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 170,190 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

A placebo may be a pharmacologically active or an inert substance, a procedure, or a patient-doctor interview. Placebos work best in symptoms or disease which vary over time and between patients. The placebo works best in behaviour disorders, somatic autonomic disorders like pain, and neurohumoral disorders like hypertension. However, placebo action is incompletely defined in its molecular pharmacology. The endogenous brain systems of opioid, antiopioid, and gamma-aminobutyric acid polypeptide transmitters and neuronal receptors account in part for placebo analgesia. Non-painful stress may be mediated through other neurohumoral systems. A separate neural system might control these subsystems. Confidence based on the doctor's empathy commonly evokes the placebo effect. How the symbolic input of thought or emotion is translated into neuronal events is unknown. Double-masked 'controlled' clinical trials use placebo to reduce bias; overuse of placebo here may harm some patients. Oral placebos for routine use include thiamine at low dose. Potent drugs like glucocorticoids cannot be justified as placebo in mild disease or non-disease. Both patient and doctor are usually unaware of the placebo effect during interviews. Doctors may increase placebo efficacy by improving interpersonal skills.
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PMID:Magic or medicine? Clinical pharmacological basis of placebo medication. 202 61

Clonidine, an alpha-2 agonist, has traditionally been used to treat hypertension. Recently, it has been found to be a potent analgesic when administered either orally, transdermally or parenterally. This antinociceptive action is mediated at the spinal cord level through presynaptic inhibition of norepinephrine. Clonidine is also a valuable adjunct to anesthesia in a variety of clinical scenarios. In this lesson, the potential uses of clonidine will be elucidated, along with an explanation of its pharmacological and physiological mechanisms of action. Clonidine will be explored as an alternative avenue for providing hemodynamic stability and analgesia without the undersirable side effects often encountered with opioids.
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PMID:AANA journal course. 13. New technologies in anesthesia: update for nurse anesthetists--clonidine: an established drug with futuristic indications. 203 97

In a randomised clinical study, two total intravenous anaesthesia techniques for microlaryngoscopic laser surgery were compared. After an induction dose of 100 mg methohexital, Group I received a maintenance infusion of 10 mg.min-1. In Group II anaesthesia was obtained by 15 mg midazolam followed by 0.1 mg.min-1 continuously and terminated by the injection of flumazenil. For analgesia 5 mg alfentanil were administered. Opiate-induced respiratory depression was antagonised by 0.08 to 0.12 mg naloxone. Prior to, during, and after surgery, adrenergic response was assessed by HPLC-analysis of blood taken from a peripheral vein. Haemodynamic responses to the operation and during the post-operative period were almost identical in both groups. In Group I, the mean recovery period of 14 min was significantly longer than in Group II (9 min), where patients received a mean dose of 0.53 mg (+/- 0.15) flumazenil. Resedation could be observed in all patients receiving flumazenil within 60 min after antagonisation, which was associated with a mean decrease in O2-saturation from 95% to 88%. There was no difference in epinephrine and norepinephrine blood levels between the two groups prior to and during anaesthesia. In all patients, arousal was associated with a significant increase in the epinephrine plasma concentration. While blood levels in Group I decreased during the post-operative period to levels prior to surgery, the concentrations in Group II remained elevated. In one patient who received no naloxone, the reversal of midazolam action induced a 16-fold increase in catecholamine levels (from 50 to 800 ng.l-1) associated with a tachycardia of 170 b.min-1 and hypertension of 160 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Methohexital vs midazolam/flumazenil anaesthesia during laryngoscopy under jet ventilation. 210 77

The tumescent technique for local anesthesia permits regional local anesthesia of the skin and subcutaneous tissues by direct infiltration. The tumescent technique uses large volumes of a dilute anesthetic solution to produce swelling and firmness of targeted areas. This investigation examines the absorption pharmacokinetics of dilute solutions of lidocaine (0.1% or 0.05%) and epinephrine (1:1,000,000) in physiologic saline following infiltration into subcutaneous fat of liposuction surgery patients. Plasma lidocaine concentrations were measured repeatedly over more than 24 hours following the infiltration. Peak plasma lidocaine levels occurred 12-14 hours after beginning the infiltration. Clinical local anesthesia is apparent for up to 18 hours, obviating the need for postoperative analgesia. Dilution of lidocaine diminishes and delays the peak plasma lidocaine concentrations, thereby reducing potential toxicity. Liposuction reduces the total amount of lidocaine absorbed systemically, but does not dramatically reduce peak plasma lidocaine levels. A safe upper limit for lidocaine dosage using the tumescent technique is estimated to be 35 mg/kg. Infiltrating a large volume of dilute epinephrine assures diffusion throughout the entire targeted area while avoiding tachycardia and hypertension. The associated vasoconstriction is so complete that there is virtually no blood loss with liposuction. The tumescent technique can be used with general anesthesia or IV sedation. However, with appropriate instrumentation and surgical method, the tumescent technique permits liposuction of large volumes of fat totally by local anesthesia, without IV sedation or narcotic analgesia.
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PMID:Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. 217 48

The critical care patient population has much to gain from properly administered neural blockade. Effective analgesia alone may make the difference between a patient who is able to compensate for their acute insult and one who cannot. A good example is the patient with multiple fractured ribs, who, after intercostal nerve blocks, no longer requires intubation and mechanical ventilation. The authors believe that effective analgesia is just the beginning of the beneficial effects of neural blockade, because blockade of the afferent limb of sympathetic and sensory nerves may circumvent the neuroendocrine response to acute injury. There is evidence that the stress response is not beneficial in the hospital setting and in fact may be detrimental. Some of the effects include elevated plasma catecholamines, ADH, cortisol, and blood glucose, which contribute to tachycardia, hypertension, increased myocardial work and oxygen consumption, salt and water retention, and a catabolic state with negative nitrogen balance. Whether these changes result in reduced morbidity and mortality has been the subject of several studies, but more studies are needed. It would seem that critically ill patients with little physiologic reserve might be the best population to study because even a small improvement may improve survival. A small beneficial effect in healthy postoperative patients may not be clinically apparent. Most would agree that neural blockade used intraoperatively results in reduced blood loss and a lower incidence of postoperative thromboembolism. The continuation of these techniques into the postoperative period may reduce morbidity and mortality in high-risk patients. A word of caution is in order. The indiscriminate application of the techniques described in this article to critically ill patients would not be in the patients' best interest. Nerve blocks are only safe in the hands of those physicians specifically trained to perform them. In addition, local anesthetics have a low therapeutic ratio, and their administration requires continual observation. The use of epidural or intrathecal opioids alone or in combination with other agents also has potentially serious side effects, and requires continual patient monitoring. The proper performance and maintenance of these techniques requires a large commitment of time, manpower, equipment, and a multidisciplinary approach to include physicians, nursing, and support staff. Nerve blocks and other sophisticated techniques started in the operating room or critical care unit should not necessarily be discontinued when the patient is transferred to a ward bed because the full benefit of this therapy may not have been fully realized.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Nerve blocks in the critical care environment. 218 9

Extracorporeal shock wave lithotripsy (ESWL) for the treatment of upper urinary tract stone disease is held in high regard by the public and the profession. Although the efficacy is good (77.4% to 100%) for the treatment of 1- to 2-cm stones in select patients, ESWL may require the assistance of adjuvant procedures in as many as 26% of patients and may need repeating in as many as 32% of patients. These represent more difficult situations in which larger, more numerous, or harder stones may be present and in which ureteral stones are manipulated before treatment. The predominant adverse effect of ESWL treatment is the microvascular disruption of the tissues through which the shock waves pass. In addition, the procedure is painful, with many patients requiring narcotic analgesia. Long-term complications such as the new onset of hypertension have occurred in as many as 8% of treated patients, but much speculation about the long-term effects remains.
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PMID:Extracorporeal shock wave lithotripsy of urinary calculi. Theory, efficacy, and adverse effects. 220 60

Nalbuphine hydrochloride, an agonist-antagonist opioid, is reported to reverse the respiratory depression of moderate doses of fentanyl (20 micrograms.kg-1) and still provide good analgesia. We report four patients having abdominal aortic aneurysm repair in which we attempted to reverse the respiratory depression of large doses of fentanyl (50-75 micrograms.kg-1) with nalbuphine (0.3 mg.kg-1, 0.1 mg.kg-1 or 0.05 mg.kg-1). Nalbuphine reversed respiratory depression in all four patients and the respiratory rate increased from 10 to 23 breaths per minute, end-tidal CO2 decreased from 7.0 +/- 0.3 per cent to 5.6 +/- 0.7 per cent, and peak inspiratory pressure after 0.1 seconds increased from 4 +/- 1.4 to 13 +/- 2.6 mmHg. However, hypertension, increased heart rate, and significant increase in analogue pain scores accompanied reversal of respiratory depression. Agitation, nausea, vomiting, and cardiac dysrhythmias also were observed frequently. We do not recommend the use of nalbuphine to facilitate early extubation of the trachea after large doses of fentanyl for abdominal aortic surgery.
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PMID:Side effects of nalbuphine while reversing opioid-induced respiratory depression: report of four cases. 165

The perioperative anaesthetic management of an adult patient with central alveolar hypoventilation syndrome (CAHS), Ondine's Curse, is described for anterior resection of a carcinoma of the bowel. This rare syndrome results in alveolar hypoventilation, hypercarbia, hypoxaemia with secondary polycythaemia, pulmonary artery hypertension, and cor pulmonale. Epidural morphine was used for postoperative analgesia in an attempt to improve postoperative respiratory function. However, postoperative mechanical ventilation was required until recovery of the respiratory drive, which was ablated by anaesthetic drugs, epidural morphine and high inspired oxygen concentrations. The pathophysiology and treatment of this syndrome are reviewed.
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PMID:Anaesthesia for a patient with central alveolar hypoventilation syndrome (Ondine's Curse). 229 95

This article provides a perspective of health care in China based upon the observations of 3 American nurses who visited the country for 6 weeks between 1986 and 1988. The authors provide an overview of the health care system including the primary mission, the hierarchy of services, the educational background of the medical personnel, and insurance programs. There is a focus on nursing as a profession that includes a history of the formal institutions established for the training of nurses. 3 of the problems identified within the nursing field were a shortage of nurses, an inadequate supply of textbooks for the training programs, and the lack of a licensure requirement to practice nursing. The authors discuss at length of issues of overpopulation, the national family planning program, and maternity care. The government had implemented a program that allowed each couple to have only 1 child. Despite this policy, many couples would continue to have children until they had a son because of the high societal value placed on males over females. The government was working to address the traditional and economic factors that contributed to the preference for male children. Some of the initiatives mentioned included providing care and financial support for the elderly, granting special benefits to couples who had only a daughter, and giving priority to women for school and employment. The majority of the paper focuses on the trends and practices in maternal and child health. In conjunction with the government's family planning policy, contraceptives, abortions, and sterilizations were easily obtained. Couples eagerly anticipate parenthood and are very cooperative in participating in prenatal care and education. Fathers are encouraged to take an active role in the educating process. There is an emphasis on proper nutrition and careful monitoring during pregnancy. Both traditional and Western style hospitals and clinics offer maternity services. Obstetric patients are often treated with a combination of traditional and Western methods. Some traditional methods described include the use of acupuncture and heat to change the position of the fetus, and an herbal medicine that is said to be effective in terminating ectopic pregnancies. Western medicine facilities offered chromosome analysis, urinary estriol, and serum alpha-feto protein levels. Genetic screening and counseling was also available. There was said to be a high rate of pregnancy-induced hypertension, (41.2% in Beijing). It was reported that premature births are rare. Perinatal mortality rates ranged between 12.7 and 13.9%. Fetal monitors were available, but were not seen in use. Analgesia was rarely administered during labor because it was believed to have a negative effect on the baby. Private rooms were not available on the maternity units due to a lack of space and extreme shortage of nursing staff. Mothers were encouraged to have their babies room-in with them. There has been an increase by almost 30% in the number of women who chose to breast feed after the rooming-in was instituted. Most women receive 10 weeks of paid maternity leave; some factories provide 4 months of paid maternity leave; some factories provide 4 months of paid leave. When mothers returned to work, most children were cared for in a state-run nursery or by a grandmother.
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PMID:Women's health care in China: American travelers' views. 229 90

We report on a patient with acute pancreatitis whose pain was resistant to simultaneous administration of morphine, procaine and Buscopan. This episode was complicated by development of hypertension, tachycardia, angina pectoris, ventricular arrhythmias and electrocardiographic modifications. Analgesia was provided by epidural administration of fentanyl and bupivacaine and brought about rapid resolution of all symptoms. The usefulness of epidural analgesia in acute pancreatitis is discussed.
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PMID:[The value of epidural analgesia in acute pancreatitis]. 230 24


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