Outcome of tracheotomized patients following reintubation.

OBJECTIVE: To evaluate the outcome of tracheotomized patients after reintubation. METHOD: Secondary analysis from a prospective, multicenter and observational study including 36 Intensive Care Units (ICUs) from 8 countries. PATIENTS: A total of 180 patients under mechanical ventilation for more than 48 hours, extubated and reintubated within 48 hours. INTERVENTIONS: None. OUTCOMES: ICU mortality, length of ICU stay, organ failure. RESULTS: Fifty-two patients (29%) underwent tracheotomy after reintubation. The median time from reintubation to tracheotomy was 2.5 days (interquartile range (IQR) 1-8 days). The length of ICU stay was significantly longer in the tracheotomy group compared with the group without tracheotomy (median time 25 days, IQR 17-43 versus 16.5 days (IQR 11-25); p<0.001). ICU mortality in the tracheotomy group was not significantly different (31% versus 27%; p 0.57). CONCLUSIONS: In our cohort of reintubated patients, tracheotomy is a common procedure in the ICU. Patients with tracheotomy had an outcome similar to those without tracheotomy.

Effects of four intraoperative ventilatory strategies on respiratory compliance and gas exchange during laparoscopic gastric banding in obese patients.

BACKGROUND: Respiratory function is impaired in obese patients undergoing laparoscopic surgery. This study was performed to determine whether repeated lung recruitment combined with PEEP improves respiratory compliance and arterial partial pressure of oxygen (Pa(O2)) in obese patients undergoing laparoscopic gastric banding. METHODS: Sixty patients with BMI >30 kg m(-2) were randomized, after induction of pneumoperitoneum, to receive either PEEP of 10 cm H2O (Group P), inspiratory pressure of 40 cm H2O for 15 s once (Group R), Group R recruitment followed by PEEP 10 cm H2O (Group RP), or Group RP recruitment but with the inspiratory manoeuvre repeated every 10 min (Group RRP). Static respiratory compliance and Pa(O2) were determined after intubation, 10 min after pneumoperitoneum (before lung recruitment), and every 10 min thereafter (after recruitment). Results are presented as mean (SD). RESULTS: Pneumoperitoneum decreased respiratory compliance from 48 (3) to 30 (1) ml cm H2O(-1) and decreased Pa(O2) from 12.4 (0.3) to 8.8 (0.3) kPa in all groups (P<0.01). Immediately after recruitment, compliance was 32 (1), 32 (2), 40 (2), and 40 (1) ml cm H2O(-1) and Pa(O2) was 9.1 (0.3), 9.1 (0.1), 11.9 (0.1), and 11.9 (0.1) kPa in Groups P, R, RP, and RRP, respectively (P<0.01). Ten and 20 min later, Pa(O2) in Group R decreased to 9.2 (0.1) kPa and compliance in Group PR decreased to 33 (2) ml cm H2O(-1), respectively (P<0.01). CONCLUSIONS: Group RRP recruitment strategy was associated with the best intraoperative respiratory compliance and Pa(O2) in obese patients undergoing laparoscopic gastric banding.

Effect of intraoperative intravenous acetaminophen vs. intramuscular meperidine on pain and discharge time after paediatric dental restoration.

BACKGROUND AND OBJECTIVE: Enteral acetaminophen (paracetamol) has limited analgesic efficacy due to its delayed absorption and sub-therapeutic plasma concentration. Intravenous (i.v.) acetaminophen solves this issue and could thus provide adequate analgesia as a single agent. We compared intraoperative i.v. acetaminophen with intramuscular (i.m.) meperidine with regard to postoperative analgesia and readiness for discharge in paediatric patients undergoing day care dental restoration. METHODS: Forty children were randomized, in this double-blind study, to receive acetaminophen 15 mg kg-1 i.v. (Group A) or meperidine 1 mg kg-1 i.m. (Group M) after anaesthesia induction and before surgery. All patients received midazolam 0.5 mg kg-1 orally 30 min preoperatively and fentanyl 1 microg kg-1 i.v. immediately after induction. Anaesthesia was induced with either sevoflurane inhalation or propofol 3 mg kg-1 i.v. and was maintained with sevoflurane. Postoperatively, the objective pain scale, Ramsay sedation score, and Aldrete score were determined every 5 min until readiness for recovery room discharge (defined as achieving an Aldrete score of 10). RESULTS: Group A had slightly higher pain scores during early recovery compared with Group M (estimated marginal means: 3 +/- SEM 0.4 vs. 2 +/- SEM 0.4, respectively (95% CI for difference: 0.4, 2.6), P = 0.012 for F-test). In contrast, Ramsay scores were higher in Group M than in Group A during assessment period (estimated marginal means: 4 +/- SEM 0.3 vs. 2 +/- SEM 0.4, respectively (95% CI for difference: -2.3, -0.3), P = 0.013 for F-test). Group A patients achieved an Aldrete score of 10 sooner than those in Group M (5 +/- SEM 2 vs. 16 +/- SEM 4 min, respectively (95% CI for difference: -9, -14), P = 0.009). CONCLUSION: Compared with i.m. meperidine, intraoperative i.v. acetaminophen resulted in slightly higher pain scores but earlier readiness for recovery room discharge in paediatric patients undergoing dental restoration. The potential economic benefit of early recovery room discharge needs to be further explored.

Dexmedetomidine vs midazolam for monitored anaesthesia care during cataract surgery.

BACKGROUND: Cataract surgery is commonly performed under local anaesthesia with midazolam sedation. Dexmedetomidine, a sedative-analgesic, is devoid of respiratory depressant effects, and its use in cataract surgery has not been reported. This double-blind study compared the use of dexmedetomidine and midazolam in patients undergoing cataract surgery. METHODS: Forty-four patients undergoing cataract surgery under peribulbar anaesthesia randomly received either i.v. dexmedetomidine 1 microg kg(-1) over 10 min; followed by 0.1-0.7 microg kg(-1) h(-1) i.v. infusion (Group D), or midazolam 20 microg kg(-1) i.v.; followed by 0.5 mg i.v. boluses as required (Group M). Sedation was titrated to a Ramsay sedation score of 3. Mean arterial pressure (MAP), heart rate (HR), readiness for recovery room discharge (time to Aldrete score of 10), and patients' and surgeons' satisfaction (on a scale of 1-7) were determined. RESULTS: MAP and HR were lower in Group D compared with Group M [86 (se 3) vs 102 (3) mm Hg and 65 (2) vs 72 (2) beats min(-1), respectively] (P<0.05). Group D patients had slightly higher satisfaction with sedation [median (IQR): 6 (6-7) vs 6 (5-7), P<0.05], but delayed readiness for discharge [45 (36-54) vs 21 (10-32) min, P<0.01] compared with patients in Group M. Surgeons' satisfaction was comparable in both groups [5 (4-6) vs 5 (4-6)]. CONCLUSION: Compared with midazolam, dexmedetomidine does not appear to be suitable for sedation in patients undergoing cataract surgery. While there was a slightly better subjective patient satisfaction, it was accompanied by relative cardiovascular depression and delayed recovery room discharge.

Effects of intraoperative i.v. acetaminophen vs i.m. meperidine on post-tonsillectomy pain in children.

BACKGROUND: Enteral acetaminophen, when used alone, is not very effective for postoperative analgesia because of delayed absorption and sub-therapeutic plasma concentrations. In contrast, i.v. acetaminophen is devoid of these shortcomings and could potentially provide adequate postoperative analgesia as a single agent. This randomized double-blind study compared the analgesic effects of i.v. acetaminophen and i.m. meperidine in paediatric patients undergoing tonsillectomy. METHODS: Eighty children undergoing tonsillectomy were randomized to receive either acetaminophen 15 mg kg(-1) i.v. (acetaminophen group) or meperidine 1 mg kg(-1) i.m. (meperidine group), intraoperatively. Anaesthesia was induced with either sevoflurane inhalation or propofol, and was maintained with sevoflurane. After operation, the objective pain scale (OPS), Ramsay sedation score and Aldrete score were recorded every 5 min, and nurses' satisfaction was determined on a 7-point scale (1-7). RESULTS: On admission to the recovery room, OPS scores were 3.1 (sem 0.3) for the acetaminophen group and 2.1 (sem 0.3) for the meperidine group (P=0.147); however, Ramsay sedation scores were 3 (sem 0.2) and 4 (sem 0.3) for the acetaminophen and meperidine groups, respectively (P<0.05). Patients in the meperidine group continued to be more sedated 5 min after arrival in recovery (P<0.05). Acetaminophen group patients achieved an Aldrete score of 10 min sooner than those in the meperidine group [median (IQR) time: 15 (0-20) min vs 25 (15-30) min, respectively, P=0.005]. Adjusted nurse satisfaction scores were similar in both groups [6.1 (sem 0.2) vs 5.7 (sem 0.2) min, P=0.311]. CONCLUSION: Compared with i.m. meperidine, i.v. acetaminophen provided adequate analgesia, less sedation and earlier readiness for recovery room discharge among paediatric patients undergoing tonsillectomy.

Treatment of cardiogenic shock with levosimendan in combination with beta-adrenergic antagonists.

Levosimendan, a calcium sensitizer, was used in combination with beta-adrenergic antagonists in a man aged 56 yr with cardiogenic shock, complicating acute myocardial infarction, who developed severe tachycardia after dobutamine administration. The patient's trachea was intubated, his lungs were ventilated, and he was started on dopamine 5 microg kg(-1) min(-1) and dobutamine 5 microg kg(-1) min(-1), titrated to a mean arterial pressure > or =65 mm Hg. He progressively became tachycardiac (>120 beats min(-1)) with a cardiac index (CI) of 1.4 litre min(-1) m(-2) despite adequate preload. Levosimendan 6 microg kg(-1) was administered intravenously over 10 min followed by a continuous infusion of 0.2 microg kg(-1) min(-1) for 24 h. Within 30 min, the patient's CI increased to 2.2 litre min(-1) m(-2), but the heart rate (HR) also increased from 142 to 155 beats min(-1). Esmolol 1 mg kg(-1) i.v. was administered with a consequent transient decrease in HR to 110 beats min(-1) without adverse haemodynamic effects; however, HR increased again shortly afterwards. Carvedilol 3.125 mg orally twice a day was then administered, and the dose was increased to 6.25 mg orally twice daily on the following day. Subsequently, HR decreased over time and both catecholamines were discontinued 14 h after starting levosimendan infusion. The trachea was extubated within 20 h and the patient was discharged to the ward on day 4 after admission. In conclusion, levosimendan in combination with a beta-adrenergic antagonist may have beneficial effects in patients with cardiogenic shock who exhibit tachycardia in response to inotropic agents.

Reduction of vasopressor requirement by hydrocortisone administration in a patient with cerebral vasospasm.

A 67-yr-old female received hypertensive, hypervolaemic treatment for cerebral vasospasm after severe subarachnoid haemorrhage. After 3 days of continuous vasopressor infusion and despite adequate hydration and normal cardiac function, the phenylephrine dose had to be increased to obtain the same systolic blood pressure. This tachyphylaxis to phenylephrine infusion was probably caused by down-regulation of alpha adrenoceptors, and was reversed by giving i.v. hydrocortisone.

Effect of intrathecal tramadol administration on postoperative pain after transurethral resection of prostate.

BACKGROUND: Tramadol administered epidurally has been demonstrated to decrease postoperative analgesic requirements. However, its effect on postoperative analgesia after intrathecal administration has not yet been studied. In this double-blind, placebo-controlled study, the effect of intrathecal tramadol administration on pain control after transurethral resection of the prostate (TURP) was studied. METHODS: Sixty-four patients undergoing TURP were randomized to receive bupivacaine 0.5% 3 ml intrathecally premixed with either tramadol 25 mg or saline 0.5 ml. After operation, morphine 5 mg i.m. every 3 h was administered as needed for analgesia. Postoperative morphine requirements, visual analogue scale for pain at rest (VAS) and sedation scores, times to first analgesic and hospital lengths of stay were recorded by a blinded observer. RESULTS: There were no differences between the groups with regard to postoperative morphine requirements (mean (SD): 10.6 (7.9) vs 9.1 (5.5) mg, P=0.38), VAS (1.6 (1.2) vs 1.2 (0.8), P=0.18) and sedation scores (1.2 (0.3) vs 1.2 (0.2), P=0.89). Times to first analgesic (6.3 (6.3) vs 7.6 (6.2) h, P=0.42) and length of hospital stay (4.7 (2.8) vs 4.4 (2.2) days, P=0.66) were similar in the two groups. CONCLUSION: Intrathecal tramadol was not different from saline in its effect on postoperative morphine requirements after TURP.

Treatment of milrinone-associated tachycardia with beta-blockers.

PURPOSE: To describe a case of milrinone-associated tachycardia that was successfully treated with two beta-blockers. CLINICAL FEATURES: A 74-yr-old male patient underwent elective abdominal aortic aneurysm repair under combined epidural/general anaesthesia. He had a history of alcohol abuse, controlled hypertension and ischaemic heart disease. Postoperatively, the patient had persistent sinus tachycardia that was initially unsuccessfully treated with metoprolol. Subsequently, the patient's blood pressure and cardiac index decreased with an associated increase in pulmonary artery pressure. Analysis of the ST-segment revealed no evidence of myocardial ischaemia or infarction. These haemodynamic changes were treated with milrinone which exacerbated the baseline tachycardia without adverse blood pressure response. The subsequent administration of beta-blockers (esmolol and metoprolol) was successful in controlling the heart rate response to milrinone without adversely affecting the patient's haemodynamic profile. CONCLUSION: This report demonstrates the efficacy of esmolol and metoprolol for the treatment of milrinone-associated tachycardia, without compromising the haemodynamic effects of milrinone.

Effect of subarachnoid morphine administration on extubation time after coronary artery bypass graft surgery.

OBJECTIVE: To determine the effects of 2 low doses of intrathecal morphine on extubation time and on postoperative analgesic requirements after coronary artery bypass graft (CABG) surgery. DESIGN: A prospective, randomized, double-blind, placebo-controlled study. SETTING: Tertiary-care university hospital. PARTICIPANTS: Fifty adult patients scheduled for elective primary CABG surgery. INTERVENTIONS: Patients were randomized to receive placebo, 250 microg, or 500 microg intrathecal morphine, preoperatively. Intraoperative fentanyl and midazolam were limited to 15 microg/kg and 20 microg/kg intravenously. Patients were extubated in the intensive care unit by a blinded observer using predefined extubation criteria. MEASUREMENTS AND MAIN RESULTS: Time to extubation and postoperative requirements for morphine, midazolam, nitroglycerin, and sodium nitroprusside were recorded by a blinded observer. Extubation times were 441 +/- 207 minutes versus 325 +/- 188 minutes versus 409 +/- 245 minutes for the placebo, 250-microg, and 500-microg groups (p = 0.27). Postoperative morphine requirements in the 250-microg and 500-microg groups were 13.6 +/- 7.8 mg and 11.7 +/- 7.4 mg, compared with 21.3 +/- 6.2 mg in the placebo group (p = 0.001). There were no differences among the study groups with regard to postoperative midazolam, nitroglycerin, and sodium nitroprusside requirements. CONCLUSIONS: Despite decreased postoperative morphine requirements, intrathecal morphine administration did not have a clinically relevant effect on extubation time after CABG surgery. This study suggests that 250 microg is the optimal dose of intrathecal morphine to provide significant postoperative analgesia without delaying tracheal extubation.

Cost-effectiveness of inhalational, balanced and total intravenous anaesthesia for ambulatory knee surgery.

PURPOSE: A randomized, blinded clinical trial was undertaken to compare recovery characteristics and cost-benefits associated with three general anaesthetic techniques for arthroscopic knee surgery in an ambulatory care setting. METHODS: Ninety three, ASA Physical Status I-II patients were randomly allocated to receive one of three types of general anaesthesia: isoflurane/fentanyl/N2O (Group INH); alfentanil/N2O (Group BAL); or propofol/alfentanil/O2 (Group TIVA). Postoperative recovery profiles were evaluated at 30, 60, 90 and 120 min after emergence from anaesthesia, and direct and indirect costs of each anaesthetic were compared. RESULTS: The most rapid emergence was observed in Group BAL (2.2 +/- 1.5 min, P < 0.0001 compared with groups INH and TIVA), although the incidence of post-operative nausea and vomiting was also highest in this group (P = 0.02 compared with groups INH and TIVA). However, overall patient satisfaction, and mean times to discharge from the Post Anesthesia Recovery Unit and hospital, were rapid and similar in all three groups. During anaesthesia which lasted 40-45 min, nearly a four-fold difference was observed in the direct costs of anaesthetic drugs: $16.4 +/- 4.4 (Group INH), $45.3 +/- 11.4 (Group BAL) and $63.4 +/- 17.9 (Group TIVA, P < 0.001 between groups); while indirect costs were similar. CONCLUSIONS: For arthroscopic knee surgery, INH anaesthesia with isoflurane/fentanyl/N2O is associated with similar hospital discharge times, and comparable levels of patient satisfaction as either BAL or TIVA. While indirect costs were similar, lower direct costs suggest that there may be a pharmacoeconomic benefit associated with the use of a "standard" isoflurane/fentanyl/N2O anaesthetic in certain day care surgery procedures.

Treatment of intrathecal morphine-induced pruritus following caesarean section.

PURPOSE: To compare both the efficacy and cost of nalbuphine and diphenhydramine in the treatment of intrathecal morphine-induced pruritus following Caesarean section. METHODS: Eighty patients, undergoing elective Caesarean section under spinal anaesthesia, were randomized, in a prospective, double-blind trial, to receive either nalbuphine (Group NAL) or diphenhydramine (Group DIP) for the treatment of SAB morphine-induced pruritus. All patients received an intrathecal injection of 10-12 mg hyperbaric bupivacaine 0.75% and 200 micrograms preservative free morphine. Postoperative pruritus was assessed, using a visual analogue scale (VAS), for 24 hr. Pruritus treatment was administered upon patient request and by a nurse blinded to the treatment given. Patients who failed to respond to three doses of the study drug were deemed treatment failures. Patient satisfaction was assessed with a questionnaire given 24 to 48 hr after surgery. Direct drug costs were calculated based on the pharmacy provision costs as of April 1996. RESULTS: Eighty patients were enrolled and 45 requested treatment for pruritus. Patients treated with NAL (n = 24) were more likely to achieve a VAS score of zero with treatment (83% vs 43%, P < 0.01), had a higher delta VAS following treatment (4 +/- 2 vs 2 +/- 2, P < 0.003), and experienced fewer treatment failures (4% vs 29%, P < 0.04), than those treated with DIP (n = 21). Group NAL patients were also more likely to rate their pruritus treatment as being good to excellent (96% vs 57%, P < 0.004). Direct drug costs were higher for NAL than for DIP ($6.4 +/- 3.1 vs $1.7 +/- 0.7, respectively, P < 0.0001). CONCLUSION: Nalbuphine is more effective than diphenhydramine in relieving pruritus caused by intrathecal morphine and the cost differences are small.