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Biomedical subjects

B Fredman

Publications and source records attributed to B Fredman.

At least 19 recordsLinked to original sources
PubMed1999

The effect of repeated epidural sympathetic nerve block on "failed back surgery syndrome" associated chronic low back pain.

STUDY OBJECTIVE: To assess the therapeutic benefits of repeated epidural local anesthetic administration on pain perception and straight leg raise (SLR) in patients suffering from chronic low back pain. DESIGN: Prospective, randomized, controlled, single-blind study protocol. PATIENTS: 50 ASA physical status I, II, and III patients at least 18 years of age, who had previously undergone spine surgery. INTERVENTIONS: All participants were admitted to hospital for the 5-day duration of the study. Following epidural catheterization, fluoroscopy was performed to verify correct placement of the epidural catheter. On the first study day, all patients received depomedrol 80 mg, in 10-ml 1% lidocaine, epidurally. Thereafter, patients were randomized into two equal groups. In Group Bupivacaine (B) 10-ml 0.125% bupivacaine was administered. In Group Saline (S), an equal volume of saline was administered. Epidural injections were performed twice daily (09H00 and 14H00) for 4 days. Sympathetic blockade was confirmed by the presence of peripheral vasodilatation. Sensory blockade was assessed using loss of pin prick and temperature sensation. SLR as well as patient-generated 100-mm visual analog score (VAS) for pain were performed prior to each injection, at 15 minutes after injection, and hourly for 2 hours thereafter. Similar parameters were measured 1 week, 1 month, and 3 months after discharge. MEASUREMENTS AND MAIN RESULTS: 46 patients completed the study. VAS for pain was marginally lower in Group B. However, statistical significance was not demonstrated. During the hospitalization period, the SLR in both study groups significantly (0.008) improved with time. However, no difference between the groups was demonstrated. In both groups, 1 week, 1 month, and 3 months after discharge, the SLR was comparable to prestudy recordings. In Group B, at 1 week, 1 month, and 3 months after discharge, patient-generated VAS for pain were significantly (p = 0.002) higher when compared to pain scores at the time of patient discharge.

Adult↗
PubMed1999

Diclofenac does not decrease renal blood flow or glomerular filtration in elderly patients undergoing orthopedic surgery.

UNLABELLED: Nonsteroidal antiinflammatory drugs (NSAIDs) have become increasingly popular in the treatment of perioperative pain. Due to concerns that cyclooxygenase inhibition may adversely affect renal function, these drugs are often not used in geriatric surgical patients. However, the perioperative effect of NSAIDs on renal blood flow (RBF) and glomerular filtration rate (GFR) has not been assessed. Therefore, using a prospective, controlled, double-blinded study design, we evaluated the effect of diclofenac on RBF and GFR in 20 patients (>65 yr) undergoing open reduction and internal fixation of the femur. All patients were normovolemic before the study. A standardized general anesthetic was administered. On induction of anesthesia, patients in the diclofenac group received an IV bolus of diclofenac (0.7 mg/kg) followed by a constant infusion (0.15 mg x kg(-1) x h(-1)) until the end of surgery. In the saline group, an equal volume of saline was administered. During four time periods (equilibration, anesthesia, surgical, recovery), GFR and effective renal plasma flow (ERPF) were measured by inulin and paraaminohippurate clearance, respectively. After the induction of anesthesia and throughout the surgical period, ERPF and GFR were significantly decreased compared with preoperative baseline values. However, no difference was demonstrated between the groups. These results suggest that, in geriatric surgical patients, the adjuvant administration of NSAIDs does not adversely affect renal function. IMPLICATIONS: As determined by inulin and paraaminohippurate clearance, the intraoperative administration of diclofenac does not decrease glomerular filtration rate or effective renal plasma flow in normovolemic geriatric patients. Therefore, diclofenac may be administered during the perioperative period.

Aged↗
PubMed1999

Long-term incidence of acute myocardial infarction after open and transurethral resection of the prostate for benign prostatic hyperplasia.

PURPOSE: Acute myocardial infarction was found to be the main cause of increased long-term mortality in patients after transurethral compared to open prostatectomy in various retrospective studies. We performed a randomized prospective study to compare morbidity and incidence of acute myocardial infarction in patients after transurethral compared to open prostatectomy for benign prostatic hyperplasia. MATERIALS AND METHODS: We studied 365 patients who were assigned to transurethral (236) or open (129) prostatectomy only according to the size of the prostate and who were followed for 7 to 8 years. The clinical status of the patients in both groups before and after the operation was compared, and the rate of myocardial infarction and long-term mortality was studied. RESULTS: More patients with a history of cerebrovascular accident (5.4 versus 0.8%) and indwelling catheters (16.3 versus 7.6%) before the operation were in the open prostatectomy group. Among the 236 patients operated on transurethrally 31 were reoperated on (6 more than once) during followup compared to 4 of the 129 patients who underwent open prostatectomy. In 15 patients from the transurethral prostatectomy group myocardial infarction developed compared to 9 patients in the open prostatectomy group. This difference was not statistically significant. The rate of acute myocardial infarction after prostatectomy, no matter which approach was used, was greater than 6% and it appeared to be higher when compared to the rate of infarction in the general population of the same age group, which is approximately 2.5% in our county. There was no statistically significant difference in the overall mortality rate between the transurethral and open prostatectomy groups, which was 14.4 and 8.5% respectively. CONCLUSIONS: Open prostatectomy is more effective in overcoming urinary obstruction than the transurethral approach. No significant differences in myocardial infarction or overall mortality rates were found between the 2 groups.

Aged↗
PubMed1999

Epidural steroids for treating "failed back surgery syndrome": is fluoroscopy really necessary?

UNLABELLED: Epidural steroids are commonly administered in the treatment of "failed back surgery syndrome." Because patient response is dependent on accurate steroid placement, fluoroscopic guidance has been advocated. However, because of ever-increasing medical expenditures, the cost-benefit of routine fluoroscopy should be critically evaluated. Therefore, 50 patients were enrolled into this institutional review board-approved, prospective, controlled, single-blinded study. At a predetermined intervertebral level, the epidural space was identified using an air loss of resistance technique. Thereafter, an epidural catheter was inserted 2 cm through the epidural needle. To determine the accuracy of the clinical placement, contrast medium was administered through the epidural catheter; antero-posterior and lateral lumbar spine radiographs were then obtained. The number of attempts required to successfully locate the epidural space, the reliability of the air loss of resistance technique in indicating successful epidural penetration in failed back surgery syndrome, the ability of the clinician to accurately predict the intervertebral space at which the epidural injection was performed, and the spread of contrast medium within the epidural space were recorded. A total of 48 epidurograms were performed. The number of attempts to successfully enter the epidural space was 2 +/- 1. In 44 cases, the radiological studies confirmed the clinical impression that the epidural space had been successfully identified. In three patients, the epidural catheter was in the paravertebral tissue. One myelogram was recorded. In 25 patients, the epidural catheter did not pass through the predetermined intervertebral space. In 35 cases, the contrast medium did not reach the level of pathology. IMPLICATIONS: The clinical sign of loss of resistance is a reliable indicator of epidural space penetration in most cases of "failed back surgery syndrome." However, surface anatomy is unreliable and may result in inaccurate steroid placement. Finally, despite accurate placement, the depot-steroid solution will spread to reach the level of pathology in only 26% of cases.

Adult↗
PubMed1998

Bupivacaine infiltration into the neurovascular bundle of the prostatic nerve does not improve postoperative pain or recovery following transvesical prostatectomy.

PURPOSE: We assessed the effect of intraoperative bupivacaine infiltration into the neurovascular bundle of the prostatic nerve on postoperative pain and patient outcome. MATERIALS AND METHODS: The study included 40 American Society of Anesthesiologists physical status I to III patients undergoing transvesical prostatectomy. Following surgical resection of the prostate the neurovascular bundle of the prostatic nerve was infiltrated with either 10 ml. bupivacaine 0.5% or saline. Postoperative pain intensity was assessed using a patient generated 100 mm. visual analog scale and a patient controlled analgesia device. Additional analgesic requirements, time to ambulation, length of hospitalization and return to normal activity were also recorded. RESULTS: There were no differences in visual analog scale for pain, patient controlled analgesia demands or actual morphine delivered. Similarly, saline versus bupivacaine infiltration did not influence ambulation time (21.3 +/- 2.7 versus 25.0 +/- 11.8 hours, respectively), length of hospitalization (7.06 +/- 0.8 versus 7.11 +/- 0.6 days, respectively), return to normal activity (14.4 +/- 8.8 versus 14.2 +/- 8.2 days, respectively) or patient satisfaction. On postoperative days 1 and 2 more patients in the saline treatment group requested additional oral analgesia compared to the bupivacaine treatment group. However, no statistical difference was demonstrated. CONCLUSIONS: Following transvesical prostatectomy, prostatic nerve blockade has no beneficial effects on postoperative pain or patient outcome.

Aged↗
PubMed1998

The induction, maintenance, and recovery characteristics of spinal versus general anesthesia in elderly patients.

STUDY OBJECTIVE: To compare the induction and recovery profiles of three combinations of general anesthesia when used as an alternative to spinal anesthesia for elderly patients. DESIGN: Randomized, prospective, open-label study. SETTING: Large referral hospital. PATIENTS: 100 [ASA physical status I, II, and III] patients over 60 years of age undergoing brief transurethral surgery. INTERVENTIONS: In Groups Propofol-Propofol (P-P), Propofol-Isoflurane (P-I), and Propofol-Desflurane (P-D), anesthesia was induced with fentanyl (1 to 2 micrograms/kg i.v.) and propofol (1.0 to 2.0 mg/kg i.v.) and maintained with 70% nitrous oxide in oxygen and either a propofol infusion (75 to 150 micrograms/kg/min) or isoflurane (end-tidal 0.7% to 1.2%) or desflurane (end-tidal 1% to 4%), respectively. After induction, a laryngeal mask airway was placed and spontaneous ventilation was maintained. In Group Spinal (S), 1.5 ml 4% lidocaine (60 mg), in an equal volume of 10% dextrose, was administered intrathecally. MEASUREMENTS AND MAIN RESULTS: Induction and recovery characteristics were compared. Induction with propofol was technically easier and significantly (medp < 0.0001) faster (4.6 +/- 1.7 min, 4.7 +/- 2.2 min, and 3.8 +/- 1.4 min for Groups P-P, P-I, and P-D, respectively) than induction of spinal anesthesia (9.3 +/- 3.4 min). During the induction period, mean arterial blood pressure and heart rate were significantly higher in Group S. Emergence, extubation, and orientation times were similar among the general anesthesia treatment groups. In Group S, patient-generated pain scores were lower (p < 0.05) and recovery room admission longer (p < 0.001). Time to return to baseline digit symbol substitution test (DSST) scores was marginally improved in Groups P-P and P-D when compared to Group P-I. Postoperative nausea, sleepiness, anxiety, and coordination were unaffected by the treatment modality. CONCLUSION: General anesthesia with propofol and desflurane facilitates shorter induction and recovery times without adversely affecting patient comfort. Therefore, this technique may be preferable to spinal anesthesia for elderly patients undergoing short transurethral surgical procedures.

Aged↗
PubMed1997

Prehospital cricothyroidotomy by physicians.

To evaluate cricothyroidotomy in the field and the influence of physicians' medical specialty or previous experience on the success rate of this procedure, a retrospective study was conducted. Between October 1991 and April 1995, 29 cricothyroidotomies were performed in the prehospital setting in Israel. Twenty-six (89.6%) cricothyroidotomies were successfully performed. There was no evidence of higher success rate when the performers were surgeons, anesthesiologists, or intensive care specialists (100% success), compared to that of all other specialties (83.33%). All physicians had successfully completed the Advanced Trauma Life Support (ATLS) course, but only three had previously performed cricothyroidotomy. Acute complications included failure to establish an airway in 3 cases, minor bleeding in 2 cases, and an air leak around the cannula in 1 patient. These results show that following brief training (eg, the ATLS course) physicians are capable of performing emergency cricothyroidotomy in the field with a high success rate and minimal complications, regardless of medical specialty.

Adult↗
PubMed1997

Acute normovolaemic haemodilution decreases postoperative allogeneic blood transfusion after total knee replacement.

We hypothesized that the success of postoperative blood conservation after acute normovolaemic haemodilution (NVHD) is influenced by the extent of intraoperative bleeding and surgical trauma, and the timing of autologous blood transfusion. As total knee replacement is associated with minimal intraoperative but extensive postoperative blood loss, this procedure is ideally suited to acute NVHD. Therefore, to test our hypothesis, 30 patients undergoing elective total knee replacement were enrolled in a prospective, randomized, controlled study. In groups NVHD-2 and NVHD-6, before induction of anaesthesia patients were bled to a target packed cell volume (PCV) of 28-30%, and in the post-anaesthesia care unit autologous blood was transfused over a 2-h period terminating after operation at 2 and 6 h, respectively. In the control group, NVHD was not performed. After operation, platelets, fibrinogen, prothrombin and partial thromboplastin time, and liver function, urea and electrolytes were measured and compared with preoperative baseline values. Significantly (P < 0.024) more allogeneic blood was transfused in the control group (21 u.) compared with either group NVHD-2 (7 u.) or group NVHD-6 (5 u.). In the control group, despite the allogeneic blood transfusion, postoperative PCV decreased until day 4 after operation. Coagulation profile, liver function and urea and electrolytes concentrations were unaffected by the method of treatment. We conclude that for total knee replacement, acute NVHD is an effective blood conservation strategy. However, there was no difference in allogeneic blood administration between the two NVHD groups. Coagulation and liver function, and urea and electrolyte concentrations were unaffected by treatment.

Aged↗
PubMed1997

The antinociceptive effect of epidural lignocaine and fentanyl during lithotripsy.

To determine the antinociceptive effect of combining epidural fentanyl with lignocaine during non-immersion lithotripsy, 56 healthy patients were enrolled into a prospective, randomized, double-blind study. Epidural anaesthesia was induced with either lignocaine 300 mg alone, or lignocaine 300 mg, or 200 mg in combination with fentanyl 100 micrograms. Throughout the procedure analgesia was assessed by comparing the incidence of (a) spontaneous complaints of pain, (b) patients' attempts to withdraw from the painful stimulus, (c) supplemental epidural lignocaine requirements, (d) the haemodynamic response to lithotripsy and (e) the time to first postoperative pain. The patients who received the fentanyl-lignocaine 300 mg combination required no supplemental lignocaine, experienced marginally less intraoperative pain and recorded lower mean arterial blood pressures when compared with lignocaine 300 mg alone. However, when the combination of lignocaine 200 mg and fentanyl 100 micrograms was administered, patients experienced significantly more pain, withdrew from the painful stimulus more often and received more supplemental lignocaine when compared with the other two treatment groups. No difference was found in the time to the first complaint of postoperative pain. Similarly, discharge times were unaffected by treatment modality. We conclude that despite the addition of fentanyl, adequate analgesia during lithotripsy is dependent upon the dose of local anaesthetic administered.

Analgesia, Epidural↗
PubMed1997

Intravenous line diameter: is bigger really better?

OBJECTIVE: To determine whether the size of an intravenous catheter influences the cannulation success rate and procedure duration among military medics. METHODS: According to a prospective, randomized, controlled crossover study design, 114 military medic cadets were paired and inserted 14-gauge (14G) and 16G intravenous catheters into veins in the antecubital fossa. Success rate and procedure duration were determined. RESULTS: The overall success rate for 14G and 16G catheters was 80 and 86%, respectively. Average procedure duration was 33 +/- 14.7 and 35.2 +/- 14.9 seconds, respectively. No significant differences were found in either success rate or procedure duration between the examined catheter sizes. CONCLUSION: Successful intravenous cannulation was unaffected by catheter size. Therefore, 14G intravenous catheters are recommended for use by military medics on the battlefield.

Adult↗
PubMed1996

Ketorolac does not decrease postoperative pain in elderly men after transvesical prostatectomy.

PURPOSE: To assess the postoperative analgesic efficacy and morphine-sparing effect of ketorolac in elderly patients. METHODS: Sixty ASA-physical status I to III men, aged 60-88 yr, undergoing transvesical prostatectomy were studied according to a randomized, placebo controlled, double-blind study protocol. A standard general anaesthetic was administered. Thirty minutes before concluding the surgical procedure either ketorolac 60 mg or an equal volume of saline was administered, im. Postoperative pain was assessed hourly for six hours using a 100 mm visual analog score (VAS) and a patient-controlled analgesia (PCA) device. RESULTS: Hourly PCA-demands, actual morphine delivered, and patient generated VAS pain scores were unaffected by the treatment modality. On conclusion of the study the total PCA morphine delivered was 11.9 mg +/- 1.38 and 10.8 mg +/- 1.52 for the saline and ketorolac groups, respectively. CONCLUSION: The intraoperative administration of ketorolac, 60 mg, im, was not associated with postoperative morphinesparing or improved analgesia in this elderly population.

Aged↗
PubMed1995

Alfentanil suppresses coughing and agitation during emergence from isoflurane anesthesia.

STUDY OBJECTIVE: To evaluate the effectiveness of alfentanil in suppressing coughing and agitation during emergence from isoflurane anesthesia. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Operating rooms at a university medical center. PATIENTS: 34 healthy ASA physical status I and II adult patients scheduled to undergo oral surgical procedures. INTERVENTIONS: During emergence from anesthesia, patients received either alfentanil 15 micrograms/kg (in 10 ml) or saline (10 ml) when the end-tidal isoflurane concentration reached 0.3%. MEASUREMENTS AND MAIN RESULTS: Hemodynamic variables were measured at one-minute intervals following administration of the study medication. A blinded observer recorded the time for patients to spontaneously open their eyes and to follow commands after discontinuing the isoflurane. The occurrence of coughing and agitation prior to extubation was noted. Patients in the alfentanil treatment group exhibited a reduced incidence of coughing prior to extubation (6% vs. 83%, respectively) and a longer time interval until the onset of spontaneous movements (21.1 +/- 2.6 min vs. 14.6 +/- 1.7 min, respectively). The interval between the onset of movement and orientation was shorter in the alfentanil-treated patients, resulting in similar extubation times for both groups. Alfentanil administration was also associated with lower heart rate, systolic diastolic, and mean arterial pressure values during the emergence period. CONCLUSION: Alfentanil decreased coughing, agitation, and cardiovascular stimulation during emergence from isoflurane anesthesia without prolonging the time of extubation.

Adult↗
PubMed1995

Tracheal anaesthesia for transthoracic endoscopic sympathectomy: an alternative to endobronchial anaesthesia.

When using endobronchial anaesthesia for the management of transthoracic endoscopic sympathectomy (TES), excessive insufflation of carbon dioxide into the pleural space may cause haemodynamic instability, hypoxaemia and tension pneumothorax. We prospectively studied an alternative technique using a tracheal tube, i.v. fentanyl, propofol, atracurium and nitrous oxide in 82 consecutive healthy patients (31 male, 51 female; mean age 26.48 (range 14-50) yr, weight 61.26 (33-100)kg.) They were suffering from severe palmar hyperhidrosis and they underwent bilateral TES (mean duration of operation 34.57 (15-90) min). After being placed in a 30-40 degree head-up position, three patients required ephedrine to treat arterial hypotension. A capnograph was used to confirm correct placement of the Verres needle in the pleural space. In two groups of 13 patients undergoing ventilation with an FlO2 of either 0.3 or 0.4, during partial collapse of the operative lung, PaO2 and the PaO2:FlO2 ratio decreased significantly (P < 0.001). TES was unsuccessful in three patients because of pleural adhesions. After operation five patients required chest drains; two for haemothorax and three for pneumothorax. Seventy-seven patients without complications were discharged from hospital within 24 h.

Adolescent↗
PubMed1995

Sevoflurane for outpatient anesthesia: a comparison with propofol.

Three different anesthetic techniques were compared in 146 healthy outpatients undergoing ambulatory surgery. In Groups I and II, anesthesia was induced with propofol (1.5-2.0 mg/kg, intravenously [iv]) and maintained with nitrous oxide (N2O) 60% in oxygen and either a propofol infusion, 75-160 micrograms.kg-1.min-1 IV, or sevoflurane, 1%-2% end-tidal, respectively. In Group III, anesthesia was induced and maintained with sevoflurane, 1%-4% end-tidal and N2O 60% in oxygen. In addition to 60% N2O in oxygen at a total gas flow of 3 L/min, all patients received fentanyl, 2-3 micrograms/kg IV, and vecuronium, 0.1 mg/kg IV. IV induction of anesthesia with propofol (90 +/- 53 s and 94 +/- 48 s in Groups I and II, respectively) was significantly faster than inhalation induction with sevoflurane (153 +/- 100 s). There were no significant differences in the incidence of coughing, airway irritation, or laryngospasm during induction of anesthesia. Although the mean arterial blood pressure values were similar in all three groups, the use of sevoflurane was associated with consistently lower heart rate values during the early maintenance period. Early and intermediate recovery times were the same in all three treatment groups. The use of sevoflurane for induction and/or maintenance of anesthesia was associated with a higher incidence of postoperative emetic sequelae compared with propofol. Finally, the times at which patients were considered "fit for discharge" and the actual discharge times were similar in all three groups. Sevoflurane is an acceptable alternative to propofol for induction and maintenance of outpatient anesthesia.

Adult↗
PubMed1995

Sevoflurane versus desflurane for outpatient anesthesia: a comparison of maintenance and recovery profiles.

The recovery characteristics of desflurane and sevoflurane were compared when used for maintenance of ambulatory anesthesia. After obtaining informed consent, 42 healthy, unpremedicated women undergoing laparoscopic sterilization procedures were studied. Anesthesia was induced with propofol, 1.5-2.0 mg/kg, and maintained with either desflurane 3%-6% (n = 21) or sevoflurane 1%-2% (n = 21) with 60% nitrous oxide in oxygen. Intraoperative analgesia and neuromuscular block was achieved using fentanyl and vecuronium, respectively. The inhaled anesthetics were titrated to achieve an adequate clinical "depth of anesthesia" and to maintain mean arterial pressure (MAP) within 20% of the preinduction baseline values. Visual analog scales (VAS) and the digit-symbol substitution test (DSST) were performed preoperatively and at 30-min intervals during the recovery period. There were no differences between the two groups in the total doses of propofol, fentanyl, or vecuronium. Heart rate (HR) values were lower in the sevoflurane group during the induction-to-incision period. However, HR and MAP were otherwise similar during the maintenance and recovery periods. Use of desflurane led to a more rapid emergence (4.8 +/- 2.4 vs 7.8 +/- 3.8 min) and shorter time to extubation (5.1 +/- 2.2 vs 8.2 +/- 4.2 min) compared to sevoflurane (mean values +/- SD). Intermediate recovery times, postoperative VAS and DSST scores, and side effects were similar in the two treatment groups. Although sevoflurane was associated with a slower emergence from anesthesia than desflurane after laparoscopic surgery, recovery of cognitive function and discharge times were similar in the two anesthetic groups. Thus, it would appear that sevoflurane is an acceptable alternative to desflurane for maintenance of outpatient anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

A comparative study of ketorolac and diclofenac on post-laparoscopic cholecystectomy pain.

In a randomized, double-blind, placebo-controlled study designed to assess the post-operative analgesic efficacy and cost-effectiveness of ketorolac and diclofenac 60 ASA I and II patients undergoing laparoscopic cholecystectomy were studied. Prior to concluding the operative procedure, an injection (i.m.) of an equal volume of either saline 3 mL, ketorolac 60 mg, or diclofenac 75 mg was administered. All patients received intravenous morphine via a patient-controlled analgesia device (PCA). Post-operative pain intensity was assessed hourly for 4 h, by recording visual analogue score (VAS) for pain, PCA demands and actual morphine administered. PCA demands (mean +/- SD) were greater in the saline treatment group (115 +/- 90) when compared with both the ketorolac (42 +/- 44) and diclofenac groups (74 +/- 77). Furthermore, the saline treatment group received significantly (P < 0.05) more PCA morphine compared with both the ketorolac and diclofenac groups (12.2 mg +/- 5.0 vs. 8.6 mg +/- 5.2 vs. 8.9 mg +/- 4.8). Improved pain scores were demonstrated in both the ketorolac and diclofenac groups compared with the saline group. PCA demands and post-operative morphine requirements were similar in the ketorolac and diclofenac groups. Diclofenac has the added advantage, in our institution, of being 60% less expensive than ketorolac. We conclude that both ketorolac and diclofenac are effective post-operative analgesic drugs. However, economic considerations may favour diclofenac administration.

Aged↗