Chloroprocaine 10 mg/ml for low-dose spinal anaesthesia in perianal surgery - a randomised dose finding study.

BACKGROUND: Low-dose spinal anaesthesia is a safe and reliable anaesthesia technique in outpatient perianal surgery. Regarding its short duration of action and its trend to hyperbaric characteristics, plain chloroprocaine 10 mg/ml seems to be ideal to perform low-dose spinal anaesthesia. The aim of this trial was to determine the optimal dosage of chloroprocaine for this indication. METHODS: Hundred and twenty patients undergoing perianal surgery were enrolled and randomly allocated to receive 10, 20 or 30 mg of chloroprocaine 10 mg/ml intrathecally. Patients had to sit upright for at least 10 min after injection. We measured the expansion of sensory and motor block and the times until voiding, walking without assistance and home discharge. RESULTS: The expansion of the sensory (P ≤ 0.0059) and the motor block (P ≤ 0.0086) gained with increasing doses. At a dose of 30 mg the incidence of a profound, clinically relevant motor block was significantly higher compared to 10 and 20 mg (P ≤ 0.0004). In the 10 mg group two patients suffered from nociceptive pain due to an incomplete block and five patients announced discomfort during procedure. Doses of 10 and 20 mg led to a significantly earlier discharge compared to 30 mg (P = 0.0003; P = 0.0406). CONCLUSION: Plain chloroprocaine 10 mg/ml can successfully be used for low-dose spinal anaesthesia in perianal outpatient surgery. Regarding the unfavourable motor block and later discharge-times in the 30 mg group on the one hand and the block-failures in the 10 mg group on the other, 20 mg can be recommended as the optimal dose.

Dosage finding for low-dose spinal anaesthesia using hyperbaric prilocaine in patients undergoing perianal outpatient surgery.

BACKGROUND: Hyperbaric prilocaine 20 mg/ml may be preferable for perianal outpatient surgery. The aim of this prospective, single-centre, randomised, single-blinded, controlled clinical trial was to determine the optimal dosage of hyperbaric prilocaine 20 mg/ml for a spinal anaesthesia (SPA) in patients undergoing perianal outpatient surgery. METHODS: One hundred and twenty patients (18-80 years/American Society of Anesthesiologists grade I-III) were enrolled in this study. The patients were randomised to receive 10, 20 or 30 mg of prilocaine for SPA. We measured expansion of the sensory and motor block, evaluated times to walk, void and being eligible for discharge, and determined the demand of analgesics. RESULTS: 116/120 patients were available for analysis. The expansion of the sensory block gained with an increasing dosage: 10 mg: 3(1-6) dermatomes; 20 mg: 4(2-6) dermatomes; 30 mg: 5(3-7) dermatomes (P < 0.0001). Dermatomes were counted upwards beginning with S(5). Also, the motor block gained with an increased dosage (Bromage score 1-3: 10 mg: n = 3, 20 mg: n = 8 and 30 mg: n = 18, P = 0.0002). Patients receiving 10 mg were ready for discharge earlier compared with both other groups (10 mg: 199 ± 39 min; 20 mg: 219 ± 47 min; 30 mg: 229 ± 32 min, P = 0.0039). Pain occurred earlier in the 10 mg group than in the 30 mg group (10 mg: 168 ± 36 min; 30 mg: 205 ± 33 min, P = 0.0427). The demand of additional analgesics was comparable in all dosage groups. CONCLUSION: Hyperbaric prilocaine 20 mg/ml can be applied in dosages of 10, 20 and 30 mg for SPA in perianal surgery. Because of sufficient analgesia, missing motor block and shorter recovery times, 10 mg of hyperbaric prilocaine 20 mg/ml can be recommended for perianal outpatient surgery.

Angina pectoris in a young man secondary to undiagnosed childhood mucocutaneous lymph node syndrome.

A case of adult onset angina in a patient with previously undiagnosed childhood Kawasaki disease is presented. Evidence to support the diagnosis--such as clinical presentation and pertinent positive and negative laboratory data to rule out other conditions--is provided. The patient was successfully treated with coronary artery bypass surgery.

Left ventricular volume response to exercise in normal and coronary artery disease patients.

The left ventricular (LV) volume response to supine exercise (EX) was studied in 15 normal volunteers (mean age 44, asymptomatic, with normal resting ECG and treadmill stress test) and 28 coronary artery disease patients (CAD, documented by cardiac catheterization) with no previous myocardial infarction. Each individual underwent stress gated equilibrium radionuclide angiography (RNA) and was on no medication. A nongeometric count based LV volume programme developed in our laboratory (correlation to biplane cineangiography R = .98), was used to calculate end diastolic volume index (EDI), end systolic volume index (ESI), stroke volume index (SVI), cardiac index (CI), and ejection fraction (EF). In normal individuals, end diastolic volume did not change from rest to exercise, while end systolic volume decreased by an average of 16%. In the patients with coronary artery disease, however, both end diastolic volume and end systolic volume increased (14% and 15% respectively). Furthermore, our preliminary data suggest that the extent of the changes may be dependent upon the extent of the underlying CAD. While all the CAD patients had an increase in their end diastolic volumes, there was no change in the end systolic volume in those with single vessel disease, an 11% increase in patients with double vessel disease and a 19% in patients with triple vessel disease.

Dopamine: its potential for inducing ischemic left ventricular dysfunction.

As an agent potentially capable of inducing ischemia in patients with coronary artery disease, dopamine administered intravenously was evaluated as a pharmacologic stress agent by supine radionuclide angiography, and the results were compared with ergometer exercise. In a preliminary group of 11 subjects (4 normal subjects and 7 patients with coronary disease), dopamine alone was administered in increments of 2.5 micrograms/kg per min to a maximum of 15 micrograms/kg per min. There were significant differences between exercise and dopamine in maximal stress heart rates, 129.3 +/- 30.0 versus 88.0 +/- 35.8 beats/min (p less than 0.05) in normal subjects and 118.9 +/- 21.1 versus 87.6 +/- 22.6 beats/min (p less than 0.05) in patients with coronary disease, as well as in maximal stress rate-pressure products, 213.3 +/- 51.4 versus 155.0 +/- 52.5 mm Hg/min X 10(2) (p less than 0.02) in normal subjects and 216.0 +/- 45.6 versus 161.0 +/- 48.6 mm Hg/min X 10(2) (p less than 0.003) in patients with coronary disease. As a result, in these patients the ejection fraction response was significantly different: -3.3 +/- 4.5% with exercise versus + 6.3 +/- 4.6% with dopamine (p less than 0.05). In a second group of 41 subjects (9 normal subjects and 32 patients with coronary disease), atropine (0.6 mg) was administered intravenously before and after every second dopamine dose increment. This produced statistically similar maximal stress heart rates as compared with exercise in all subjects, rate-pressure products in normal subjects and slightly higher values with dopamine in patients with coronary disease: 200.3 +/- 47.2 versus 183.1 +/- 43.0 (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

The role of beta blockade, with and without intrinsic sympathomimetic activity, in preserving compromised left ventricular function in patients with ischemic heart disease.

To determine if intrinsic sympathomimetic activity (ISA) is associated with a hemodynamic advantage over non-ISA beta blockade, 17 patients with ischemic heart disease underwent resting echocardiography and symptom-limited stress radionuclide angiography on three occasions: control, pindolol (with ISA), 10 mg twice a day, and propranolol, 40 mg four times a day, in a nonrandomized design. In six patients with normal resting ejection fraction (EF) (mean = 57 +/- 4%), neither drug was associated with a significant hemodynamic improvement over control. In 11 patients with reduced resting EF (mean = 37 +/- 9%), pindolol was associated with a higher EF and peak velocity of circumferential fiber shortening at rest compared with propranolol but not control. On maximal exertion, pindolol was associated with a higher EF than that during control but was similar to propranolol. These observed beneficial effects on pindolol appear primarily to be related to the partial beta agonist activity which this agent possesses.

Effects on ventricular function of disopyramide, procainamide and quinidine as determined by radionuclide angiography.

To evaluate the effects of the 3 commonly used antiarrhythmic agents--disopyramide, procainamide and quinidine--on left ventricular (LV) function, these 3 agents were administered in random sequence after control radionuclide angiography performed at rest and during exercise in 17 patients. Drug dosages were tailored to achieve therapeutic blood levels 5 minutes before and 2 to 3 hours after drug administration. The mean dose of disopyramide was 141 +/- 26 mg every 6 hours, procainamide, 441 +/- 100 mg every 4 hours, and quinidine, 401 +/- 101 mg of the gluconate preparation every 6 hours. The patients received the appropriate dosage for 7 or more days before repeat radionuclide angiography was performed. The ejection fraction at rest was: control 60 +/- 13%, disopyramide 55 +/- 11%, procainamide 58 +/- 11%, and quinidine 59 +/- 12%. The exercise ejection fraction was: control 61 +/- 14%, disopyramide 58 +/- 13%, procainamide 58 +/- 12% and quinidine 61 +/- 13%. In neither case, at rest nor during exercise was there any significant difference observed between any of the agents or between any individual agent and control. However, at rest 8 subjects had a 5% or more decrease from the control value with disopyramide, 5 had a 5% or more decrease with procainamide and 6 had a 5% or more decrease with quinidine, whereas during exercise the decreases were 8, 6 and 5%, respectively. These values were not statistically different but suggest that caution should be taken in administering all 3 agents, particularly to patients with impaired LV function, because individual sensitivity to a given agent may precipitate a significant decline in LV function.

Comparative effects of propranolol and verapamil alone and in combination on left ventricular function and volumes in patients with chronic exertional angina: a double-blind, placebo-controlled, randomized, crossover study with radionuclide ventriculography.

With the use of equilibrium radionuclide ventriculography the effects on left ventricular (LV) function of 160 mg oral propranolol daily and 360 mg verapamil daily alone and in combination were compared in 18 patients with chronic exertional angina. A randomized, double-blind, placebo-controlled, crossover protocol was used. The reduction in exercise rate-pressure product induced by the combination (118 +/- 28 mm Hg/min) was significantly greater (p less than .05) than that by propranolol (135 +/- 27 mm Hg/min) or verapamil alone (163 +/- 28 mm Hg/min). In patients at rest, neither single nor combined therapy altered global or regional left ventricular ejection fractions (EFs). Verapamil, but not propranolol, increased (p less than .05) cardiac volumes of resting subjects; used in combination, no further increase in LV volume occurred. With placebo, exercise global EF did not decrease from the level at rest and therefore no drug effect could be demonstrated for this parameter of LV function. By an evaluation of normalized regional EF measurements the combination was shown to reduce exercise-induced hypokinesis (placebo 52 +/- 20%, combination 61 +/- 23%; p less than .01). No significant improvement was noted with propranolol or verapamil alone; only the combination prevented a significant increase in end-systolic and end-diastolic volumes during exercise. Thus, propranolol and verapamil, used alone in moderate doses, exert no beneficial effect on exercise LV function as measured by EF and volume changes, and resting function deteriorates slightly with verapamil.(ABSTRACT TRUNCATED AT 250 WORDS)