The incidence of acute cardiorespiratory and vascular dysfunction following intramedullary nail fixation of femoral metastasis.

Intramedullary nail fixation is a common treatment for metastatic tumors of the femur with overt or impending femoral fracture. This procedure sometimes causes severe cardiorespiratory and vascular dysfunction. The clinical relevance of this is not dear. We reviewed 45 operations in 43 patients, where intramedullary nail fixation was used to treat metastatic femoral fractures and impending fractures. We studied the incidence of intraoperative oxygen desaturation and hypotension associated with intramedullary manipulation as markers of cardiorespiratory and vascular dysfunction. Acute oxygen desaturation and hypotension occurred in 11 of our 45 patients. Of these, 3 died, 2 required intensive care postoperatively and 6 made uneventful recoveries. We hope to highlight a serious complication in this patient group.

Early extubation following coronary artery bypass surgery: a prospective randomized controlled trial. The Fast Track Cardiac Care Team.

STUDY OBJECTIVES: To determine the safety of early extubation (EE) after coronary artery surgery. DESIGN: Prospective randomized controlled trial. SETTING: The cardiac surgery operating room and ICU of a university-affiliated teaching hospital. PATIENTS: One hundred eligible patients presenting for elective coronary artery surgery. INTERVENTIONS: Patients randomized to the EE group were administered a reduced dose of fentanyl (15 microg/kg) and an anesthetic compatible with EE, while patients randomized to the conventional extubation (CE) group were given fentanyl (50 microg/kg). MEASUREMENTS AND RESULTS: The time to extubation in the EE group (median, 240 min; range, 30 to 930 min) was significantly less than the CE group (median, 420 min; range, 125 to 1,140 min) (p<0.01). Twenty patients were withdrawn from the study according to protocol guidelines. There were no cases of reintubation or complications attributable to EE. CONCLUSIONS: By using an appropriate anesthetic technique and postoperative management, EE can be achieved following coronary artery bypass surgery without major complications.

Comparison of clonidine and epinephrine in lidocaine for cervical plexus block.

BACKGROUND AND OBJECTIVES: Carotid endarterectomy under cervical plexus block offers the advantage of awake neurologic assessment. The hypothesis was tested that the addition of clonidine 5 micrograms/mL to lidocaine 1.5% for the block is as effective clinically as the addition of epinephrine 5 micrograms/mL but without the associated tachycardia. METHODS: In a double-blind, randomized, prospective trial of 40 patients, local anesthetic solutions of lidocaine 1.5% containing either clonidine 5 micrograms/mL or epinephrine 5 micrograms/mL were compared for cervical plexus block in patients undergoing carotid endarterectomy. Each solution was administered to 20 patients with a total lidocaine dose of 7 mg/kg. The electrocardiogram, heart rate, and arterial pressure (radial artery catheter) were continuously monitored. Blood samples were drawn for determination of serum lidocaine levels during the first hour. RESULTS: The block onset time (8.4 +/- 0.6 minutes for epinephrine, 8.8 +/- 0.8 minutes for clonidine) and duration (139 +/- 6.7 minutes for epinephrine, 148 +/- 5.8 minutes for clonidine) were not different between the two groups. During the period from completion of the block until incision there was a significant heart rate increase in the epinephrine group (23% mean rise) as compared with the clonidine group (4% mean rise) (P < .003). There was no difference in blood pressure between the two groups. The maximum plasma concentrations of lidocaine were 2.5-7.6 micrograms/mL (mean, 4.5 +/- 0.3 micrograms/mL) for the epinephrine group and 4.7-18.4 micrograms/mL (mean, 7.5 +/- 0.7 micrograms/mL) for the clonidine group (P < .0002). The maximum concentrations were reached 0-30 minutes (mean, 8 +/- 1.4 minutes) after injection for the epinephrine group and 0-10 minutes (mean, 4.5 +/- 7.1 minutes) for the clonidine group (P < .03). CONCLUSIONS: Clonidine 5 micrograms/mL is a useful additive to lidocaine 1.5% for cervical plexus block to reduce the incidence of tachycardia; however, omission of epinephrine results in higher serum lidocaine levels.