RESUMEN
PURPOSE: Spinal anesthesia can be technically challenging in young infants. We studied whether the distance between the skin and the lumbar subarachnoid space in premature and former-premature young infants could be predicted prior to lumbar puncture. METHODS: The distance from skin entry point to tip of the spinal needle was measured using a caliper after lumbar spinal anesthesia at the L4-5 interspace. This distance was correlated to the patient's weight, postconceptual age and lumbar ultrasonographic measurement of the skin-to-subarachnoid space and predictive statistical models were sought. RESULTS: Thirty-five premature or former-premature infants were studied. Three models were examined: all three independent variables, weight and postconceptual age only, and weight only. The model selected contained the weight and postconceptual age, because it had the highest value for adjusted R squared, as well as the lowest value for the mean squared error. Adding the ultrasonic measurement to the model worsened the results. The statistical model that described the depth of the subarachnoid space at the L4-5 level was Y = 13.19 + 0.0026 x W - 0.12 x PCA, where Y is the distance (mm) from the skin to the subarachnoid space, W is the patient's weight (g) and PCA is the postconceptual age (weeks). Adjusted R squared was 0.72, mean square error was 2.63 and P < 10(-9). CONCLUSION: The distance between the skin and the subarachnoid space at the level of L4-5 interspace can be predicted using a statistical model based on the infant's weight and postconceptual age. Spinal ultrasound has no value in L4-5 subarachnoid space depth prediction.
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Pesos y Medidas Corporales/métodos , Recien Nacido Prematuro/fisiología , Modelos Estadísticos , Piel/anatomía & histología , Punción Espinal/normas , Espacio Subaracnoideo/anatomía & histología , Anestesia Raquidea/métodos , Peso Corporal/fisiología , Edad Gestacional , Humanos , Recién Nacido , Modelos Lineales , Región Lumbosacra , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los Resultados , Piel/diagnóstico por imagen , Punción Espinal/métodos , Espacio Subaracnoideo/diagnóstico por imagen , UltrasonografíaRESUMEN
STUDY OBJECTIVES: To compare the analgesic efficacy of a nonsteroidal antiinflammatory drug (NSAID) alone (basic pain treatment) with that of NSAID in conjunction with either intravenous (IV) patient-controlled analgesia (IV-PCA) or intermittent epidural morphine (epidural morphine), among patients recovering from major intraabdominal surgery; and to assess the fixed and variable costs of providing the respective acute pain treatment modalities. DESIGN: Prospective, nonrandomized study. SETTING: Postanesthesia care unit (PACU) and surgical departments of a large referral hospital. PATIENTS: All patients (n = 358) treated by our Acute Pain Service (APS) who were recovering from major intraabdominal surgery (colectomy, cholecystectomy, colostomy, gastrectomy, splenectomy). MEASUREMENTS AND MAIN RESULTS: The structure of our APS, analgesic regimens, and the associated patient monitoring and event-response algorithms are detailed. Data of 358 patients recovering from major intraabdominal surgery and treated according to one of the three treatment protocols were collected and analyzed. The cost of providing our APS and the nursing time required to monitor and treat patients in each treatment group were also calculated. The median visual analog scale (VAS) scores were low in all three treatment groups (23.5 mm vs. 6 mm vs. 4, for the basic pain treatment, IV-PCA, and epidural morphine groups, respectively). However, the median VAS was significantly (p < 0.04) lower among patients who received epidural morphine than either the IV-PCA or basic pain treatment groups. Similarly, the number of patients who had at least one episode of a pain VAS >30 mm was significantly (p < 0.04) lower in the epidural morphine group than either of the other two groups. The frequency of nausea and vomiting was similar among the groups. However, the frequency of postoperative pruritus was significantly (p < 0.001) higher in the epidural morphine group than the other two groups. Patient satisfaction was unaffected by group allocation. Institutional costs per patient and the nursing time required to provide the APS were lowest in the basic pain treatment group. CONCLUSIONS: Considering the respective pain profiles, complication rates, and institutional costs associated with the three analgesic regimens analyzed, the basic pain Treatment alone constitutes a useful alternative to the other two analgesic regimens assessed.
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Abdomen/cirugía , Dolor Postoperatorio/tratamiento farmacológico , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Analgesia Epidural , Analgesia Controlada por el Paciente , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Antiinflamatorios no Esteroideos/administración & dosificación , Antiinflamatorios no Esteroideos/uso terapéutico , Femenino , Humanos , Inyecciones Intravenosas , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Morfina/administración & dosificación , Morfina/uso terapéutico , Dimensión del Dolor , Dolor Postoperatorio/economía , Satisfacción del Paciente , Estudios Prospectivos , Sala de Recuperación , Pruebas de Función RespiratoriaRESUMEN
This retrospective study was performed to assess and compare the immediate safety and long term outcome of surgical decompression of spinal stenosis when performed for geriatric patients aged 65-74 years (Group A) and those >75 years (Group B) of age. Some 283 patients were studied (179 and 104 patients in Groups A and B, respectively). The mean follow-up time was 41.5 months (range: 9-115) and 42.9 months (range: 9-106) for Groups A and B, respectively. Within both treatment groups, there was a significant (P<0.0001) subjective improvement in low back and radicular pain, as well as the ability to perform daily activities. When compared to preoperative levels, the oral scores for pain while performing daily activities were significantly (P<0.001) improved in both treatment groups. The overall postoperative complication rate was similar between the groups. Age is not a contraindication for decompressive lumbar spine surgery. However, since both Group A and B patients are likely to suffer minor perioperative complications, increased vigilance and careful monitoring are essential for this high risk population.
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Estenosis Espinal/cirugía , Actividades Cotidianas , Factores de Edad , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Laminectomía , Masculino , Dimensión del Dolor , Satisfacción del Paciente , Complicaciones Posoperatorias , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Factores de Tiempo , Resultado del TratamientoRESUMEN
STUDY OBJECTIVE: To assess the analgesic efficacy of ketamine when administered as an adjuvant to bupivacaine for patient-controlled wound instillation following cesarean section. DESIGN: Prospective, randomized, double-blind study. SETTING: Large referral hospital. PATIENTS: 50 term parturients undergoing cesarean section. INTERVENTION: In all cases, a standard spinal anesthetic was administered. On completion of the surgery, a multihole 20 G epidural catheter (B. Braun, Melsungen, Germany) was placed above the fascia such that the tip was sited at the point which demarcated 50% of the length of the surgical wound. Thereafter, the catheter was connected to a patient-controlled drug delivery device. The device was filled with either 0.125% bupivacaine (bupivacaine group) or 0.125% bupivacaine and ketamine (1 mg/mL) (bupivacaine-ketamine group). Postoperatively, wound instillation was performed via the patient-controlled analgesia device. During the first 6 postoperative hours, a co-investigator administered "rescue" morphine (2 mg IV). Thereafter, "rescue" dipyrone (1 g) was administered on patient request. MEASUREMENTS AND MAIN RESULTS: At all time intervals, visual analog scale (VAS) for pain at rest, on coughing, and during leg raise were similar between the groups. All patients (100%) in both treatment groups received "rescue" morphine. Similarly, the number of doses of 2 mg "rescue" morphine administered was unaffected by patient randomization. The total "rescue" morphine administered during the first 6 postoperative hours was 11.2 +/- 4.6 mg versus 11.3 +/- 5.6 mg for the bupivacaine group and bupivacaine-ketamine group, respectively. The number of pump infusions during the 24-hour study period was 9 +/- 2 and 9 +/- 3 for the bupivacaine group and bupivacaine-ketamine group, respectively. The volume infused via the delivery device was similar between the groups (81 +/- 18 mL vs. 85 +/- 24 mL for the bupivacaine group and bupivacaine-ketamine group, respectively). Psychomental and cognitive function as measured by the Digit Symbol Substitution and Mini Mental Tests were unaffected by adjuvant ketamine administration. Patient satisfaction was similar between the groups. CONCLUSION: Adjuvant local ketamine does not enhance bupivacaine-induced wound instillation following cesarean section.
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Analgesia Controlada por el Paciente/estadística & datos numéricos , Analgésicos/administración & dosificación , Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Cesárea , Ketamina/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Adulto , Método Doble Ciego , Femenino , Humanos , Persona de Mediana Edad , Dimensión del Dolor , Satisfacción del Paciente , Embarazo , Estudios Prospectivos , Factores de TiempoRESUMEN
PURPOSE: To present our experience with spinal anesthesia in premature and former premature infants, and to focus on technical aspects and pitfalls enlightened with increasing experience. METHODS: The perioperative course of all premature and former premature infants below 60 weeks postconceptual age undergoing spinal anesthesia within an 35-month-period was analyzed. Lumbar puncture was performed while the patient was held seated at L4-5 or L5-S1. Anesthetics included hyperbaric tetracaine or bupivacaine, dose 1 mg/kg with adrenaline. The patients were positioned in the reverse Trendelenburg for 2-3 minutes, and later horizontally. RESULTS: Sixty seven infants (gestational age 30.1 +/- 3.6 weeks, postconceptual age 42.9 +/- 3.4, weight 3234 +/- 1165 grams) underwent spinal anesthesia and surgery. Thirty two had other diseases, including congenital heart (12), lung (15) brain pathology (8) and urological findings (6). Sixty five patients underwent hernia repair and two underwent pyloromyotomy. N2O was added in three infants, and two required general anesthesia. All were found to have lower limb motor blockade postoperatively. Intraoperatively, hypoxemia was diagnosed in two infants, short apnea in two cases and bradycardia in one. The apnea and hypoxemia episodes were successfully treated by reverse Trendelenburg positioning and bag and mask ventilation and the bradycardia that did not respond to tactile stimulation was relieved by atropine. Postoperatively, a short episode of apnea and hypoxemia (one patient) and hypoxemia (one patient) responded to free oxygen administration with/without tactile stimulation. Brief bradycardia (three infants) terminated without intervention. Supplementation and postoperative complication rates resembled previous studies. CONCLUSION: Successful spinal anesthesia in premature and former premature infants depends on close attention to preoperative assessment, patient positioning during and immediately after anesthetic induction, drug dosing and perioperative monitoring. A relatively high dose of local anesthetic should be administered.
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Anestesia Raquidea , Recien Nacido Prematuro , Anestesia Raquidea/efectos adversos , Peso al Nacer , Bupivacaína , Preescolar , Edad Gestacional , Humanos , Lactante , Recién Nacido , Tetracaína , Resultado del TratamientoRESUMEN
UNLABELLED: Our primary objective was to assess the feasibility of geriatric patients (>65 yr) bypassing the postanesthesia care unit (PACU) after ambulatory surgery. A secondary objective was to compare recovery profiles when using three different maintenance anesthetics. Ninety ASA physical status I--III consenting outpatients (>65 yr) undergoing short urologic procedures were randomly assigned to one of three anesthetic treatment groups. After a standardized induction with fentanyl and propofol, anesthesia was maintained with propofol (75-150 microg center dot kg(-1) center dot min(-1) IV), isoflurane (0.7%-1.2% end tidal), or desflurane (3%-6% end tidal), in combination with nitrous oxide 70% in oxygen. In all three groups, the primary anesthetic was titrated to maintain an electroencephalographic-bispectral index value of 60-65. Recovery times, postanesthesia recovery scores, and therapeutic interventions in the PACU were recorded. Although emergence times were similar in the three groups, the time to achieve a fast-track discharge score of 14 was significantly shorter in patients receiving desflurane compared with propofol and isoflurane (22 +/- 23 vs 33 +/- 25 and 44 +/- 36 min, respectively). On arrival in the PACU, a significantly larger percentage of patients receiving desflurane were judged to be fast-track eligible compared with those receiving either isoflurane and propofol (73% vs 43% and 44%, respectively). The number of therapeutic interventions in the PACU was also significantly larger in the Isoflurane group when compared with the Propofol and Desflurane groups (21 vs 11 and 7, respectively). In conclusion, use of desflurane for maintenance of anesthesia should facilitate PACU bypass ("fast-tracking") of geriatric patients undergoing short urologic procedures. IMPLICATIONS: Geriatric outpatients undergoing brief urologic procedures more rapidly achieve fast-tracking discharge criteria after desflurane (versus isoflurane and propofol) anesthesia. Use of isoflurane was also associated with an increased need for nursing interventions in the early recovery period compared with desflurane and propofol.
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Anestesia/métodos , Uretra/cirugía , Anciano , Anciano de 80 o más Años , Método Doble Ciego , Electroencefalografía , Electromiografía , Femenino , Humanos , Monitoreo Intraoperatorio , Enfermería Posanestésica , Estudios ProspectivosRESUMEN
PURPOSE: To highlight technical aspects and pitfalls of spinal anesthesia (SA) in infants. METHODS: The medical history and perioperative course of all infants who underwent SA over a 28-month period were collected (retrospectively in the first 20). RESULTS: Sixty-two infants underwent surgery under SA. Fifty-five were premature and former-premature, postconceptional age 43.3 +/- 5.0 weeks, weight 3261 +/- 1243 g. Of these, 21 had co-existing disease: cerebral (six), cardiac (nine), pulmonary (11) and urological (six). Hyperbaric tetracaine or bupivacaine 1 mg x kg(-1) with adrenaline was administered. Four infants (three premature) required N(2)O supplementation and three needed general anesthesia. The supplementation rate was similar or lower than in previous studies. Postoperatively, all seven were shown to have lower limb motor and sensory blockade. Complications in premature patients included intraoperative hypoxemia (two), apnea (two) and bradycardia (one). Postoperative complications included bradycardia (three), hypoxemia (one) and apnea and hypoxemia (one). The postoperative complication rate was similar to previous studies. CONCLUSION: Successful SA in infants depends on close attention to preoperative assessment, appropriate patient positioning during and after lumbar puncture, drug dosing and intra- and postoperative cardiorespiratory monitoring. A relatively high dose of hyperbaric solution of tetracaine or bupivacaine with adrenaline should be administered.
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Anestesia Raquidea/métodos , Apnea/etiología , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Recien Nacido Prematuro , Complicaciones Intraoperatorias/etiología , Masculino , Complicaciones Posoperatorias/etiologíaRESUMEN
OBJECTIVE: To assess the effects of 2 different anesthetic techniques on early complications after superior pharyngeal flap surgery. DESIGN: Randomized, prospective, single-blind study. SETTING: Large referral hospital. PATIENTS: One hundred patients undergoing superior pharyngeal flap surgery for the correction of velopharyngeal insufficiency were randomly divided into 2 equal groups to receive either isoflurane or propofol-based anesthesia. INTERVENTIONS: Following induction of anesthesia with fentanyl citrate and propofol, patients were randomized to receive either isoflurane or propofol for the maintenance of general anesthesia. The inspired isoflurane concentration and propofol infusion rate were adjusted to maintain a stable depth of anesthesia as judged by clinical signs and hemodynamic responses to surgical stimuli. MAIN OUTCOME MEASURES: Recovery from anesthesia, recovery from surgery, and early postoperative complications. RESULTS: The groups were similar in age, weight, height, induction time, surgery time, extubation time, and anesthetic time. The time (mean +/- SD) required to achieve a maximal Steward Recovery Score was 7 +/- 14 minutes in the propofol group compared with 32 +/- 28 minutes in the isoflurane group (P<.04). No significant differences in postoperative patient satisfaction scores, time to first swallow, drinking time, and time to "home readiness" were noted. Overall, 17 patients (17%) developed airway-related complications and 2 of the patients (2%) were accounted as severe. Two patients (2%) bled from the operation site. However, there was no difference in the incidence of postoperative complications between the groups. CONCLUSIONS: When compared with isoflurane administration for maintenance of general anesthesia, propofol-based anesthesia was associated with more rapid mental and psychomotor recovery. However, airway-related complications and "home readiness" were similar between the groups.
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Anestesia General , Procedimientos Quirúrgicos Otorrinolaringológicos , Faringe/cirugía , Complicaciones Posoperatorias , Colgajos Quirúrgicos , Adolescente , Adulto , Anestesia por Inhalación , Anestésicos por Inhalación , Anestésicos Intravenosos , Niño , Preescolar , Humanos , Isoflurano , Propofol , Estudios Prospectivos , Método Simple CiegoRESUMEN
This retrospective study examines the results of surgical decompression of the lumbar spinal canal in 122 geriatric patients (age range 75-89 years) treated under general anesthesia by the same surgeon between the years 1990 and 1999. Patient demographics, perioperative complications, pain profiles before surgery and at the time of data collection (December 2000), as well as overall mortality were recorded. One hundred and twenty-two patients were studied. The average age at the time of surgery was 78.8 years (range 75-89 years). No perioperative deaths were recorded. The mean time elapsed from surgery until patient follow-up was 45.7 months (range 12-119 months). Fourteen patients had died at the time of patient follow-up (December 2000). When compared to pain experienced before surgery, at the time of the interview a significant (P<0.0001) improvement in low-back and radicular pain as well as in the ability to perform daily activities (dressing, washing, getting out of bed and walking) was described. We conclude that, for geriatric patients rated as physical status I-II (>75 years) under the American Society of Anesthesiologists (ASA) classification, surgical release of lumbar spinal stenosis is a safe and effective treatment option. However, the suitability of ASA III patients requires further investigation.