Influence of acute preload changes on mitral annulus velocity measured by tissue Doppler echocardiography in critically ill patients.

AIM: The assessment of diastolic function remains difficult in critical care patients because of unstable preload conditions. Described as fairly insensitive to preload changes, tissue Doppler velocity measurement at the lateral mitral annulus (e' (lat) ) may help evaluate diastolic function. Our aim was to prospectively evaluate e' (lat) changes in relation to fluid expansion in critically ill patients. METHODS: This prospective observational study was conducted in critically ill, mechanically ventilated, patients in sinus rhythm without previously known cardiac disease. Echocardiography was performed before and 1 hour after a fluid challenge (infusion of Gelofusine 500 ml in 30 minutes). Conventional pulsed wave Doppler indices of left ventricular diastolic function and tissue Doppler velocity lateral (e' (lat) ) and septal (e' (sept) ) mitral annulus velocity were measured, whereas hemodynamic data were simultaneously collected. RESULTS: Twenty patients (age, 55 ± 15 years; Simplified Acute Physiology Score II, 45 ± 10) were enrolled. Systolic function was preserved in all patients. Cardiac index increased (p < 0.05), as did early diastolic mitral velocity (E wave) (p = 0.001), and e' (lat) and e' (sept) (p = 0.02) after fluid challenge. CONCLUSIONS: This study confirms the preload dependence and limited clinical usefulness of most Doppler variables, such as e' (lat) , to evaluate diastolic function in intensive care unit patients. Indices, such as E/e', may be of interest in these cases.

Fast-track anesthesia with remifentanil and spinal analgesia for cardiac surgery: the effect on pain control and quality of recovery.

OBJECTIVES: To assess pain intensity and quality of postoperative recovery in patients given fast-track anesthesia and spinal analgesia versus patients treated with standard anesthesia. DESIGN: A prospective, randomized, controlled study. SETTING: A private institution. PARTICIPANTS: Eighty-three patients who underwent cardiac surgery with cardiopulmonary bypass were analyzed. INTERVENTIONS: General anesthesia consisted of remifentanil and spinal analgesia (low-dose morphine and clonidine) for the fast-track group (FTG) and sufentanil without spinal analgesia for the control group (CG). During the postoperative period, paracetamol and patient-controlled intravenous analgesia (PCA) with morphine were given. MEASUREMENTS AND MAIN RESULTS: Postoperative pain intensity was evaluated during 48 hours with visual analog scale scores and intravenous morphine consumption. Pain impact on quality of life was assessed with the brief pain inventory (BPI) score (days 1-8), and recovery was evaluated with the quality of recovery score (QoR-40, day 4). Compared with the CG, FTG pain intensity was significantly lower 0 to 4 (p < 0.01) and 6 to 12 hours (p < 0.05) after surgery, as was their cumulative intravenous PCA morphine consumption (p = 0.01). BPI scores supported that FTG patients had significantly (p < 0.01) less "pain at its worst" on days 1 and 2, their BPI-assessed pain interfered significantly less with daily life on day 1 (p < 0.001), and their global QoR-40 score (day 4) was significantly higher (p < 0.05). CONCLUSIONS: Fast-track anesthesia combined with morphine-clonidine spinal analgesia controlled postoperative pain better and obtained a better QoR than conventional analgesia.

Remifentanil versus propofol for radio frequency treatment of atrial flutter.

PURPOSE: Radio frequency treatment in cardiology generates short acute pain during the heating process. The present study evaluates two techniques used for sedation/analgesia for this procedure. METHODS: Two groups of 20 patients each were studied prospectively. Patients were randomized to receive sedation for the procedure using either a patient-controlled analgesia device with remifentanil (Group R), or a target controlled infusion of propofol (Group P). Patients in Group R had a basal infusion of remifentanil 0.02-0.04 microg x kg(-1) x min(-1) with self administered bolus doses of 0.3 microg x kg(-1) i.v. every minute as required, with a delivery time greater than 30 sec. Patients in Group P had an initial plasma target concentration set at 3-4 microg x mL(-1). RESULTS: Sedation scores were significantly higher in Group P, and two patients required supplementation with remifentanil and insertion of an laryngeal mask airway. Pain scores were higher in Group R, and two patients experienced muscular rigidity, one with transient apnea. Systolic blood pressure decreased significantly in Group P, and at the end of the procedure, PaCO(2) values were higher in that group (P < 0.01). Recovery time was significantly longer in Group P. Patient and physician satisfaction scores were similar in the two groups. CONCLUSIONS: A basal infusion of remifentanil plus remifentanil patient controlled analgesia and target controlled infusion of propofol were adequate but not optimal techniques for sedation/analgesia for radio frequency treatment of atrial flutter.

Subdural placement of an epidural catheter detected by nerve stimulation.

PURPOSE: Subdural placement of an epidural catheter is rare and difficult to detect. Electrical stimulation of the epidural space can be useful to detect such an event. The purpose of the present case report is to confirm the efficacy of electrical stimulation to detect a subdural placement of an epidural catheter and to illustrate this unusual positioning by computed tomography (CT) scan images. CLINICAL FEATURES: A 51-yr-old man was scheduled for an aorto-iliac bypass on a combined epidural and general anesthesia technique. Electrical epidural stimulation was used. A very low threshold of 0.3 mA was observed with diffuse response movement at T3 and at T10, without cerebrospinal fluid return on catheter aspiration. An injection of 12 mL of 2% lidocaine with epinephrine 1/200,000 produced signs of iv injection of local anesthetic and an extensive block. Subdural placement of the catheter, suspected by the low current threshold response to epidural catheter stimulation, was confirmed by CT scan imaging. CONCLUSION: The present case report confirms that electrical stimulation of the epidural space is useful to detect misplacement of epidural catheter such as a subdural placement. CT scan imaging of subdural positioning of an epidural catheter is presented.

Fast-track coronary artery bypass grafting surgery under general anesthesia with remifentanil and spinal analgesia with morphine and clonidine.

OBJECTIVE: Effective postoperative analgesia is a critical part of fast-track cardiac surgery. This study compared the postoperative analgesic effect of fast-track anesthesia with remifentanil and spinal morphine and clonidine with that of sufentanil anesthesia followed by patient-controlled administration of intravenous morphine. DESIGN: Prospective, blinded, randomized study. SETTING: Single private institution. PARTICIPANTS: Forty patients selected for coronary artery bypass graft surgery allocated randomly into 2 groups. INTERVENTIONS: General anesthesia was performed with etomidate, isoflurane, cisatracurium, and either remifentanil (0.10-0.25 microg/kg/min) or sufentanil (up to 3.5 microg/kg). In the remifentanil group, patients received spinal morphine (4 microg/kg) and clonidine (1 microg/kg) before induction. Postoperatively, patients in both groups were connected to an intravenous patient-controlled analgesia (PCA) morphine pump that delivered a 1-g bolus with a 7-minute lockout interval. MEASUREMENTS AND MAIN RESULTS: Patients were evaluated for pain on a visual analog scale (VAS), at rest and on deep breathing, and for intravenous PCA morphine consumption during 24 hours. The intravenous PCA morphine 24-hour cumulative dose was lower in the fast-track than in the control group (15.8+/-12.6 v 32.7+/-22.3 mg, p<0.05). Before extubation, VAS scores were higher in the fast-track group, but after they were lower both at rest and during deep breathing. Extubation delay was shorter in the fast-track group (156.5+/-46.1 v 272+/-116.4 minutes, p<0.05). CONCLUSION: The combination of anesthesia with remifentanil and spinal analgesia with morphine and clonidine produces effective analgesia after coronary artery surgery and a rapid extubation time.