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Showing papers in "Anesthesiology in 2006"


Journal ArticleDOI
TL;DR: This review provides a comprehensive summary of basic and clinical research concerning opioid-induced hyperalgesia, suggests a framework for organizing pertinent information, delineates the status quo of knowledge, identifies potential clinical implications, and discusses future research directions.
Abstract: Opioids are the cornerstone therapy for the treatment of moderate to severe pain. Although common concerns regarding the use of opioids include the potential for detrimental side effects, physical dependence, and addiction, accumulating evidence suggests that opioids may yet cause another problem, often referred to as opioid-induced hyperalgesia. Somewhat paradoxically, opioid therapy aiming at alleviating pain may render patients more sensitive to pain and potentially may aggravate their preexisting pain. This review provides a comprehensive summary of basic and clinical research concerning opioid-induced hyperalgesia, suggests a framework for organizing pertinent information, delineates the status quo of our knowledge, identifies potential clinical implications, and discusses future research directions.

1,076 citations


Journal ArticleDOI
TL;DR: This article has been selected for the Anesthesiology CME Program and the instructions to take the test may be found in the CME section at the back of this issue.
Abstract: This article has been selected for the Anesthesiology CME Program. After reading the article, go to http:// www.asahq.org/journal-cme to take the test and apply for Category 1 credit. Complete instructions may be found in the CME section at the back of this issue. PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints. Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data.

1,072 citations


Journal ArticleDOI
TL;DR: Lorazepam administration is an important and potentially modifiable risk factor for transitioning into delirium even after adjusting for relevant covariates and increasing age and Acute Physiology and Chronic Health Evaluation II scores were also independent predictors of transitioning to delirity.
Abstract: Background:Delirium has recently been shown as a predictor of death, increased cost, and longer duration of stay in ventilated patients. Sedative and analgesic medications relieve anxiety and pain but may contribute to patients’ transitioning into delirium.Methods:In this cohort study, the authors d

1,008 citations



Journal ArticleDOI
TL;DR: A retrospective analysis suggests that paravertebral anesthesia and analgesia for breast cancer surgery reduces the risk of recurrence or metastasis during the initial years of follow-up.
Abstract: Background: Regional anesthesia is known to prevent or attenuate the surgical stress response; thus, inhibiting surgical stress by paravertebral anesthesia might attenuate perioperative factors that enhance tumor growth and spread. We hypothesized that breast cancer patients undergoing surgery with paravertebral anesthesia and analgesia combined with general anesthesia have a lower incidence of cancer recurrence or metastases than patients undergoing surgery with general anesthesia and patient-controlled morphine analgesia. Methods: In this retrospective study, we examined the medical records of 129 consecutive patients undergoing mastectomy and axillary clearance for breast cancer between September 2001 and December 2002. Results: 50 patients had surgery with paravertebral anesthesia and analgesia combined with general anesthesia and 79 patients had general anesthesia combined with postoperative morphine analgesia. The follow-up time was 32±5 months (mean±SD). There were no significant differences in patients or surgical details, tumor presentation, or prognostic factors. Recurrence and metastasis-free survival was 94% (95% CI 87,100) and 82% (74, 91) at 24 months and 94 (87, 100) and 77 (68, 87) at 36 months in the paravertebral and general anesthesia patients, respectively, P=0.012. Conclusions: This retrospective analysis suggests that paravertebral anesthesia and analgesia for breast cancer surgery reduces the risk of recurrence or metastasis during the initial years of follow-up. Prospective trials evaluating the effects of regional analgesia and morphine sparing on cancer recurrence seem warranted.

844 citations


Journal ArticleDOI
TL;DR: The SD of glucose concentration is a significant independent predictor of intensive care unit and hospital mortality and decreasing the variability of blood glucose concentration might be an important aspect of glucose management.
Abstract: Background:Intensive insulin therapy may reduce mortality and morbidity in selected surgical patients. Intensive insulin therapy also reduced the SD of blood glucose concentration, an accepted measure of variability. There is no information on the possible significance of variability in glucose conc

776 citations


Journal ArticleDOI
TL;DR: The patient was a 58-yr-old, 82-kg, 170-cm male who presented for arthroscopic repair of a torn rotator cuff in the right shoulder who was considered by his cardiologist to be stable on medical therapy and plans were being made to institute cardiopulmonary bypass.
Abstract: The patient was a 58-yr-old, 82-kg, 170-cm male who presented for arthroscopic repair of a torn rotator cuff in the right shoulder His medical history was significant for coronary artery bypass graft surgery at age 43 yr He gave a history of angina upon exertion and occasionally at rest He declined further preoperative cardiac workup but was considered by his cardiologist to be stable on medical therapy This included nitroglycerine as needed, lisinopril, atenolol isosorbide mononitrate, and clopidogrel and enteric-coated aspirin, both of which had been discontinued 1 week previously His preoperative electrocardiogram revealed a right bundle-branch block, a left anterior hemiblock, and evidence of an old anterior wall myocardial infarction The patient arrived at the operating room holding area, where standard monitors were applied Blood pressure was 120/80 mmHg, room air oxygen saturation measured by pulse oximetry was 98%, and heart rate was 60 beats/min Supplemental oxygen was delivered at 3 l/min via a nasal cannula A 20-gauge intravenous catheter was placed in the dorsum of his left hand, through which 2 mg midazolam and 50 g fentanyl were administered A 50-mm, 22-gauge Stimuplex insulated needle was connected to a Stimuplex-DIG nerve stimulator (both B Braun, Inc, Bethlehem, PA), and the interscalene groove was identified at the level of C6 The brachial plexus was identified by eliciting biceps stimulation (01-ms duration, 2 Hz) at 034 mA, following which 40 ml local anesthetic solution (20 ml bupivacaine, 05%, and 20 ml mepivacaine, 15%) were injected slowly (over approximately 25 min) in 5-ml increments with gentle aspiration between doses The patient was awake and conversant during the performance of the block At no time was any blood aspirated, nor did he report pain or paresthesias Approximately 30 s after removal of the block needle, the patient became incoherent and then developed a tonic–clonic seizure Oxygen was delivered by a facemask attached to a self-inflating resuscitation bag while 50 mg propofol was injected intravenously The seizure stopped, and spontaneous respirations resumed Approximately 90 s later, the patient began to seize again; this time, 100 mg intravenous propofol was administered The electrocardiogram showed asystole, and no pulse, by carotid or femoral palpation, or blood pressure was detectable Advanced cardiac life support was immediately started The trachea was intubated, and end-tidal carbon dioxide was detected with an EasyCapII (Nellcor Inc, Hayward, CA) Tube position was confirmed by auscultation, after which chest compressions were immediately resumed During the first 20 min of advanced cardiac life support, a total of 3 mg epinephrine, given in divided doses, 2 mg atropine, 300 mg amiodarone, and 40 U arginine vasopressin were administered In addition, monophasic defibrillation was used at escalating energy levels—200, 300, 360, and 360 J, according to the advanced cardiac life support protocol Cardiac rhythms included ventricular tachycardia with a pulse, pulseless ventricular tachycardia that momentarily became ventricular fibrillation, and eventually asystole The arrhythmias observed during most of the resuscitation period were pulseless ventricular tachycardia and asystole After 20 min, at which time plans were being made to institute cardiopulmonary bypass, the administration of a lipid emulsion was suggested, and 100 ml of 20% Intralipid (for Baxter Pharmaceuticals by Fresenius Kabi, Uppsala, Sweden) was given through the peripheral intravenous catheter Cardiac compressions continued, and a defibrillation shock at 360 J was given Within seconds, a single sinus beat appeared on the electrocardiogram, and 1 mg atropine and 1 mg epinephrine were administered Within 15 s, while external chest compressions were continued, the cardiac rhythm returned to sinus at a rate of 90 beats/min The blood pressure and pulse became detectable An infusion of lipid emulsion was started and continued at 05 ml · kg 1 · min 1 over the following 2 h and then discontinued The patient remained in sinus rhythm He was weaned from mechanical ventilation, and his trachea was extubated, approximately 25 h later He was awake and responsive, and had right upper extremity weakness consistent with a brachial plexus block No neurologic sequelae were sustained, and he was subsequently transferred to a monitored setting for overnight observation There was no evidence of complications secondary to the administration of intralipid (ie, pancreatitis) during the following 2 weeks Because the patient had a cardiac arrest after which he had increased levels of cardiac enzymes, he agreed to undergo cardiac catheterization This revealed total occlusion of the right coronary artery and a left ventricular ejection fraction of 32% As a consequence, an automatic implantable cardiac defibrillator was inserted without any complications, and the patient was discharged home

609 citations


Journal ArticleDOI
TL;DR: The authors observed the incidence of grade 3 MV to be 1.4%, similar to studies with the same definition of difficult MV, and found the mandibular protrusion test may be an essential element of the airway examination.
Abstract: Background:Mask ventilation is an essential element of airway management that has rarely been studied as the primary outcome. The authors sought to determine the incidence and predictors of difficult and impossible mask ventilation.Methods:A four-point scale to grade difficulty in performing mask ve

557 citations


Journal ArticleDOI
TL;DR: Urinary NGAL may be a useful early biomarker of ARD after cardiac surgery and facilitate the early detection of acute renal injury and potentially prevent progression to acute renal failure.
Abstract: Background:Acute renal dysfunction (ARD) and subsequent acute renal failure after cardiac surgery are associated with high mortality and morbidity. Early therapeutic or preventive intervention is hampered by the lack of an early biomarker for acute renal injury. Recent studies showed that urinary ne

544 citations


Journal ArticleDOI
TL;DR: The anesthesia-related mortality rate in France seems to be reduced 10-fold in 1999, and concerns regarding aspiration of gastric contents and anemia associated with postoperative ischemic complications were the associated factors most often encountered.
Abstract: Background: This study describes a nationwide survey that estimates the number and characteristics of anesthesia-related deaths for the year 1999. Methods: Death certificates from the French national mortality database were selected from the International Classification of Diseases, Ninth Revision codes using a variable sampling fraction. Medical certifiers were sent a questionnaire (response rate, 97%), and the anesthesiologist in charge was offered a peer review (acceptance rate, 97%). Files were reviewed to determine the mechanism of each perioperative death and its relation to anesthesia. Mortality rates were calculated using the number of anesthetic procedures estimated from a national 1996 survey and compared with a previous (1978‐1982) nationwide study. Results: Among the 4,200 certificates analyzed, 256 led to a detailed evaluation. The death rates totally or partially related to anesthesia for 1999 were 0.69 in 100,000 (95% confidence interval, 0.22‐1.2 in 100,000) and 4.7 in 100,000 (3.1‐6.3 in 100,000), respectively. The death rate increased from 0.4 to 55 in 100,000 for American Society of Anesthesiologists physical status I and IV patients, respectively. Rates increased with increasing age. Although concerns regarding aspiration of gastric contents remain, intraoperative hypotension and anemia associated with postoperative ischemic complications were the associated factors most often encountered. Deviations from standard practice and organizational failure were often found to be associated with death. Conclusion: In comparison with data from a previous nationwide study (1978‐1982), the anesthesia-related mortality rate in France seems to be reduced 10-fold in 1999. Much remains to be done to improve compliance of physicians to standard practice and to improve the anesthetic system process.

540 citations


Journal ArticleDOI
TL;DR: Exposure to a simulated crisis without constructive debriefing by instructors offers little benefit to trainees, and the addition of video review did not offer any advantage over oral feedback alone, which means valuable simulation training can be achieved even when video technology is not available.
Abstract: Background:The debriefing process during simulation-based education has been poorly studied despite its educational importance. Videotape feedback is an adjunct that may enhance the impact of the debriefing and in turn maximize learning. The purpose of this study was to investigate the value of the

Journal ArticleDOI
TL;DR: A protective ventilatory strategy decreases the proinflammatory systemic response after esophagectomy, improves lung function, and results in earlier extubation.
Abstract: Background:Esophagectomy induces a systemic inflammatory response whose extent has been recognized as a predictive factor of postoperative respiratory morbidity. The aim of this study was to determine the effectiveness of a protective ventilatory strategy to reduce systemic inflammation in patients

Journal ArticleDOI
TL;DR: Oversedation leading to respiratory depression was an important mechanism of patient injuries during monitored anesthesia care, and Appropriate use of monitoring, vigilance, and early resuscitation could have prevented many of these injuries.
Abstract: Background:To assess the patterns of injury and liability associated with monitored anesthesia care (MAC) compared with general and regional anesthesia, the authors reviewed closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1990.Methods:All surgical

Journal ArticleDOI
TL;DR: Ischemic optic neuropathy was the most common cause of visual loss after spine surgery in the Postoperative Visual Loss Registry, and most patients were relatively healthy.
Abstract: Background:Postoperative visual loss after prone spine surgery is increasingly reported in association with ischemic optic neuropathy, but its etiology is unknown.Methods:To describe the clinical characteristics of these patients, the authors analyzed a retrospectively collected series of 93 spine s

Journal ArticleDOI
TL;DR: Although the results suggest that aprotinin and tranexamic acid significantly reduce allogeneic erythrocyte transfusion, further evaluation of safety is required before recommending the use of antifibrinolytics in orthopedic surgery.
Abstract: Studies have shown that antifibrinolytic (aprotinin, tranexamic acid, epsilon-aminocaproic acid) reduce blood loss in orthopedic surgery. However, most lacked sufficient power to evaluate the efficacy and safety on clinical outcomes. This meta-analysis aims to evaluate whether intravenous antifibrinolytics, when compared with placebo, reduce perioperative allogeneic erythrocyte transfusion requirement in adults undergoing orthopedic surgery and whether it might increase the risk of venous thromboembolism. From MEDLINE, EMBASE, and the Cochrane Controlled Trials Register, the authors identified 43 randomized controlled trials in total hip and knee arthroplasty, spine fusion, musculoskeletal sepsis, or tumor surgery performed to July 2005 (for aprotinin, 23 trials with 1,268 participants; tranexamic acid, 20 with 1,084; epsilon-aminocaproic acid, 4 with 171). Aprotinin and tranexamic acid reduced significantly the proportion of patients requiring allogeneic erythrocyte transfusion according to a transfusion protocol. The odds ratio was 0.43 (95% confidence interval, 0.28-0.64) for aprotinin and 0.17 (0.11-0.24) for tranexamic acid. Results suggest a dose-effect relation with tranexamic acid. Epsilon-aminocaproic acid was not efficacious. Unfortunately, data were too limited for any conclusions regarding safety. Although the results suggest that aprotinin and tranexamic acid significantly reduce allogeneic erythrocyte transfusion, further evaluation of safety is required before recommending the use of antifibrinolytics in orthopedic surgery.

Journal ArticleDOI
TL;DR: At doses of 2.0mg/kg or greater, sugammadex safely reversed 0.6 mg/kg rocuronium–induced neuromuscular block in a dose-dependent manner and was safe and well tolerated.
Abstract: Background:Sugammadex (Org 25969) forms a complex with steroidal neuromuscular blocking agents, thereby reversing neuromuscular block. This study investigated the dose–response relation, safety, and pharmacokinetics of sugammadex to reverse rocuronium-induced block.Methods:Twenty-seven male surgical

Journal ArticleDOI
TL;DR: The nicotinic (neuronal) α7 acetylcholine receptors, recently described to be expressed in muscle also, can be depolarized not only by acetyl choline and succinylcholine but also by choline, persistently, and possibly play a critical role in the hyperkalemic response to succinyl choline in patients with up-regulated AChRs.
Abstract: Lethal hyperkalemic response to succinylcholine continues to be reported, but the molecular mechanisms for the hyperkalemia have not been completely elucidated. In the normal innervated mature muscle, the acetylcholine receptors (AChRs) are located only in the junctional area. In certain pathologic states, including upper or lower motor denervation, chemical denervation by muscle relaxants, drugs, or toxins, immobilization, infection, direct muscle trauma, muscle tumor, or muscle inflammation, and/or burn injury, there is up-regulation (increase) of AChRs spreading throughout the muscle membrane, with the additional expression of two new isoforms of AChRs. The depolarization of these AChRs that are spread throughout the muscle membrane by succinylcholine and its metabolites leads to potassium efflux from the muscle, leading to hyperkalemia. The nicotinic (neuronal) 7 acetylcholine receptors, recently described to be expressed in muscle also, can be depolarized not only by acetylcholine and succinylcholine but also by choline, persistently, and possibly play a critical role in the hyperkalemic response to succinylcholine in patients with upregulated AChRs.

Journal ArticleDOI
TL;DR: There are no outcome data that would support a recommendation for a particular practice option for airway management, but a number of options seem appropriate and acceptable.
Abstract: Cervical spinal injury occurs in 2% of victims of blunt trauma; the incidence is increased if the Glasgow Coma Scale score is less than 8 or if there is a focal neurologic deficit. Immobilization of the spine after trauma is advocated as a standard of care. A three-view x-ray series supplemented with computed tomography imaging is an effective imaging strategy to rule out cervical spinal injury. Secondary neurologic injury occurs in 2‐10% of patients after cervical spinal injury; it seems to be an inevitable consequence of the primary injury in a subpopulation of patients. All airway interventions cause spinal movement; immobilization may have a modest effect in limiting spinal movement during airway maneuvers. Many anesthesiologists state a preference for the fiberoptic bronchoscope to facilitate airway management, although there is considerable, favorable experience with the direct laryngoscope in cervical spinal injury patients. There are no outcome data that would support a recommendation for a particular practice option for airway management; a number of options seem appropriate and acceptable. THE provision of acute medical care to patients with cervical spinal injuries (CSIs) is a complex, challenging, and rewarding task. It is also an anxiety-provoking endeavor because care is provided in a milieu where there is constant concern about medical interventions resulting in the conversion of a spinal injury without neurologic sequelae to one in which the two are now concurrent. It is also a topic of continuous debate because care providers struggle in an environment of limited data and incomplete answers to try to craft clinical care paradigms designed to optimize preservation and return of neurologic function, while minimizing the risk of creating additional injury and neurologic compromise. Many questions regarding the initial care of these patients, particularly as they relate to airway management, remain unresolved, but there has been great effort, energy, and enthusiasm expended during the past two decades searching for these answers. This article reviews the literature that has been generated on the topic of airway management after CSI, particularly that published in the past 10 yr, identifying new areas of knowledge and evolving practice patterns. It also attempts to address and resolve controversy surrounding areas of care that have proven more contentious, most particularly the use of the direct laryngoscope to facilitate direct tracheal intubation in these patients.

Journal ArticleDOI
TL;DR: Under the conditions of this study, puncturing of the peripheral nerves and apparent intraneural injection during axillary plexus block did not lead to a neurologic injury.
Abstract: Background: Nerve puncture by the block needle and intraneural injection of local anesthetic are thought to be major risk factors leading to neurologic injury after peripheral nerve blocks. In this study, the author sought to determine the needle‐nerve relation and location of the injectate during ultrasound-guided axillary plexus block. Methods: Using ultrasound-guided axillary plexus block (10MHz linear transducer, SonoSite, Bothel, WA; 22-gauge B-bevel needle, Becton Dickinson, Franklin Parks, NJ), the incidence of apparent nerve puncture and intraneural injection of local anesthetic was prospectively studied in 26 patients. To determine the onset, success rate, and any residual neurologic deficit, qualitative sensory and quantitative motor testing were performed before and 5 and 20 min after block placement. At a follow-up 6 months after the blocks, the patients were examined for any neurologic deficit. Results: Twenty-two of 26 patients had nerve puncture of at least one nerve, and 21 of 26 patients had intraneural injection of at least one nerve. In the entire cohort, 72 of a total of 104 nerves had intraneural injection. Sensory and motor testing before and 6 months after the nerve injections were unchanged. Conclusions: Under the conditions of this study, puncturing of the peripheral nerves and apparent intraneural injection during axillary plexus block did not lead to a neurologic injury. ULTRASOUND is a useful aid for the performance of peripheral nerve block. Its use has resulted in a decreased incidence of vascular puncture, faster onset times, decreased dose requirements, and higher success rates. 1‐4 The practice of ultrasound-guided nerve block is still evolving. Most practitioners continue to use a nerve stimulator even while performing the procedure under real-time viewing. There is also considerable debate about what the images mean. Most publications have shown a black (hypoechoic) local anesthetic ring around the nerve after injection is done (fig. 1). This is consistent with a nerve that is surrounded by a tissue plane that is separated from the epineurium. Local anesthetic is injected into this potential space. In the author’s experience, as the needle touches the nerve, the nerve moves 1 or 2 cm before the needle pierces an anatomical structure that may be the fascia. As the needle pierces this anatomical structure/fascia, the practitioner may feel a pop, and the patient often reports a paresthesia or dysesthesia. Simultaneously, the needle seems to enter the substance of the nerve. Injection of 2‐3 ml of local anesthetic usually proceeds with minimal pain and resistance. When compared with the undisturbed nerve (fig. 2A), the injected nerve seems to swell with a uniform stippled image and little or no black ring around it (fig. 2B). Some of the local anesthetic forms a black hypoechoic shadow in the nerve, and some of the local anesthetic leaks out of the nerve, forming a small hypoechoic ring around the nerve (fig. 2C). These observations are intriguing because they contradict the common assumptions that needle‐nerve contact and intraneural injection are invariably associated with neurologic injury. A retrospective review of 50 ultrasoundguided blocks in the author’s archive showed that one or more nerves in each patient was punctured and followed by an intraneural injection with local anesthetic. Because these patients did not experience any known sequelae, the author decided to perform a prospective study of his ultrasound-guided axillary blocks to determine the incidence of needle entry into the nerve as well as the images formed if local anesthetic was injected into the nerve. The author also studied any transient or permanent injuries to the nerves. Materials and Methods

Journal ArticleDOI
TL;DR: Rigorous assessment of teamwork climate is possible using this psychometrically sound teamwork climate scale and initial benchmarks allow others to compare their teamwork climate to national means, in an effort to focus more on what excellent surgical teams do well.
Abstract: Background:The Joint Commission on Accreditation of Healthcare Organizations is proposing that hospitals measure culture beginning in 2007. However, a reliable and widely used measurement tool for the operating room (OR) setting does not currently exist.Methods:OR personnel in 60 US hospitals were s

Journal ArticleDOI
TL;DR: Mechanical ventilation with large intraoperative VT is associated with increased risk of postpneumonectomy respiratory failure and the interaction between larger VT and fluid administration was significant.
Abstract: Background:Respiratory failure is a leading cause of postoperative morbidity and mortality in patients undergoing pneumonectomy. The authors hypothesized that intraoperative mechanical ventilation with large tidal volumes (VTs) would be associated with increased risk of postpneumonectomy respiratory

Journal ArticleDOI
TL;DR: Evidence-based strategies for preventing and treating pain after thoracic surgery, the most recognized pain syndrome associated with a specific surgery, are reviewed.
Abstract: THE pain that accompanies thoracic surgery is notable for its intensity and duration. Acutely, moderate to severe levels of pain may not decrease substantially over the course of hospitalization and the first postoperative month. Chronically, pain can last for months to years, and even low levels of pain can decrease function. Other than pain syndromes associated with limb amputation, pain after thoracic surgery may be the most recognized pain syndrome associated with a specific surgery. Although used with increasing frequency, thoracoscopic approaches have not had the favorable impact on pain that many had anticipated. Given that the adverse effects of thoracic surgery on pulmonary function can be mitigated by effective perioperative analgesia, it is not surprising that thoracic surgeons have joined anesthesiologists in becoming strong advocates of analgesic interventions known to limit the pain accompanying thoracic surgery. Here, we review evidence-based strategies for preventing and treating this type of pain.

Journal ArticleDOI
TL;DR: Three subtypes of vasopressin receptors, V1, V2, and V3, have been identified, mediating vasoconstriction, water reabsorption, and central nervous system effects, respectively, in patients with sepsis, vasodilatory shock, intraoperative hypotension, and cardiopulmonary resuscitation.
Abstract: Vasopressin, synthesized in the hypothalamus, is released by increased plasma osmolality, decreased arterial pressure, and reductions in cardiac volume. Three subtypes of vasopressin receptors, V1, V2, and V3, have been identified, mediating vasoconstriction, water reabsorption, and central nervous system effects, respectively. Vasopressin and its analogs have been studied intensively for the treatment of states of "relative vasopressin deficiency," such as sepsis, vasodilatory shock, intraoperative hypotension, and cardiopulmonary resuscitation. Infusion of vasopressin (0.01-0.04 U/min) decreases catecholamine requirements in patients with sepsis and other types of vasodilatory shock. Bolus application of 1 mg terlipressin, the V1 agonist, reverses refractory hypotension in anesthetized patients and has been studied in patients with septic shock and chronic liver failure. During cardiopulmonary resuscitation, a 40-U bolus dose of vasopressin may be considered to replace the first or second bolus of epinephrine regardless of the initial rhythm. The side effects of vasopressin and its analogs must be further characterized.

Journal ArticleDOI
TL;DR: A clinically relevant concentration of isoflurane induces apoptosis, alters APP processing, and increases A&bgr; production in a human neuroglioma cell line, which may have implications for use of this anesthetic agent in individuals with excessive levels of cerebral amyloid and elderly patients at increased risk for postoperative cognitive dysfunction.
Abstract: Background:The common inhalation anesthetic isoflurane has previously been reported to enhance the aggregation and cytotoxicity of the Alzheimer disease–associated amyloid β protein (Aβ), the principal peptide component of cerebral β-amyloid deposits.Methods:H4 human neuroglioma cells stably transfe

Journal ArticleDOI
TL;DR: Genetic variation of the &mgr;-opioid receptor may contribute to interindividual differences in postoperative morphine consumption and identifying single nucleotide polymorphisms of patients may provide information to modulate the analgesic dosage of opioid for better pain control.
Abstract: Background: Animal and human studies indicate that genetics may contribute to the variability of morphine efficacy. A recent report suggested that cancer patients homozygous for the 118G allele caused by the single nucleotide polymorphism at nucleotide position 118 in the -opioid receptor gene require higher doses of morphine to relieve pain. The purpose of the current study was to investigate whether this polymorphism contributes to the variability of morphine efficacy in women who undergo abdominal total hysterectomy. Methods: After informed consent was obtained, 80 female patients (American Society of Anesthesiologist physical status I or II) scheduled to undergo elective total hysterectomy surgery were enrolled in this study. All patients received general anesthesia and were screened for A118G polymorphism by blood sample. Intravenous morphine patient-controlled analgesia was provided postoperatively for satisfactory analgesia. The authors recorded the morphine consumption doses and demand times. Pain at rest and side effects were measured with rating scales. Results: Forty-three women were A118 homozygous, 19 were heterozygous, and 18 were G118 homozygous. Patients homozygous for G118 required more morphine doses (33 10 mg) to achieve adequate pain relief compared with patients homozygous for A118 (27 10 mg) in the first 24 h (P 0.02). However, there was no statistically significant difference for morphine consumption at 48 h. Conclusion: Genetic variation of the -opioid receptor may contribute to interindividual differences in postoperative morphine consumption. In the future, identifying single nucleotide polymorphisms of patients may provide information to modulate the analgesic dosage of opioid for better pain control. IT has been known for a long time that the effects of morphine as an agent for pain control vary in different individuals. Morphine produces its clinical effects mainly through -opioid receptors. Polymorphisms in the -opioid receptor gene may be associated with the clinical effects of opioid analgesics, 1–3 which encourages research into human genetic polymorphisms and their clinical consequences. Several single nucleotide polymorphisms (SNPs) have been identified in the human -opioid receptor gene. The A118G mutation is the most common one leading to a change in the gene product in the human -opioid receptors, which is an A to G substitution in exon 1 and results in an amino acid exchange at position 40 from asparagine to aspartate (N40D). 4 Functional effects of the A118G polymorphism have been demonstrated both in vitro and in vivo. In vitro, -endorphin has been shown to bind three times more tightly at the receptor of homozygous G allele than at that of homozygous A allele. 4 A recent report also suggested that cancer patients who were homozygous for the G118 variant required higher doses of oral morphine for long-term treatment of their pain. 2 Romberg et al. 5,6 studied the pharmacokinetics and pharmacodynamics of morphine-6-glucuronide (M6G), a -opioid agonist, and also found that A118G mutation of the human -opioid receptor gene reduced analgesic responses to M6G. The effect of -opioid receptor genotype on acute postoperative morphine requirements has not been reported; therefore, we decided to determine morphine consumption with intravenous patient-controlled analgesia in women undergoing total abdominal hysterectomy according to A118G polymorphism.

Journal ArticleDOI
TL;DR: Risk estimates for superficial and deep infections, hematoma, and transient and permanent neurologic injury were obtained from studies reporting adverse events with obstetric epidural analgesia, and incidence presented as individual risk for a woman, number of events per million women, and percentage incidence.
Abstract: Of the 4 million annual births in the United States, 2.4 million involve epidural analgesia. Serious adverse events are rare but are important in young women. Robust estimates for the risk of harm are not available. Data for superficial and deep infections, hematoma, and transient and permanent neurologic injury were obtained from studies reporting adverse events with obstetric epidural analgesia, and incidence presented as individual risk for a woman, number of events per million women, and percentage incidence. A total of 1.37 million women received an epidural for childbirth, reported in 27 articles. Most information (85% of women) was in larger (> 10,000 women) studies published after 1990, with risk estimates as follows: epidural hematoma, 1 in 168,000; deep epidural infection, 1 in 145,000; persistent neurologic injury, 1 in 240,000; and transient neurologic injury, 1 in 6,700. Earlier and smaller studies produced significantly higher risk estimates for transient neurologic injury plus injury of unknown duration.

Journal ArticleDOI
TL;DR: Preoperative statin therapy may reduce postoperative mortality in patients undergoing surgical procedures, however, the statin associated effects on postoperative cardiovascular morbidity are too variable to draw any conclusion.
Abstract: Statin therapy is well established for prevention of cardiovascular disease. Statins may also reduce postoperative mortality and morbidity via a pleiotropic (non-lipid-lowering) effect. The authors conducted a meta-analysis to determine the influence of statin treatment on adverse postoperative outcomes in patients undergoing cardiac, vascular, or noncardiovascular surgery. Two independent authors abstracted data from 12 retrospective and 3 prospective trials (n = 223,010 patients). A meta-analysis was performed to evaluate the overall effect of preoperative statin therapy on postoperative outcomes. Preoperative statin therapy was associated with 38% and 59% reduction in the risk of mortality after cardiac (1.9% vs. 3.1%; P = 0.0001) and vascular (1.7% vs. 6.1%; P = 0.0001) surgery, respectively. When including noncardiac surgery, a 44% reduction in mortality (2.2% vs. 3.2%; P = 0.0001) was observed. Preoperative statin therapy may reduce postoperative mortality in patients undergoing surgical procedures. However, the statin associated effects on postoperative cardiovascular morbidity are too variable to draw any conclusion.

Journal ArticleDOI
TL;DR: The results suggest that upregulation of prostaglandin E2 and interleukin 6 at central sites is an important component of surgery induced inflammatory response in patients and may influence clinical outcome.
Abstract: Background:The central and peripheral inflammatory response to surgery may influence patient outcomes. This study examines the time course and clinical relevance of changes in prostaglandin E2 and cytokines in cerebrospinal fluid, local tissue (surgical site), and circulating blood during and after

Journal ArticleDOI
TL;DR: Previous recurrent hypoxemia in OSA is associated with increased analgesic sensitivity to subsequent morphine administration, and opiate dosing in children with OSA must take into account a history of recurrent Hypoxemia.
Abstract: Background:Postsurgical administration of opiates in patients with obstructive sleep apnea (OSA) has recently been linked to an increased risk for respiratory complications. The authors have attributed this association to an effect of recurrent oxygen desaturation accompanying OSA on endogenous opio

Journal ArticleDOI
TL;DR: The incidence of persistent pain after sternotomy was lower than previously reported and, reassuringly, 1 year after surgery this pain was mostly mild in nature both at rest and on movement.
Abstract: Background:Persistent chest pain may originate from cardiac surgery. Conflicting results have been reported on the incidence of persistent poststernotomy pain with considerable discrepancies between the retrospective reports and the one prospective study conducted to assess this pain. Therefore, the