronium and fentanyl for intubation, followed by desflurane with or without N2O (randomisation list) and fentanyl supplements if required for maintenance of anesthesia. At the end of anesthesia PONV was recorded during 24 h in different periods. There were no significant differences between the groups with respect to demographic data and duration of anesthesia. In addition, there were no significant differences in the amount of intraoperative fentanyl or postoperative narcotics. The incidence of PONV was significantly higher in the group of patients receiving desflurane in N2O-O2 mixture compared with the group receiving desflurane in AIR-O2 mixture. The combination of desflurane with N2O in female patients undergoing breast surgery is associated with a significantly higher incidence of PONV and a higher need of antiemetic drugs, when compared to a N2O free regime.

Treatment for postdural puncture headache associated with late postpartum eclampsia.

Postdural puncture headache (PDPH) is the most common complication of accidental or deliberate dural puncture. It also occurs after epidural or spinal analgesia for labor and delivery. Treatment may be conservative with analgesics and/or caffeine. Definitive treatment can be accomplished with an epidural blood patch (EBP). We present a case of postpartum convulsions which were temporally related to a caffeine infusion and an EBP.

Sevoflurane mask induction in adults: comparison of two inhalation techniques.

The efficacy and safety of two inhalation techniques for mask induction using high concentrations of sevoflurane (8%) were compared in female patients planned for short gynecological procedures in an out-patient setting. One group (n = 20) received single breath vital capacity rapid inhalation induction (VCRII), the other group (n = 20) multiple deep breaths inhalation induction (DBI). The induction time was short and comparable in both groups (70 +/- 4 and 62 +/- 3 seconds respectively). The respiratory and hemodynamic side effects were also similar. The appreciation of the induction technique was comparable in both groups and most patients agreed to the same inhalation technique with a mask in future anesthetics.

The effect of prophylactic clonidine on postoperative shivering. A large prospective double-blind study.

The primary goal of this study was to assess the influence of clonidine administered after induction on postoperative shivering after elective peripheral surgery. The effect of clonidine on intra-operative haemodynamics (blood pressure and heart rate) during the first 30 min after induction and on the postoperative sedation of the patient was also investigated. Two hundred and eighty male ASA 1 and 2 patients, undergoing elective peripheral surgery were randomly administered either placebo or clonidine 2 micrograms.kg-1 intravenously over 10 min after induction of anaesthesia. Clonidine was found to reduce the total incidence (p = 0.024), the severity (p = 0.005) and the duration (p = 0.01) of postoperative shivering. Clonidine did not increase postoperative sedation or diminish overall consciousness. We conclude that administration of clonidine 2 micrograms.kg-1 intravenously after induction of anaesthesia is safe and reduces postoperative shivering in this group of patients.

Investigation of the pharmacokinetics and analgesic effects of an intramuscular injection of sustained-release sufentanil for postoperative pain: an open study.

STUDY OBJECTIVES: To investigate the pharmacokinetics after an intramuscular (IM) injection of sufentanil in thin vegetable oil in postsurgical patients and to determine whether sustained-release IM sufentanil can provide safe and sufficient analgesia of long duration in these patients. DESIGN: Open study. SETTING: University hospital. PATIENTS: 10 ASA physical status I and II patients aged 18 to 65 years who were scheduled for elective surgery. INTERVENTIONS: All patients were premedicated with lorazepam and anesthetized with a general anesthetic technique containing nitrous oxide, fentanyl, and isoflurane. As soon as significant pain [visual analog scale score of 5 or greater (range, 0 = no pain to 10 = worst pain imaginable)] occurred during the early postoperative period, the patient received an IM injection of sustained-release sufentanil. MEASUREMENTS AND MAIN RESULTS: During the first 48 hours following surgery, blood samples were taken for determination of plasma sufentanil concentrations. Blood pressure, heart rate, respiratory rate, pain scores, and sedation scores were documented at the same time. The IM administration of sufentanil in thin vegetable oil provided sufficient pain relief, although the onset of analgesia was rather slow (+/- 1 hour). The analgesic effect was still apparent 48 hours later. Plasma concentration of sufentanil at the different time points varied from 0.021 to 0.142 ng/ml, with a mean maximal peak concentration of 0.103 ng/ml. The plasma concentration 48 hours after injection varied from 0.026 to 0.074 ng/ml. CONCLUSIONS: Although an IM injection of sufentanil in thin vegetable oil is effective for postoperative pain relief, it is associated with wide interindividual variability in plasma concentration of sufentanil and long duration of action.

Influence of combined use of nicotinamide and carbogen on rat spinal cord radiation tolerance.

The effect of combining oxygen or carbogen breathing with the systemic administration of nicotinamide (NA) on spinal cord tolerance in Ethrane anesthetised male WAG/Rij rats has been investigated. Ten fraction experiments were carried out with daily (24 h between fractions) and twice a day fractionation (8 h between fractions). Nicotinamide (500 mg/kg) was injected 1 h prior to each irradiation. In addition, a 10-fraction experiment with daily intervals was carried out in which NA was added immediately after irradiation under carbogen breathing conditions. Single dose irradiations showed a minimal decrease in ED50 from 21 Gy in oxygen conditions to 19.9 Gy in carbogen conditions and 19.4 Gy when combined with NA. In the fractionation experiments, comparing the response to irradiation in oxygen (O) and nicotinamide oxygen (NO) conditions for the 24-h interval experiment, the ED50 for O was 61.6 Gy compared with 54.5 Gy for NO. When carbogen (C) was compared with nicotinamide carbogen (NC), the ED50 for C was 62.3 Gy and 53.9 Gy for NC. When NA was administered immediately after irradiation under carbogen breathing conditions the ED50 increased to 57.8 Gy. For twice a day fractionation the modifying effect of nicotinamide was similar to that observed for daily fractionation (ED50 of 57.9 Gy for O, 57 Gy for C and 50.9 Gy for CN), when corrected for incomplete repair in between the two fractions given on 1 day.(ABSTRACT TRUNCATED AT 250 WORDS)

[Quality of induction and adrenocortical function. A clinical comparison of Etomidate-Lipuro and Hypnomidate]. / Induktionsqualität und Nebennierenrindenfunktion. Ein klinischer Vergleich von Etomidat-Lipuro und Hypnomidate.

UNLABELLED: The purpose of this study was to compare etomidate in a lipid emulsion (Etomidat-Lipuro; Braun, Melsungen) and in propylene glycol (Hypnomidate, Janssen Pharmaceutica) in 90 patients in terms of anaesthetic induction characteristics with special reference to injection side effects, haemodynamic changes, and quality of induction. Adrenocortical hormones were determined in 30 patients who received either Etomidat-Lipuro, Hypnomidate, or propofol (Diprivan, ICI Pharma) for induction of anaesthesia. METHODS: One hundred twenty patients gave their informed consent to the study. In the first part, 90 patients were assigned at random to two groups in which induction of anaesthesia was performed either with Etomidat-Lipuro or Hypnomidate. Anaesthesia was started by i.v. injection of 25 micrograms/kg alfentanil (Rapifen, Janssen Pharmaceutica). One minute later, the hypnotic agent was injected into a freely running i.v. line (18 Gcannula) that was used only for the hypnotic and was removed 15 min later. During injection, the patients were asked to inform the anaesthesiologist spontaneously and on request about their sensations at the injection site. The time from the beginning of anaesthesia until the disappearance of the eyelash reflex was measured. The patients were ventilated and vecuronium was administered to allow good intubation conditions 2-3 min later. For the first 10 min, blood pressure and heart rate were measured every minute. Postoperatively, the same investigator made rounds once a day and examined the injection sites. Signs of pain, redness, swelling, induration, thrombophlebitis, or thrombosis were noted. In the second part of the study, 30 patients were investigated for endocrinological changes after induction of anaesthesia with Etomidat-Lipuro, Hypnomidate, or Diprivan. The patients were allocated to the groups at random. A radial artery catheter was inserted in every patient. Sampling took place 30 min before and 1 and 2 h after induction. Additional samples were drawn 30 min and 1, 2, and 22 h after i.v. administration of 0.25 mg ACTH (Synacthen, Ciba-Geigy). The plasma concentrations of cortisol, 17 alpha-OH-progesterone, and aldosterone and the renin activity were determined by high-performance liquid chromatography. RESULTS: The loss of the eyelash reflex occurred 42.9 +/- 8.7 and 42.2 +/- 11.0 s after the administration of Etomidat-Lipuro and Hypnomidate. The haemodynamic changes were minimal in both groups. After administration of alfentanil, local side effects of the hypnotics were scarce, with a tendency to be weaker and more seldom after Etomidat-Lipuro (3/55 versus 8/55). The postoperative vein reactions were generally mild and occurred in 17 out of 55 patients after Etomidat-Lipuro and 15 out of 55 patients after Hypnomidate. In most cases these signs were no longer present on the 2nd day after the procedure. Cortisol levels were depressed initially by all the hypnotic drugs used. While there was spontaneous recovery in the Diprivan group after 2 h combined with a positive overshooting response to ACTH stimulation, in the etomidate groups cortisol could not be stimulated; it normalized slowly during the following 24 h. The 17 alpha-OH-progesterone increase was significant in the etomidate groups after the administration of ACTH. The aldosterone levels decreased after etomidate injection and had not normalized 24 h later, while there was a normal response to ACTH in the propofol group. There was a normal decrease in renin activity in all three groups after the administration of ACTH. CONCLUSION: Local side effects are minimal after the administration of Etomidat-Lipuro and Hypnomidate. Alfentanil reduces the injection pain of etomidate induction agents. Cortisol and aldosterone are depressed by etomidate, but the clinical relevance is minimal after a single bolus injection.

Propofol-nitrous oxide versus thiopental sodium-isoflurane-nitrous oxide for strabismus surgery in children.

STUDY OBJECTIVES: To assess the quality of anesthesia and recovery and the frequency of postanesthetic retching and vomiting with propofol anesthesia for pediatric strabismus surgery. DESIGN: Randomized, open, prospective study. SETTING: University hospital. PATIENTS: Forty children scheduled for strabismus surgery. INTERVENTIONS: The 40 patients were all premedicated with oral midazolam and received intraoperative opioids. They were divided into two groups: Twenty children received propofol at induction, followed by maintenance of anesthesia with propofol infusion and an oxygen-nitrous oxide (O2-N2O) mixture. The other 20 children received thiopental sodium at induction, followed by isoflurane in an O2-N2O mixture. MEASUREMENTS AND MAIN RESULTS: At induction, pain and spontaneous movements were seen significantly more with propofol (11 of 20 vs. 0 of 20 for pain and 13 of 20 vs. 0 of 20 for spontaneous movements; p < 0.001), whereas thoracic rigidity was observed only with thiopental sodium (4 of 20). During maintenance of anesthesia, significantly more oculocardiac reflexes were seen with propofol (10 of 20 vs. 3 of 20; p < 0.02). The interval between termination of anesthesia and extubation was significantly shorter with propofol (13 minutes vs. 16 minutes; p < 0.02). For the first 24 hours after surgery, significantly less retching and vomiting were observed in the propofol group (4 of 20 vs. 11 of 20; p = 0.02). CONCLUSIONS: Propofol induction and maintenance of anesthesia for strabismus surgery in children significantly lowers the frequency of postanesthetic retching and vomiting, but propofol is associated with pain and spontaneous movements at induction and a high frequency of oculocardiac reflexes during maintenance infusion.

The influence of ketanserin on blood pressure and heart rate during induction of anesthesia: a randomized double blind controlled evaluation.

Increases in blood pressure and heart rate often seen with laryngoscopy and endotracheal intubation during induction of anesthesia can be dangerous for many patients. In twenty five patients pretreated with ketanserin, a new antihypertensive agent, changes in blood pressure and heart rate were compared with the hemodynamic parameters of twenty untreated patients. Ketanserin 10 mg intravenously was administered prior to induction of anesthesia. Ten mg i.v. ketanserin will not prevent increases in arterial pressure; however the increases in diastolic and mean arterial pressure are significantly lower than these increases in untreated patients.

Current concepts of inhalation injury in burn victims.

Twenty patients with bronchoscopic diagnosis of inhalation injury were reviewed. The history of a burn in a closed space was present in 90% of the patients in our study and evidence of orofacial burns in 100%. In four of these patients serum concentrations of human placental alkaline phosphatate (hPLAP) were determined. This protein can be detected in serum with hPLAP specific monoclonal antibody and increased serum levels of hPLAP are found when there is damage of pneumocyt I cells.

Alizapride in the prevention of postoperative vomiting. A double-blind comparison.

Alizapride 50 mg intravenously was compared with placebo in a double-blind trial on 170 women undergoing planned soft tissue surgery under general anesthesia. Alizapride or placebo was given intravenously about 20 minutes before the end of the operation. A second and a third prophylactic dose was administered 4 and 8 hours after the first injection. The patients were observed for 24 hours postoperatively. A therapeutic dose of alizapride 50 mg was administered intravenously in the two groups if retching or emesis occurred in the postoperative period. In the alizapride group there was less retching or emesis than in the placebo-group and the difference was statistically significant. However, there was still a significant incidence of 34% of postoperative vomiting in the alizapride group. There were no effects on heart rate or on respiratory rate but small changes of blood pressure after the first and second prophylactic injection of alizapride have been noted.

Changes in intraocular pressure associated with the administration of propofol.

The effect of propofol on intraocular pressure (IOP) was measured in 25 patients presenting for elective non-ophthalmological surgery when propofol was used for the induction and maintenance of anaesthesia (together with 67% nitrous oxide in oxygen, and vecuronium). Normocapnia was maintained. After induction of anaesthesia, intraocular pressure was significantly lower than the baseline value; during maintenance IOP never exceeded the preinduction value. There was a temporary decrease in arterial pressure after induction. In nine patients a cutaneous flush was observed and in seven patients there was discomfort on injection. Spontaneous movement in 20% and hiccup in 12% of the patients were observed at the time of tracheal intubation.

The neuromuscular blocking action of vecuronium in normal patients and in patients with no renal function and interaction vecuronium-tobramycin in renal transplant patients.

The new short acting steroid muscle relaxant vecuronium was tested clinically in 42 surgical patients and compared in three different groups of patients: normal patients, renal graft patients who received tobramycin preoperatively and other anephric patients undergoing surgery. Twenty-five percent recovery of initial twitch height as measured by NTM was significantly longer in the renal graft group than in the two other groups where recovery time is normal. Cardiovascular parameters were recorded before and after the injection of vecuronium. Reversal of the neuromuscular block was spontaneous or pharmacologically evoked by neostigmine. Clinical recovery was complete in all patients and there was no residual block.

Comparison of intramuscular buprenorphine and a buprenorphine/naloxone combination in the treatment of post-operative pain.

The analgesic efficacy and tolerance of a single intramuscular injection of either buprenorphine (0.3 mg) or a buprenorphine (0.3 mg)/naloxone (0.2 mg) combination was compared in 70 patients suffering from moderate to severe pain after abdominal surgery. Patients in both treatment groups experienced good analgesia which was apparent within 10 minutes of administration and lasted for approximately 12 hours. The most frequently reported unwanted effects were drowsiness and/or sleepiness and nausea and/or vomiting which were of mild or moderate severity in most cases. No significant differences were seen between the two treatment groups with regard to the overall assessments of efficacy and tolerance.

Total I.V. anesthesia using a continuous etomidate infusion.

Total I.V. anesthesia was given to 20 patients using an Etomidate continuous infusion to maintain sleep, combined to Fentanyl analgesia, Droperidol, Pancuronium for muscular relaxation and artificial ventilation with an oxygen-air mixture. All these patients were carefully observed during and for several hours after the anesthesia and the results noted. With the Fentanyl dosages used in this technique, peroperative analgesia was frequently insufficient. More Fentanyl would probably be needed with the inherent dangers of prolonged postoperative depression.