Acute postoperative pain in lung transplant recipients.

BACKGROUND: This retrospective study was designed to assess the quality of postoperative pain control and the facility of transition from epidural to oral analgesia in lung transplant recipients. METHODS: After institutional review board approval, data were collected from the charts of all patients who underwent lung transplantation at our institution between 1998 and 2002. The study group consisted of the patients for whom an epidural was the first postoperative pain management modality. To serve as a control group we reviewed the charts of 30 patients, randomly selected over the same period, who underwent a thoracotomy for indications other than transplantation and who received postoperative epidural analgesia. RESULTS: Eighty-three patients were available for analysis. Unilateral and bilateral lung transplant recipients had equivalent quality of pain control. However, lung transplant recipients had a lower incidence of adequate pain relief than patients undergoing thoracotomy for other indications (73% vs 87%, p < 0.05). Lung transplant recipients also had a higher incidence of epidural to oral analgesia transition failure (47% vs 20%, p < 0.01). CONCLUSIONS: This is the first study to assess the quality of postoperative pain control and success of transition from epidural to oral analgesia in lung transplant recipients. Prospective studies are needed to assess the impact of our findings on patients' outcome.

Cisatracurium pharmacodynamics in patients with oculopharyngeal muscular dystrophy.

The pharmacodynamics of muscle relaxants in patients with oculopharyngeal muscular dystrophy (OPMD) have never been studied. We designed this study to compare the pharmacodynamics of cisatracurium in OPMD patients versus a control group. Forty patients were enrolled: 20 OPMD patients requiring general anesthesia for cricopharyngeal myotomy and 20 age-matched controls undergoing an operation of similar duration and expected blood loss. Anesthesia was standardized, and both groups received a bolus of cisatracurium 0.1 mg/kg. Onset time, time to 10% T1 recovery, and the intervals 10%-25% and 25%-75% were calculated for both groups. A subgroup analysis was performed in patients with a more severe form of OPMD. Demographic and intraoperative data were similar. Onset time was significantly longer in OPMD patients compared with the control group (4.6 +/- 1.5 min versus 3.4 +/- 1.0 min; P = 0.001). There was no difference in recovery times or indices between groups, regardless of the severity of the disease. In conclusion, there was no difference in the duration of a cisatracurium-induced neuromuscular block between OPMD patients and a control group. A delayed onset of action of the drug may occur.

Cisatracurium-induced neuromuscular blockade is affected by chronic phenytoin or carbamazepine treatment in neurosurgical patients.

The effect of chronic anticonvulsant therapy (CAT) on the maintenance and recovery profiles of cisatracurium-induced neuromuscular blockade has not been adequately studied. In this study, we compared the pharmacokinetics and pharmacodynamics of cisatracurium after a prolonged infusion in patients with or without CAT. Thirty patients undergoing intracranial surgery were enrolled in the study: 15 patients under CAT (carbamazepine and phenytoin, Group A) and 15 controls receiving no anticonvulsant therapy (Group C). Anesthesia was standardized and both groups received a bolus of cisatracurium followed by an infusion to maintain a 95% twitch depression. A steady-state was obtained and the infusion was kept constant for 2 additional hours. Neuromuscular blockade was then allowed to spontaneously recover. Blood samples were taken for measurement of cisatracurium plasma concentration during the steady-state period (Cp(ss)95) and at various times during recovery. Demographic and intraoperative data were similar. CAT resulted in faster 25% and 75% recovery of the first twitch. The rate of infusion of cisatracurium needed to maintain a 95% twitch depression at steady-state was 44% faster in Group A (P < 0.001). The clearance of cisatracurium was significantly faster in Group A when compared with Group C (7.12 +/- 1.87 versus 5.72 +/- 0.70 L . kg(-1) . min(-1), P = 0.01). The Cp(ss)95 was also significantly larger in Group A (191 +/- 45 versus 159 +/- 36 ng/mL, P = 0.04). In addition, patients receiving CAT had a 20% increase in the clearance of cisatracurium that, in turn, resulted in a faster recovery of neuromuscular blockade after an infusion of the drug. Also, patients under CAT had a 20% increase in their Cp(ss)95, indicating an increased resistance to the effect of cisatracurium.

The effect of propofol sedation on the intracranial pressure of patients with an intracranial space-occupying lesion.

The fear of producing CO(2) retention and a secondary increase of intracranial pressure (ICP) sometimes precludes the use of sedation for the spontaneously breathing patient in the presence of an intracranial space-occupying lesion. In this study we assessed the effect of moderately deep propofol sedation on the ICP of patients undergoing stereotactic brain tumor biopsy under regional anesthesia. Thirty patients were randomized into 2 groups to receive propofol titrated to a level of 2 on the Observer's Assessment of Alertness/Sedation Scale or no sedation. ICP was measured via the biopsy needle. Preoperative data were similar in both groups. During surgery, patients receiving propofol had a higher arterial Pco(2) (48 +/- 8 mm Hg versus 41 +/- 3 mm Hg; P = 0.005) (95% confidence interval, 43-53 mm Hg and 39-43 mm Hg, respectively), resulting in a lower arterial pH (P = 0.002) than patients in the no-sedation group. The median ICP (95% confidence interval) for both groups was similar-13 mm Hg (8.2-16.2 mm Hg) and 15 mm Hg (8.3-21.7 mm Hg)-for the propofol and no-sedation groups, respectively (P = 0.66). Cerebral perfusion pressure was lower in the propofol group (76 +/- 18 mm Hg versus 89 +/- 18 mm Hg; P = 0.003). Moderately deep propofol sedation does not result in a higher ICP than no sedation in patients undergoing stereotactic brain tumor biopsy. Further studies are needed to assess the effect on ICP of other sedative medications.

The effect of music on the neurohormonal stress response to surgery under general anesthesia.

UNLABELLED: Several pharmacological interventions reduce perioperative stress hormone release during surgery under general anesthesia. Listening to music and therapeutic suggestions were also studied, but mostly in awake patients, and these have a positive effect on postoperative recovery and the need for analgesia. In this study, we evaluated the effect of listening to music under general anesthesia on the neurohormonal response to surgical stress as measured by epinephrine, norepinephrine, cortisol, and adrenocorticotropic hormone (ACTH) blood levels. Thirty female patients scheduled for abdominal gynecological procedures were enrolled and randomly divided into two groups: group NM (no music) and group M (music). In group M, music was played from after the induction of anesthesia until the end of surgery. In the NM group, the patients wore the headphones but no music was played. We established three sample times for hormonal dosage during the procedure and one in the recovery room. Hemodynamic data were recorded at all times, and postoperative consumption of morphine in the first 24 h was noted. There was no group difference at any sample time or in the postoperative period in terms of mean arterial blood pressure, heart rate, isoflurane end-tidal concentration, time of the day at which the surgery was performed, bispectral index (BIS) value, doses of fentanyl, or consumption of postoperative morphine. There was no difference between the two groups with regard to plasmatic levels of norepinephrine, epinephrine, cortisol, or ACTH at any sample time, although the blood level of these hormones significantly increased in each group with surgical stimulation. In conclusion, we could not demonstrate a significant effect of intraoperative music on surgical stress when used under general anesthesia. IMPLICATIONS: Listening to music under general anesthesia did not reduce perioperative stress hormone release or opioid consumption in patients undergoing gynecological surgery.