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Ropivacaine is a new local anaesthetic with advantages that suggest an important role in the provision of postoperative analgesia. The main aim of this study was to investigate the dose-response relationship of extradural infusion of ropivacaine. We studied 36 ASA I-III patients undergoing upper abdominal surgery during general anaesthesia and extradural block (catheter insertion at T6-9) using 0.5% ropivacaine in a randomized, double-blind study. After surgery nine patients each received an extradural infusion of either ropivacaine 0.1%, 0.2%, 0.3% or saline at a rate of 10 ml h-1 for 21 h. All patients had access to i.v. morphine via a PCA device. The ropivacaine groups consumed significantly less morphine over the 21-h infusion period than the saline group (medians: saline 75 mg; 0.1% ropivacaine 32 mg; 0.2% ropivacaine 39 mg; 0.3% ropivacaine 13 mg) (P < 0.05). Pain (VAS scores) at rest was significantly lower in all ropivacaine groups than in the saline group after 4 h of infusion (medians: saline 45 mm; 0.1% ropivacaine 15 mm; 0.2% ropivacaine 12 mm; 0.3% ropivacaine 0 mm). Pain on coughing was significantly less in all ropivacaine groups than in the saline group after 4 h infusion (medians: saline 67 mm; 0.1% ropivacaine 44 mm; 0.2% ropivacaine 33 mm; 0.3% ropivacaine 0 mm) and for 0.2% and 0.3% ropivacaine at later times. Motor block was negligible throughout the infusion. Patient satisfaction was higher in the 0.2% and 0.3% ropivacaine groups than in the two other groups.
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PMID:Postoperative analgesia by continuous extradural infusion of ropivacaine after upper abdominal surgery. 865 17

We have determined if thoracic extradural block before surgical incision for thoracotomy produces pre-emptive analgesia. Using a double-blind, placebo-controlled, crossover design, 45 patients (ASA II-III) undergoing posterolateral thoracotomy for lung resection were randomized to one of three groups: group 1 received 0.5% bupivacaine and adrenaline 1/200,000 (B+E) 8 ml through a thoracic extradural catheter (tip T3-T5) 30 min before skin incision and saline 8 ml 15 min after skin incision; group 2 received saline 8 ml extradurally before incision and B+E 8 ml after incision; group 3 received saline 8 ml extradurally before and after incision. General anaesthesia was induced and maintained with propofol, alfentanil and atracurium. The alfentanil infusion was stopped before chest closure and fentanyl 50 micrograms in saline 10 ml was given extradurally. Patient-controlled extradural analgesia (PCEA) was commenced with 0.125% bupivacaine, adrenaline 1/400,000 and fentanyl 6 micrograms ml-1 (continuous rate of 2 ml h-1 and supplementary doses of 0.5 ml per 6 min). Visual analogue scale (VAS) scores (recorded at rest, on mobilization and after cough), verbal rating scale (VRS) (recorded at rest), number of successful PCEA demands and complications were measured during the first 48 h after operation. There was no significant difference between groups, either in PCEA requirements (P > 0.21) or in VAS scores (either at rest, during mobilization of the ipsilateral arm of surgery or after cough). No significant differences between groups were found in the VRS. Thoracic extradural block with bupivacaine did not produce an early preemptive effect after thoracotomy.
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PMID:Absence of an early pre-emptive effect after thoracic extradural bupivacaine in thoracic surgery. 867 84

We evaluated the addition of midazolam to propofol during induction of anaesthesia by assessing laryngeal mask tolerance, haemodynamic variables, recovery times and cost. Forty patients (ASA grades I-IV) undergoing elective surgery were allocated randomly to receive a standard dose of propofol or a smaller dose of propofol combined with midazolam. A laryngeal mask was inserted and any episodes of coughing or hiccuping during its insertion or removal were recorded. Anaesthesia was maintained with nitrous oxide and enflurane with fentanyl for analgesia. After surgery, recovery times, pain, shivering, nausea, vomiting and analgesic requirements were recorded. The cost of the drugs used was also calculated. No significant differences were detected in any variables, except that patients given propofol needed more morphine in the recovery ward. The average cost of propofol alone was 3.47 pounds per anaesthetic, while the midazolam plus propofol cost was 2.03 pounds. Adding midazolam to propofol allowed a reduced dose of propofol to be used without adverse effects, while reducing the anaesthetic costs.
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PMID:Propofol versus propofol with midazolam for laryngeal mask insertion. 871 68

We carried out a perspective study in order to assess the ease of insertion, the type and the incidence of perioperative complications connected with the use of the Laryngeal Mask Airway (LMA). We examined 300 consecutive patients, M/F 261/39, average age 4.2 yrs. (range 0.1-16), ASA I-II, who underwent surgical operations of short or average length not involving the pleural, the oropharyngeal or the peritoneum cavity. The choice about anesthesia was left to the discretion of the anesthesiologist. In 27 cases the position of the LM was controlled through a flexible fiberoptics. In 269 patients (89.6%) the LMA was correctly positioned during the first attempt. In 27 patients (9%), 2 or more attempts were necessary, and in 4 patients (1.4%) it was not possible to set the LMA. No differences of statistical significance were noticed between the different size of LMA, with regards to the facility of insertion. The control through fiberoptics showed a correct position, from an anatomical point of view, in 11 patients (41%), whereas in 13 patients (48%) some signs of partial obstruction were noticed (epiglottis interposing between the opening of LMA and larynx) and in 3 patients (11%) vocal cords are not visible. The following complications took place: laryngeal spasm on induction (2.3%), cough or movements on positioning (2.3%), hypoxia (4.3%), obstruction (1%), laryngeal spasm on awakening (1.7%), trauma (5%) and vomiting (0.3%). No connections were found between the size of LMA and total complications. Nevertheless, cough or movement during positioning and laryngeal spasm on awakening were significantly more frequent with LMA n. 3. In our experience, the LMA proved to be effectual and safe in the control of the airway during elective operations in pediatric surgery.
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PMID:[The laryngeal mask in pediatric anesthesia]. 876 51

Prompted by the ongoing discussion of the pros and cons of using succinylcholine, this study was conducted to compare the responses to bolus injections of atracurium or vecuronium with those after sequential injection of these drugs (priming principle). We evaluated the earliest possible intubation times, intubating conditions, and the onset times (i.e. times from the end of injection to the maximum blockade) under conditions approaching real use as closely as possible. METHODS. The randomized and double-blind study was carried out with 80 ASA risk class 1 and 2 patients. Approval of the institutional ethics committee was obtained, and each patient gave informed consent. Patients were randomly allocated to four study groups of 20 patients each. Isotonic saline was administered to those patients assigned to the atracurium or vecuronium bolus groups, whereas the patients assigned to the other two groups received a priming injection of either atracurium (0.05 mg/kg) or vecuronium (0.01 mg/kg). We observed the patients for signs of incipient muscular weakness before the induction of anaesthesia. Anaesthesia was induced with thiopental 3.5 min after the first injection (5 mg/kg and 50-100 mg before intubation). After a further 1 min during which adequate mask ventilating with oxygen was assured, corresponding to a priming interval of 4.5 min, 0.5 mg/kg of atracurium or 0.1 mg/kg of vecuronium was administered to the patients in the bolus groups and 0.45 mg/kg of atracurium or 0.09 mg/kg of vecuronium as intubating doses to those in the priming groups. Intubation was attempted at 90, 120, 150 and 180 s thereafter. Intubating conditions were evaluated on the basis of laryngoscopy, vocal cord movement and coughing or bucking of the patients. Neuromuscular function was monitored via accelerometry at the adductor pollicis muscle (TOF stimulation of the ulnar nerve every 15 s). RESULTS. The priming doses did not diminish the elicited twitches of the adductor pollicis muscle, but led to heavy eyelids and double vision in 35% of the atracurium patients and 47% of the vecuronium patients; these symptoms were well tolerated by the patients. At the time of intubation the adductor pollicis muscle was relaxed to approximately the same degree in all groups (mean +/- SD for the TOF ratios in the bolus groups was 0.46 +/- 0.37 for atracurium, 0.45 +/- 0.4 for vecuronium; in the priming groups 0.52 +/- 0.39 for atracurium, 0.53 +/- 0.36 for vecuronium). The administration of the relaxants in divided doses significantly shortened the intubating time after atracurium (100 vs 124 s) and improved the intubating conditions of vecuronium (good vs tolerable), but had no effect on the time course of the neuromuscular blockade (onset times in the bolus groups 224 +/- 84 s for atracurium and 209 +/- 64 s for vecuronium; in the priming groups 249 +/- 112 s for atracurium and 205 +/- 52 s for vecuronium). CONCLUSIONS. The priming technique presented here is clinically superior to the bolus method and therefore should be preferred in all elective cases and in those patients in whom succinylcholine is contraindicated.
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PMID:[Intubation conditions following administration of atracurium and vecuronium. Bolus method versus priming technique]. 876 64

The thoracoscopy is used both for diagnosis and treatment of pleural and lung diseases. We describe our experience in managing anesthesia for such procedures, the number of which is increasing thanks to technical advances. We review 82 thoracoscopic procedures, 48 of which were video assisted. Sixty-two were performed under balanced general anesthesia (GA) with isoflurane, fentanyl and atracurium. Local anesthesia (LA) with fractionated doses of propofol and fentanyl was used in 20 cases. The mean age of patients receiving LA (63 +/- 17 years) was significantly greater (p < 0.05) than those receiving GA (49 +/- 13 years). ASA IV patients were given LA and sedation. Selective bronchial intubation was performed in 46 cases. Complications during surgery were severe hypoxemia (SpO2 < 85%) requiring suspension of selective lung ventilation in 8 cases, moderate hypoxemia (spO2 < 90% and > 85%) in 1 case, coughing in 3 cases and agitation in 1 case. Video-thoracoscopy is a safe technique that is less invasive than conventional thoracotomy. The number of applications is increasing, although its future place in thoracic surgery must still be determined.
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PMID:[Anesthesia for thoracoscopy]. 901 4

We analyzed data from 1233 Chinese patients of a wide age range who received patient-controlled analgesia (PCA) intravenous morphine for postoperative pain relief, during the period of January 1992 to May 1995. The analgesic regimen was standardized as follows: PCA bolus 1 to 1.5 mg; lock-out interval 5 minutes; one-hour maximum dose 0.075 to 0.1 mg.kg-1 and background infusion 0 or 0.5 mg.h-1. Most patients underwent major surgery that was broadly subclassified according to the anatomical area involved. The median verbal numerical rating scales of pain (0 to 10) at rest and while coughing for the first, second and third 24 hours were 3.0/5.0, 1.5/4.0 and 0/3.0 respectively and the corresponding demand to delivery ratios were 2.8 +/- 2.9, 2.6 +/- 2.4 and 2.4 +/- 2.6. The overall morphine consumptions in 1004 of these Chinese patients were 27.5 +/- 16.8, 17.8 +/- 16.1 and 18.1 +/- 21.0 micrograms.kg-1.h-1 during the first 16, 17 to 41 and 42 to 66 postoperative hours respectively. These figures were the same as for Caucasian patients managed in the same institution. Morphine consumption was significant higher following thoracic, upper abdominal and spinal surgery. Also it was higher in patients younger than 65 years, males, cigarette smokers and those with ASA physical status I or II. The commonest side-effects were nausea (34.5%) and vomiting (18.2%). Bradypnoea and oxygen desaturation occurred in 0.5% and 1.6% respectively. All cases were promptly detected and managed with no adverse outcomes. Most patients were satisfied (76.7% ranked "good") with their postoperative analgesia. The commonest reasons for dissatisfaction were inadequate pain relief, nausea and reluctance to self-control analgesic administration. It is concluded that PCA with intravenous morphine is effective and safe as a routine postoperative technique for Chinese surgical patients.
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PMID:The efficacy, applicability and side-effects of postoperative intravenous patient-controlled morphine analgesia: an audit of 1233 Chinese patients. 897 12

We have assessed tracheal intubating conditions in 45 ASA I-II children, aged 4-14 years, undergoing elective ear, nose and throat surgery. After the induction dose of propofol 2.5 mgkg-1, Group I received alfentanil 10 ugkg-1, Group II received alfentanil 20 ugkg-1 and Group III received atracurium 0.5 mgkg-1 for tracheal intubation. The mean arterial pressure (MAP), heart rate (HR), arterial oxygen saturation (SaO2), end tidal carbondioxide (ETCO2) and intubation conditions were investigated. The quality of tracheal intubation was graded according to ease of laryngoscopy, position of the vocal cords, coughing and jaw relaxation. There were no significant differences in the overall assessment of intubating conditions between the three groups. Intubations were accomplished in 94% of the patients in Group I and II, and 100% of the patients in Group III. We conclude that the combination of propofol and alfentanil conditions for treacheal intubation in children and attenuate the hemodynamic responses to layngoscopy and tracheal intubation.
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PMID:Comparison of intubation conditions under propofol in children--alfentanil vs atracurium. 898 40

Pretreatment regimens that decrease the incidence of fasciculations and postoperative myalgias have been the focus of many research studies. The subject of pretreatment remains controversial. An experimental double blind study was conducted of 50 patients, men and women, aged 18 to 65 years who were having elective minor orthopedic surgery. Group A participants (n = 24) received normal saline, and group B participants (n = 26) received atracurium 0.05 mg/kg, followed by succinylcholine 1.5 mg/kg. Data that were collected included age, ASA physical status, weight, height, anesthesia and postanesthesia recovery times, type of procedure, medications administered, and allergies. Phase I of the study consisted of evaluation for the presence of fasciculations. In phase II, the intubation conditions (e.g., character of the vocal cords, presence of coughing, and degree of ease with laryngoscopy) were evaluated. Phase III included evaluation of postoperative myalgias at 24 and 72 hours. Data were analyzed using measures of central tendency, chi square, Pearson's r and the Student's t test. The incidence of fasciculations was less in the atracurium pretreatment group (group B) than in the group treated with normal saline (group A). Intubation conditions were not compromised by atracurium pretreatment. There was no statistically significant difference between group B and group A in postoperative myalgias. Thus, no recommendations for pretreatment can be made on the basis of this study.
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PMID:Evaluation of succinylcholine-induced fasciculations and myalgias with or without atracurium pretreatment. 909 7

The quality of laryngoscopy and tracheal intubation with propofol augmented by alfentanil was investigated as an alternative technique for rapid tracheal intubation. 119 patients aged between 18 and 60 years (ASA 1 and 2) undergoing elective surgery were prospectively studied in a randomized double-blind controlled fashion. Tracheal intubation facilitated by suxamethonium 1.0 mg/kg alfentanil 15 mu g/kg alfentanil 30 mu g/kg or saline control was compared after propofol induction. The quality of laryngoscopy and intubation were graded according to jaw relaxation, ease of insertion of the endotracheal tube and coughing on intubation. Failure to intubate occurred in 4% and 17% with alfentanil 15 mu g/kg and saline control respectively Tracheal intubation was successful in all patients with alfentanil 30 mu g/kg and suxamethonium 1.0 mg/kg. Alfentanil 15 mu g/kg was not statistically significantly different from saline (P = 0.112). Alfentanil 30 mu g/kg provided similar overall intubating conditions (P = 0.5) to suxamethonium 1.0 mg/kg. Alfentanil in both dosages effectively attenuated the haemodynamic responses to laryngoscopy and tracheal intubation.
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PMID:Intubation without muscle relaxant: an alternative technique for rapid tracheal intubation. 913 97


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