The efficacy of elastomeric patient-control module when connected to a balloon pump for postoperative epidural analgesia: A randomized, noninferiority trial.

When considering the principles of a pain control strategy by patients, reliable administration of additional bolus doses is important for providing the adequate analgesia and improving patient satisfaction. We compared the efficacy of elastomeric patient-control module (PCM) with conventional PCM providing epidural analgesia postoperatively.A noninferiority comparison was used. Eighty-six patients scheduled for open upper abdominal surgery were randomized to use either an elastomeric or conventional PCM connected to balloon pump. After successful epidural catheter insertion at T6-8 level, fentanyl (15-20 µg/kg) in 0.3% ropivacaine 100 mL was administered at basal rate 2 mL/h with bolus 2 mL and lock-out time 15 minutes. The primary outcome was the verbal numerical rating score for pain.The 95% confidence intervals for differences in pain scores during the first 48 hours postoperatively were <1, indicating noninferiority of the elastomeric PCM. The duration of pump reservoir exhaustion was shorter for the elastomeric PCM (mean [SD], 33 hours [8 hours] vs 40 hours [8 hours], P = 0.0003). There were no differences in the frequency of PCM use, additional analgesics, or adverse events between groups.The elastomeric PCM was as effective as conventional PCM with and exhibited a similar safety profile.

Bispectral index monitoring during anesthesiologist-directed propofol and remifentanil sedation for endoscopic submucosal dissection: a prospective randomized controlled trial.

PURPOSE: Endoscopic submucosal dissection (ESD) is a technically difficult and lengthy procedure requiring optimal depth of sedation. The bispectral index (BIS) monitor is a non-invasive tool that objectively evaluates the depth of sedation. The purpose of this prospective randomized controlled trial was to evaluate whether BIS guided sedation with propofol and remifentanil could reduce the number of patients requiring rescue propofol, and thus reduce the incidence of sedation- and/or procedure-related complications. MATERIALS AND METHODS: A total of 180 patients who underwent the ESD procedure for gastric adenoma or early gastric cancer were randomized to two groups. The control group (n=90) was monitored by the Modified Observer's Assessment of Alertness and Sedation scale and the BIS group (n=90) was monitored using BIS. The total doses of propofol and remifentanil, the need for rescue propofol, and the rates of complications were recorded. RESULTS: The number of patients who needed rescue propofol during the procedure was significantly higher in the control group than the BIS group (47.8% vs. 30.0%, p=0.014). There were no significant differences in the incidence of sedation- and/or procedure-related complications. CONCLUSION: BIS-guided propofol infusion combined with remifentanil reduced the number of patients requiring rescue propofol in ESD procedures. However, this finding did not lead to clinical benefits and thus BIS monitoring is of limited use during anesthesiologist-directed sedation.

Finding the 'ideal' regimen for fentanyl-based intravenous patient-controlled analgesia: how to give and what to mix?

PURPOSE: This analysis was done to investigate the optimal regimen for fentanyl-based intravenous patient-controlled analgesia (IV-PCA) by finding a safe and effective background infusion rate and assessing the effect of adding adjuvant drugs to the PCA regimen. MATERIALS AND METHODS: Background infusion rate of fentanyl, type of adjuvant analgesic and/or antiemetic that was added to the IV-PCA, and patients that required rescue analgesics and/or antiemetics were retrospectively reviewed in 1827 patients who underwent laparoscopic abdominal surgery at a single tertiary hospital. RESULTS: Upon multivariate analysis, lower background infusion rates, younger age, and IV-PCA without adjuvant analgesics were identified as independent risk factors of rescue analgesic administration. Higher background infusion rates, female gender, and IV-PCA without additional 5HT3 receptor blockers were identified as risk factors of rescue antiemetics administration. A background infusion rate of 0.38 µg/kg/hr [area under the curve (AUC) 0.638] or lower required rescue analgesics in general, whereas, addition of adjuvant analgesics decreased the rate to 0.37 µg/kg/hr (AUC 0.712) or lower. A background infusion rate of 0.36 µg/kg/hr (AUC 0.638) or higher was found to require rescue antiemetics in general, whereas, mixing antiemetics with IV-PCA increased the rate to 0.37 µg/kg/hr (AUC 0.651) or higher. CONCLUSION: Background infusion rates of fentanyl between 0.12 and 0.67 µg/kg/hr may safely be used without any serious side effects for IV-PCA. In order to approach the most reasonable background infusion rate for effective analgesia without increasing postoperative nausea and vomiting, adding an adjuvant analgesic and an antiemetic should always be considered.

Risk assessment of postoperative nausea and vomiting in the intravenous patient-controlled analgesia environment: predictive values of the Apfel's simplified risk score for identification of high-risk patients.

PURPOSE: Opioid-based intravenous patient-controlled analgesia (IV PCA) is popular method of postoperative pain control, but many patients suffer from IV PCA-related postoperative nausea and vomiting (PONV). In this retrospective observational study, we have determined independent predictors of IV PCA-related PONV and predictive values of the Apfel's simplified risk score in pursuance of identifying high-risk patients. MATERIALS AND METHODS: We analyzed 7000 patients who received IV PCA with background infusion after elective surgery. Patients who maintained IV PCA for a postoperative period of 48 hr (completion group, n=6128) were compared with those who have discontinued IV PCA within 48 hr of surgery due to intractable PONV (cessation group, n=872). Patients, anesthetics, and surgical factors known for predicting PONV were evaluated by logistic regression analysis to identify independent predictors of IV PCA related intractable PONV. RESULTS: In a stepwise multivariate analysis, weight, background infusion dose of fentanyl, addition of ketolorac to PCA, duration of anesthesia, general anesthesia, head and neck surgery, and Apfel's simplified risk score were revealed as independent risk factors for intractable PONV followed by the cessation of IV PCA. In addition, Apfel's simplified risk score, which demonstrated the highest odds ratio among the predictors, was strongly correlated with the cessation rate of IV PCA. CONCLUSION: Multimodal prophylactic antiemetic strategies and dose reduction of opioids may be considered as strategies for the prevention of PONV with the use of IV PCA, especially in patients with high Apfel's simplified risk scores.

Patient-controlled Epidural Analgesia with Ropivacaine and Fentanyl: Experience with 2,276 Surgical Patients.

BACKGROUND: Good postoperative pain control is an important part of adequate postoperative care. Patient-controlled epidural analgesia (PCEA) provided better postoperative analgesia compared to other conventional analgesic methods, but several risks have been observed as well. We therefore surveyed the efficacy and safety of PCEA in this retrospective observational study. METHODS: We analyzed collected data on 2,276 elective surgical patients who received PCEA with ropivacaine and fentanyl. Patients were assessed by a PCA service team in the post-anesthesia care unit (PACU), at 1-6 h, 6-24 h, and 24-48 h postoperatively for adequate pain control. The presence of PCEA-related adverse events was also assessed. RESULTS: Numerical pain score (median [interquartile range]) were 3 [1-4], 5 [4-7], 4 [3-5], and 3 [3-5] in the PACU, at 1-6 h, 6-24 h, and 24-48 h postoperatively. Median pain scores in patients underwent major abdominal or thoracic surgery were higher than other surgical procedure in the PACU, at 1-6 h after surgery. Nausea and vomiting (20%) and numbness and motor weakness (15%) were revealed as major PCEA-related adverse events during the postoperative 48 h period. There were 329 patients (14%) for whom PCEA was ceased within 48 h following surgery. CONCLUSIONS: Our data suggest that the use of PCEA provides proper analgesia in the postoperative 48 h period after a wide variety of surgical procedures and that is associated with few serious complications. However, more careful pain management and sustainable PCEA monitoring considering the type of surgical procedure undergone is needed in patients with PCEA.

Anesthetic experience of a patient with relapsing polychondritis -A case report-.

Relapsing polychondritis is a rare disease characterized by progressive inflammation and destruction of cartilaginous structures such as ears, nose, and tracheolaryngeal structures. As a result, tracheolaryngeal involvement makes anesthetic management a challenge. Anesthetic management of a patient with relapsing polychondritis may encounter airway problems caused by severe tracheal stenosis. We present the case of a 60-year-old woman with relapsing polychondritis who underwent wedge resection of the stomach under epidural analgesia. Thoracic epidural blockade of the T4-10 dermatome was achieved by epidural injection of 7 ml of 0.75% ropivacaine and 50 µg of fentanyl. The patient was tolerable during the operation. We suggest that epidural analgesia may be an alternative to general anesthesia for patients with relapsing polychondritis undergoing upper abdominal surgery.

Effect of caudal block on sevoflurane requirement for lower limb surgery in children with cerebral palsy.

BACKGROUND: Caudal block is a widely used technique for providing perioperative pain management in children. In this randomized double-blinded study, we evaluated the effects of preoperative caudal block on sevoflurane requirements in children with cerebral palsy (CP) undergoing lower limb surgery while bispectral index (BIS) values were maintained between 45 and 55. METHODS: 52 children undergoing Achilles-tendon lengthening were randomized to receive combined general-caudal anesthesia (caudal group, n = 27) or general anesthesia alone (control group, n = 25). Caudal block was performed with a single dose of 0.7 ml·kg(-1) of 1.0% lidocaine containing epinephrine at 5 µg·ml(-1). The control group received no preoperative caudal block. The endtidal sevoflurane concentrations (ET(sev)) were adjusted every minute to maintain the BIS values between 45 and 55. RESULTS: The ET(sev) required to maintain the BIS values were not significantly different between the control and caudal groups after induction of anesthesia [2.1 (0.2) vs 2.2 (0.4); P = 0.773]. However, significantly higher ET(sev) was observed in the control group before surgical incision [2.0 (0.2) vs 1.8 (0.3); P = 0.013] and during the first 20 min after surgical incision [2.2 (0.3) vs 1.4 (0.3); P < 0.001]. There was no significant difference in BIS values between the control and caudal groups throughout the study period (P > 0.05). In the caudal group, the caudal block was successful in 25 of 27 (92.6%) patients. CONCLUSIONS: Caudal block effectively reduced sevoflurane requirements by 36% compared to general anesthesia alone in children with CP undergoing lower limb surgery while BIS values were maintained between 45 and 55.

A randomized, clinical trial of frozen versus standard nasogastric tube placement.

BACKGROUND: Insertion of a nasogastric tube (NGT) in an anesthetized, paralyzed, and intubated patient is difficult, and many methods have been proposed to aid in the procedure. We present a simple insertion technique. METHODS: A silicone NGT was made rigid by filling it with distilled water and freezing it. Patients were randomized into either the control or the frozen group, and an NGT was inserted after intubation. RESULTS: A total of 100 patients (50 in each group) were included in this study. The success rate increased significantly by making the tube more rigid (control:frozen = 58%:88%; p = 0.001). There was no difference between groups in the incidence of nasal bleeding. CONCLUSIONS: A simple method of freezing an NGT with distilled water increased the success rate of insertion for intubated patients.

Spinal anesthesia with isobaric tetracaine in patients with previous lumbar spinal surgery.

PURPOSE: Previous lumbar spinal surgery (PLSS) is not currently considered as a contraindication for regional anesthesia. However, there are still problems that make spinal anesthesia more difficult with a possibility of worsening the patient's back pain. Spinal anesthesia using combined spinal-epidural anesthesia (CSEA) in elderly patients with or without PLSS was investigated and the anesthetic characteristics, success rates, and possible complications were evaluated. MATERIALS AND METHODS: Fifty patients without PLSS (Control group) and 45 patients with PLSS (PLSS group) who were scheduled for total knee arthroplasty were studied prospectively. A CSEA was performed with patients in the left lateral position, and 10 mg of 0.5% isobaric tetracaine was injected through a 27 G spinal needle. An epidural catheter was then inserted for patient controlled analgesia. Successful spinal anesthesia was defined as adequate sensory block level more than T12. The number of skin punctures and the onset time were recorded, and maximal sensory block level (MSBL), time to 2-segment regression, success rate and complications were observed. RESULTS: The success rate of CSEA in Control group and PLSS group was 98.0%, and 93.3%, respectively. The median MSBL in PLSS group was higher than Control group [T4 (T2-L1) vs. T6 (T3-T12)] (p < 0.001). There was a significant difference in the number of patients who required ephedrine for the treatment of hypotension in PLSS group (p = 0.028). CONCLUSION: The success rate of CSEA in patients with PLSS was 93.3%, and patients experienced no significant neurological complications. The MSBL can be higher in PLSS group than Control group.

Spinal anesthesia with 3.75 mg of 0.25% hyperbaric bupivacaine for diabetic foot surgery.

BACKGROUND: Spinal anesthesia in the sitting position with low-dose local anesthetics usually provides satisfactory anesthesia for diabetic foot surgery because most operations do not require tourniquet application. This study was designed to investigate the influence of different sitting periods after subarachnoid injection of low dose bupivacaine on the spread of analgesia. METHODS: In this randomized, controlled clinical trial, 60 patients undergoing diabetic foot surgery under spinal anesthesia without a tourniquet were randomized to three groups. Patients remained sitting for 2 (Group D2, n = 20), 5 (Group D5, n = 20), or 10 (Group D10, n = 20) min after the completion of subarachnoid administration of 3.75 mg of 0.25% hyperbaric bupivacaine solution. They were then placed in the supine position. Analgesia levels were assessed bilaterally using pinpricks. Blood pressure and heart rate were also recorded. RESULTS: The maximal sensory block level [median (range)] was higher in Group D2 [L3 (L2-L3)] compared with Group D10 [L4 (L3-L4)] (P = 0.002). The highest sensory block levels were T12, T11, and L2 in Group D2, 5 and 10, respectively. There were no hemodynamic differences among the three groups and none of the patients showed hemodynamic instability except for one patient in Group D10. CONCLUSIONS: Although spinal anesthesia using a minimal dose of 0.25% hyperbaric bupivacaine provides adequate anesthesia for diabetic foot surgery without profound hypotension, regardless of the time spent in the sitting position, maintaining the position for 10 min required to confine the sensory blockade on the lower level.

Anesthetic experience for orthopedic surgery on a patient with Glanzmann's thrombasthenia refractory to platelet transfusion: A case report.

Glanzmann's thrombasthenia is an autosomal recessive bleeding disorder caused by qualitative or quantitative abnormalities of the platelet glycoprotein IIb/IIIa (GP IIb/IIIa), which can lead to excessive bleeding. Glanzmann thrombasthenia is associated with clinical variability, with some patients only having minimal bruising and others having frequent, severe and potentially fatal hemorrhages. Platelet transfusions, which used to be the standard treatment, may lead to the development of antibodies to HLA and/or GPIIb/IIIa, thereby rendering future transfusions ineffective. Glanzmann's thrombasthenia can be a severe hemorrhagic disease; however, the prognosis is excellent with careful supportive care. In this case, administering allogenic plateletpheresis to patients with Glanzmann's thrombasthenia who were refractory to platelet transfusions was found to be successful during bone surgeries.

Nitroglycerin- and nicardipine-induced hypotension does not affect cerebral oxygen saturation and postoperative cognitive function in patients undergoing orthognathic surgery.

PURPOSE: The aim of this study was to investigate the influence of nitroglycerin- and nicardipine-induced hypotension on regional cerebral oxygen saturation (rSO(2)) and postoperative cognitive function in patients undergoing orthognathic surgery. PATIENTS AND METHODS: Sixty adult patients scheduled for orthognathic surgery were randomly assigned to either the nitroglycerin group (group 1) or nicardipine group (group 2). After induction of anesthesia, hypotension was induced with continuous infusion of nitroglycerin or nicardipine. Mean arterial pressure (MAP), heart rate (HR), and rSO(2) were measured at the following time points: before induction of anesthesia, immediately before commencing induced hypotension, at 30 and 60 minutes after induced hypotension, and immediately before the end of surgery. Cerebral desaturation was defined as a reduction of rSO(2) less than 75% of baseline for > or = 15 seconds. The Mini Mental State Examination (MMSE) was conducted before surgery and then repeated after 1 week. RESULTS: Baseline rSO(2) values were similar in the 2 groups. There were no significant differences in rSO(2) values between the 2 groups. Cerebral desaturation was not observed in any of the patients. Both nitroglycerin and nicardipine reduced MAP and increased HR during induced hypotension as compared with the baseline values (P < .05). No differences in MAP and HR during baseline and induced hypotension were observed between the 2 groups. Decreased MMSE scores were not observed in any of the patients. CONCLUSION: Cerebral oxygen saturation and postoperative cognitive function were not impaired during nitroglycerin- and nicardipine-induced hypotension in patients undergoing orthognathic surgery.

The duration of intrathecal bupivacaine mixed with lidocaine.

BACKGROUND: Although spinal bupivacaine may have too long duration to be useful in the ambulatory setting, recent animal data suggest that lidocaine added to spinal bupivacaine may reduce the duration of bupivacaine spinal anesthesia. We explored whether lidocaine added to spinal bupivacaine could shorten the duration of bupivacaine spinal anesthesia in humans similarly to what has been reported in animals. METHODS: Ninety patients presenting for transurethral resection of bladder tumor or prostate were assigned to one of three groups by double blind randomization to receive intrathecal 1.5 mL of hyperbaric 0.5% bupivacaine, plus 0.6 mL of one of three solutions: saline (Group I, n = 30, control), 1% lidocaine (Group II, n = 30), and 2% lidocaine (Group III, n = 30). Peak sensory block level, time to peak sensory block, times to two-segment, L1, and S2 regressions from peak sensory block, motor blocks at peak sensory block, L1, and S2 regressions, and postanesthesia care unit stay time (PACU time) were measured. RESULTS: Times to peak sensory block were similar in all three groups. Times to two-segment, L1, and S2 regressions from peak sensory block, and PACU time were significantly reduced in Group II compared to Group I. Times to L1, S2 regressions, and PACU times in Group III were significantly prolonged. CONCLUSIONS: We conclude that lidocaine (6 mg) mixed to spinal bupivacaine (7.5 mg) can shorten the duration of bupivacaine spinal anesthesia, therefore provide more rapid recovery from the spinal anesthesia compared to the same dose of bupivacaine (7.5 mg) alone.

Neutralized rocuronium (pH 7.4) before administration prevents injection pain in awake patients: a randomized prospective trial.

STUDY OBJECTIVE: To determine (1) the amount of 8.4% sodium bicarbonate (NaHCO(3)) to adjust the pH of rocuronium to 7.4 (neutralization), (2) to show whether neutralizing the pH of rocuronium can prevent pain, and (3) to confirm that rocuronium mixed with NaHCO(3) does not change the physical property and efficacy of rocuronium. DESIGN: Prospective studies. SETTING: University medical center. PATIENTS: 180 ASA physical status I and II women patients undergoing elective gynecologic surgery. INTERVENTIONS AND MEASUREMENTS: 60 patients were randomly allocated to group 1 (rocuronium only), group 2 (rocuronium 50 mg mixed with 0.9% NaCl 3 mL), and group 3 (rocuronium 50 mg mixed with 8.4% NaHCO(3) 3 mL). All patients received mixtures equal to 0.04 mg/kg of rocuronium and were asked to evaluate their pain with visual analog scale (VAS) and pain scores. In other settings, the onset time and duration of action of each group of rocuronium were measured. The dose of rocuronium required to produce a 50% twitch depression (ED(50)) was calculated. MAIN RESULTS: The amount of 8.4% NaHCO(3) needed to neutralize 50 mg of rocuronium was 3.1 +/- 0.3 mL. VAS scores were lower in group 3 than in groups 1 or 2 (P < 0.05). There were no differences in onset time, duration of action, or ED(50) values among the groups. CONCLUSIONS: Rocuronium neutralized with NaHCO(3) prevents intravenous injection pain. The physical and pharmacologic properties of rocuronium mixed with NaHCO(3) immediately before administration are not altered.

Optimal end-tidal concentration of sevoflurane to test an ankle clonus in children.

STUDY DESIGN: A prospective randomized study on the end-tidal concentrations of sevoflurane at which ankle clonus existed. SUMMARY OF BACKGROUND DATA: The ankle clonus reflex is a transient neurologic abnormality, which normally occurs in patients during emergence from general anesthesia. OBJECTIVE: To determine the optimal end-tidal concentration of sevoflurane to test an ankle clonus in children during emergence from general anesthesia. METHODS: We studied 30 children (aged 5-15 years). General anesthesia was induced with thiopental sodium. Anesthesia was maintained with sevoflurane, oxygen, and air. At completion of surgery, 3% volume of the end-tidal sevoflurane concentration was maintained for at least 10 minutes. Ankle clonus was checked at 1.0% to 0.1% volume of the end-tidal sevoflurane concentration with an interval of 0.05% volume. RESULTS: Of children, 80% had bilateral ankle clonus, which was found most frequently when patients responded poorly to verbal commands. The median of the end-tidal sevoflurane concentration for a reactive ankle clonus was 0.45% volume (interquartile range 0.5% to 0.4% volume). CONCLUSIONS: The ankle clonus should be tested at 0.45% volume of end-tidal sevoflurane concentration in children undergoing scoliosis surgery during emergence from the general anesthesia.

Optimal end-tidal sevoflurane concentration for the removal of the laryngeal mask airway in anesthetized adults.

UNLABELLED: Sevoflurane provides smooth and rapid emergence from anesthesia and can be used when the removal of a laryngeal mask airway (LMA) is required in anesthetized patients. We sought to determine the optimal end-tidal concentrations of sevoflurane required for the removal of LMA in anesthetized adults. We studied 35 adults, aged 22-64 years old with an ASA physical status I or II, who were undergoing perineal surgery. General anesthesia was induced with thiopental, and the LMA was then inserted. Anesthesia was maintained with sevoflurane, oxygen, and air. After the surgery, the target concentration was maintained for at least 10 min, and then the LMA was removed. Each target concentration at the time of removal was predetermined by the Dixon up-down method (with 0.1% as a step size) starting at 1.7% end-tidal concentration of sevoflurane. The LMA removal was considered successful when there was no coughing, clenching of teeth, or gross purposeful movements during or within 1 min after removal and also if there was no breath holding, laryngospasm, or desaturation after removal. The end-tidal concentration of sevoflurane to achieve successful LMA removal in 50% of adults was 0.99% +/- 0.09% (mean +/- SD) and in 95% of adults was 1.18% (95% confidence limits, 1.07%-1.79%). In conclusion, we have determined that LMA removal in 50% and 95% of anesthetized adults can be safely accomplished without coughing, moving, or any other airway complications at 0.99% and 1.18% end-tidal concentrations of sevoflurane. IMPLICATIONS: Because the removal of the laryngeal mask airway (LMA) in the anesthetized state is required in some clinical situations, we sought to determine the end-tidal concentration of sevoflurane to safely remove the LMA in anesthetized adults.

Comparison of continuous epidural and intravenous analgesia for postoperative pain control in pediatric lower extremity surgery.

In recent years epidural anesthesia and analgesia techniques were used in pediatric surgery owing to the development of pediatric epidural catheter needles. And the need of postoperative pain control in pediatric patients is also increasing. We compared combined general-epidural anesthesia and analgesia technique with intravenous fentanyl analgesia after general anesthesia for postoperative analgesic effect and complications in these pediatric patients. We randomly allocated 91 pediatric patients undergoing lower extremities surgery into epidural lidocaine group (n=61) and IV fentanyl group (n=30). During the operation, end-tidal sevoflurane concentration (ET(sev)) was controlled to maintain the blood pressure and heart rate within 10% of preoperative value. At the postoperative period, Parent Visual Analog Scale (PVAS), Objective Pain Score (OPS) and the incidence of nausea/ vomiting were checked immediately, 6 hours and 24 hours after the patient's arrival at general ward. ET(sev) was significantly low in epidural lidocaine group (p < 0.05). Compare to IV fentanyl group, epidural lidocaine group had significantly lower OPSs at 6 hours after arrival. Epidural lidocaine group had significantly lower PVASs immediately, 6 hrs and 24 hours after arrival. There was no significant difference in the incidence of postoperative nausea and vomiting. A combined general-epidural anesthesia technique significantly reduces intraoperative end-tidal sevoflurane concentration compared to general anesthesia alone. And continuous patient-controlled epidural analgesia reduces postoperative pain scores significantly more than continuous patient-controlled IV fentanyl analgesia without any serious complications in pediatric lower extremity surgery.