Intrathecal ziconotide and baclofen provide pain relief in seven patients with neuropathic pain and spasticity: case reports.

Seven cases of combination of intrathecal (IT) ziconotide and baclofen therapy in patients with refractory neuropathic pain and spasticity were reviewed. Five of the seven adult patients were receiving IT baclofen treatment when ziconotide was initiated. All five patients had experienced at least one previous failed IT treatment regimen. Pain intensity scores improved by a mean of 50.3% with the use of ziconotide-baclofen therapy. Mean time to onset of pain relief was 15 weeks, at a mean ziconotide dose of 3.7 microg/day. Within this group of patients, adverse events were observed in one patient, but they were not considered to be ziconotide related and subsequently resolved. The remaining two patients were receiving ziconotide treatment when baclofen was initiated. Pain intensity scores improved by 75% and 30%, respectively. Pain relief was evident at two weeks and one week, with corresponding ziconotide doses of 2.4 microg/day and 14.4 microg/day, respectively. One patient in this group reported adverse events, but all resolved during continued treatment with the study drugs. Treatment regimens varied between patients in these case series; each regimen used a different titration strategy and different concentrations of ziconotide and baclofen. Combination IT ziconotide and baclofen therapy may be a treatment option for patients with neuropathic pain and spasticity. Future studies are warranted to determine the optimal dosing and titration schedules for ziconotide-baclofen usage.

Effect of hemodilution on tissue perfusion and blood coagulation during radical hysterectomy.

OBJECTIVE: The goal of this study was to evaluate the safety of hemodilution on global and splanchnic perfusion and blood coagulation during radical hysterectomy. METHODS: A pulmonary artery catheter and a gastric tonometry catheter were placed in 16 patients with cervical carcinoma. Global perfusion indices, splanchnic perfusion index, and coagulation tests were obtained. Blood was removed to achieve a hemoglobin measurement of 8-9 9 g/dL. Three more measurements were repeated after hemodilution, at the end of surgery, and after the retransfusion of blood. Analysis of variance was used to determine statistical significance. RESULTS: Sixteen patients with cervical carcinoma had 1.0 +/- 0.3 L (mean +/- SD) of blood removed and had a blood loss of 0.8 +/- 0.7 L. Hemodiluted preoperative hemoglobin was 8.7 +/- 1 g/dL. All of the global perfusion indices, except for arterial pH and oxygen consumption, decreased after hemodilution and recovered with the retransfusion of blood (P < or = 0.004). Splanchnic perfusion and coagulation tests were unchanged (P > or = 0.1). Major complication was pulmonary edema in one patient. CONCLUSION: Hemodilution during radical hysterectomy, in this select group of patients, does not appear to compromise tissue perfusion or coagulation.

Preconditioning the human myocardium with intracoronary adenosine.

This study was designed to study the role of adenosine in ischaemic preconditioning. The clinical, electrocardiographic and metabolic parameters of ischaemia were compared before and after intracoronary adenosine during percutaneous transluminal coronary angioplasty in 15 patients with significant stenosis of the left anterior descending artery. Baseline ischaemia was demonstrated by inflating the balloon of appropriate size at its nominal pressure for 30 seconds. Intracoronary adenosine was then administered in dose of 1000 to 6000 mgm/ml. The balloon was repositioned and inflated at nominal pressure for 180 seconds. As compared to 1st balloon inflation, the 2nd balloon inflation produced less severe chest pain, less ST segment deviation on the intracoronary ECG (7.40 +/- 3.94 vs 4.30 +/- 2.15 mm; p < 0.05) and lower coronary sinus lactate levels as compared to the first (0.28 +/- 0.06 vs 0.22 +/- 0.04 mmol/lit; p < 0.05). In conclusion, this study proves that by injecting intracoronary adenosine it is possible to precondition the human myocardium.

A prospective evaluation of clinical tests for placement of laryngeal mask airways.

BACKGROUND: Reliable tests of correct anatomic placement of the laryngeal mask airway (LMA) may enhance safety during use and minimize the need for fiberoptic instrumentation during airway manipulation through the device. This study assessed the correlation between the outcomes of nine clinical tests to place the LMA and the anatomic position of the device as graded on a standard fiberoptic scale. METHODS: During 150 anesthetics, the outcome of nine clinical tests of correct placement was individually scored as satisfactory (positive) or unsatisfactory (negative) for clinical use of the LMA. Anatomic placement was assessed (by fiberoptic evaluation) by an anesthesiologist, who was blinded to the placement of the device, as grade 1, vocal cords not seen; grade 2, cords plus the anterior epiglottis seen; grade 3, cords plus the posterior epiglottis seen; and grade 4, only vocal cords seen. The outcomes of clinical tests were correlated with fiberoptic grade. RESULTS: Tests that correlated with the fiberoptic grade were the ability to generate an airway pressure of 20 cm water, the ability to ventilate manually, a black line on the LMA in midline, anterior movement of the larynx, outward movement of the LMA on inflation of the cuff, and movements of the reservoir bag with spontaneous breathing. Two tests, ability to generate airway pressure of 20 cm water and ability to ventilate manually, correlated with fiberoptic grades 4 and 3 combined (i.e., the epiglottis was supported by the LMA) and grade 2 (the epiglottis was not supported by the LMA). Tests with poor correlation with fiberoptic grade were the presence of resistance at the end of insertion, inability to advance LMA after inflation of the cuff, and presence of a capnographic trace. CONCLUSIONS: The outcome of clinical tests correlates with the anatomic placement of LMAs, as judged by fiberoptic examination. Two tests that best correlated with the fiberoptic grade were the ability to generate airway pressure of 20 cm water and the ability to ventilate manually.

Augmented autologous transfusions in major reconstructive spine surgery.

Intraoperative autologous transfusion during major reconstructive spine surgery decreased allogeneic red blood cell transfusions, but patients were exposed to significant numbers of allogeneic blood products. This study reports a prospective study of 160 randomized patients undergoing major reconstructive spine surgery. Without delaying start of surgery, 80 patients underwent hemapheresis with coincidental normovolemic hemodilution in the operating room to sequester autologous blood components. A therapeutic dose plateletpheresis product and an average of 2 U each of freshly collected autologous red cells and fresh plasma were prepared prior to surgical incision. The same supplies and equipment were used subsequently to carry out intraoperative autologous transfusion (IAT). Autologous plasma and platelets were transfused to Sequestration patients, contributing to a significant decrease of total allogeneic donor exposures. One or more autologous red blood cell unit equivalents were cost effectively salvaged and retransfused to 78% of the Sequestration patients. Altogether, autologous red cells comprised 87% of the total red cells transfused. During the same time period, 80 age-, sex-, and weight-matched controls, who received IAT only, were accrued for comparison with Sequestration patients. Of all red cells transfused to control patients, autologous units comprised 47%. Both patient groups received the same total perioperative red blood cell support. The per patient cost for IAT, with or without sequestration, was competitive with supplying one unit of cross-matched allogeneic red cells. IAT only patients had greater allogeneic blood donor exposures than Sequestration patients, in whom the numbers of allogeneic red cells, plasma and platelet transfusions were decreased. Compared with IAT alone, the hospital post-operative stay of Sequestration patients was 23% less than IAT only patients.

Audit of autotransfusion in spine surgery.

A prospective evaluation has been undertaken of 382 patients undergoing reconstructive spine surgery during a thirty-six month period. Acute normovolaemic haemodilution and haemapheresis for blood component sequestration was used in 80 patients in the operating theatre. An average of two units each of freshly collected autologous red cells and fresh plasma together with a therapeutic dose of a plateletpheresis product were prepared for each patient prior to surgical incision. The same supplies and equipment were subsequently used for conventional blood salvage and autotransfusion. The other 302 patients received salvaged blood only. Of the total blood transfused, autologous red cells comprised 87% of sequestration and 49% of autotransfusion-only patients. Each group received the same total perioperative red blood cell support. The cost for one red cell equivalent by intraoperative autologous transfusion was competitive with that of providing one unit of cross-matched allogeneic red cells. As compared with salvage alone, sequestration combined with salvage was even more cost effective and decreased reliance on allogenic products and preoperative autologous blood donations. The rate of transfusing autologous blood products was markedly increased.

Adenosine-induced chest pain: is it due to myocardial ischaemia? Clinical, electrocardiographic, haemodynamic and metabolic study.

Adenosine has recently been demonstrated to be a mediator of angina in human beings. The present study was undertaken to document the presence or absence of myocardial ischaemia on clinical, haemodynamic, electrocardiographic and metabolic evidences after intracoronary administration of adenosine. Fifteen patients with chronic stable angina (12 males and 3 females), positive exercise stress test and documented significant stenosis of the left anterior descending coronary artery (LAD) were included in the study. The surface and intracoronary electrocardiograms (ECGs), pulmonary artery diastolic pressure and coronary sinus lactate levels were monitored at baseline and after intracoronary administration of adenosine in all patients. Adenosine was administered intracoronary in doses of 1000-8000 microgram depending on the provocation of chest pain. Typical angina was observed in all patients. There were no signs of ischaemia on surface or intracoronary ECG. There was no statistically significant difference between the pulmonary artery diastolic pressure and coronary sins lactate levels at baseline and post-adenosine administration (p > 0.05). It is concluded that intracoronary administration of adenosine produces chest pain in patients with chronic stable angina by mechanism other than myocardial ischaemia.

Coronary artery stenting in acute myocardial infarction.

Little information is available on the use of coronary stents to treat suboptimal results during direct angioplasty in acute myocardial infarction (AMI). In this study, we report 16 cases of AMI who underwent stent implantation in infarct-related artery for suboptimal results and their 6 months angiographic follow-up. Immediate angiographic success was achieved in all patients. The minimal luminal diameter increased from 0.06 +/- 0.12 mm to 2.89 +/- 0.12 mm (p < 0.001). One patient died in the hospital on day 8 due to subacute stent thrombosis. No patient required emergency bypass surgery. Two patients required blood transfusion for groin haematoma and one required intracoronary thrombolysis. All patients underwent exercise stress test at 1 month and at 3 months and coronary angiography at 4 months or earlier it indicated. At the end of 6 months follow-up, 4 patients had a positive exercise test and coronary angiography revealed angiographic restenosis in 3 and progression of disease in other vessels in 1 patient. We conclude that stent deployment is a viable option to treat suboptimal results after direct angioplasty in AMI.

A phase III, multicenter, open-label, randomized, comparative study evaluating the effect of sevoflurane versus isoflurane on the maintenance of anesthesia in adult ASA class I, II, and III inpatients.

STUDY OBJECTIVE: To compare the clinical efficacy and safety of sevoflurane and isoflurane when used for the maintenance of anesthesia in adult ASA I, II, and III inpatients undergoing surgical procedures of at least 1 hour's duration. DESIGN: Phase III, randomized, open-label clinical trial. SETTING: 12 international surgical units. PATIENTS: 555 consenting inpatients undergoing surgeries of intermediate duration. INTERVENTIONS: Subjects received either sevoflurane (n = 272) or isoflurane (n = 283) as their primary anesthetic drug, each administered in nitrous oxide (N2O) (up to 70%) and oxygen (O2) after an intravenous induction using thiopental and low-dose fentanyl. The concentration of volatile drug was kept relatively constant but some titration in response to clinical variable was permitted. Comparison of efficacy was based on observations made of the rapidly and ease of recovery from anesthesia and the frequency of untoward effects for the duration of anesthesia in the return of orientation. Safety was evaluated by monitoring adverse experiences, hematologic and non-laboratory testing, and physical assessments. In 25% of patients (all patients 171 both treatment groups at selected investigational sites), plasma inorganic fluoride concentrations were determined preoperatively, every 2 hours during maintenance, at the end of anesthesia, and at 1, 2, 4, 8, 12, 24, 48, and 72 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Emergence, response to commands, orientation, and the first request for postoperative analgesia were all more rapid following discontinuation of sevoflurane than following discontinuation of isoflurane (sevoflurane, 11.0 +/- 0.6, 12.8 +/- 0.7, 17.2 +/- 0.9, 46.1 +/- 3.0 minutes, respectively, versus isoflurane, 16.4 +/- 0.6, 18.4 +/- 0.7, 24.7 +/- 0.9, 55.4 +/- 3.2 minutes). The incidence of adverse experiences was similar for sevoflurane and isoflurane patients. Forty-eight percent of patients on the sevoflurane group had no untoward effect versus 39% in the isoflurane group. Three patients who received sevoflurane had serum inorganic fluoride levels 50 microM/I. or greater though standard tests indicated no evidence of associated renal dysfunction. CONCLUSION: Sevoflurane anesthesia, as compared with isoflurane, may be advantageous in providing a smoother clinical course with a more rapid recover.

Dose-response study of oral famotidine for reduction of gastric acidity and volume in outpatients and inpatients.

A relatively new H2-antagonist, famotidine, has become clinically available, but its effectiveness in decreasing gastric acidity and volume has not been compared in inpatients and outpatients. We reexamined the difference in gastric acidity and volume in inpatients and outpatients, and tested the effectiveness of different oral doses and dosage regimens of famotidine in reducing gastric acidity and volume in both groups of patients. Patients received either placebo or 20 mg or 40 mg of famotidine orally the night before surgery (HS) and on the morning of surgery (AM). One hundred forty-two inpatients and 180 outpatients were randomized to one of seven groups as follows: 1) placebo (HS)/placebo (AM); 2) 20 mg of famotidine (HS)/20 mg of famotidine (AM); 3) 20 mg of famotidine (HS)/placebo (AM); 4) placebo (HS)/20 mg of famotidine (AM); 5) 40 mg of famotidine (HS)/40 mg of famotidine (AM); 6) 40 mg of famotidine (HS)/placebo (AM); and 7) placebo (HS)/40 mg of famotidine (AM). We measured the gastric acidity and volume after induction of anesthesia and found no difference between the inpatients and outpatients, with or without famotidine. We found that famotidine given HS and AM or AM only was effective in reducing gastric acidity in both groups of patients, and that there was no difference between the 20-mg and 40-mg doses of famotidine. Gastric volume was not affected by any famotidine dose.

Serum bupivacaine concentrations after intraarticular injection for pain relief after knee arthroscopy.

Intraarticular injection of local anesthetic drugs after arthroscopic knee surgery is used to provide postoperative analgesia. Toxic serum levels of bupivacaine have been reported after its use both in regional anesthesia and for intraarticular injection. The toxicity of the former is related to needle misplacement and the latter is presumed to be absorptive. This study evaluates the effect of tourniquet inflation and the addition of epinephrine on serum concentrations of bupivacaine after intraarticular injection. The results shows that the peak serum bupivacaine concentrations can be reduced by adding epinephrine and injecting it after tourniquet inflation.

The effects of intravenous cimetidine and metoclopramide on gastric volume and pH.

The effects on gastric pH and volume of intravenous administration of cimetidine and metoclopramide before induction of anesthesia were studied. Sixty ASA Class I patients scheduled for elective surgery were randomly divided into four groups of 15 each, and the study was double-blinded. Group I received normal saline only; Group II received 4 mg/kg of cimetidine only; Group III received 0.15 mg/kg of metoclopramide only; and Group IV received 4 mg/kg of cimetidine and 0.15 mg/kg of metoclopramide. All drugs were given intravenously 30 min before induction of anesthesia. Gastric aspirates were collected during anesthesia, 30 min and 60 min after administration of the drugs. Metoclopramide reduced gastric volume significantly when administered alone (P = 0.0001), but cimetidine did not (P = 0.10). Cimetidine increased the gastric fluid pH significantly (P = 0.0001) as did metoclopramide (P = 0.0023). The effects of cimetidine and metoclopramide on gastric fluid pH were additive when administered together. The combination of cimetidine and metoclopramide when given intravenously before anesthesia provides greater protection against aspiration pneumonitis in patients at risk than does either drug alone.