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PubMed1993

Interactions of pre-operative erythromycin administration with general anaesthesia.

Previous reports have demonstrated a gastric emptying effect of erythromycin due to a motilin-like mechanism. We studied 50 patients, scheduled for daycase laparoscopy, randomly assigned to one of two groups: Group P patients received 30 min before induction of anaesthesia, in a double-blind manner an infusion of 250 ml dextrose 5% while patients in Group E (n = 25) received 500 mg of erythromycin diluted in 250 ml dextrose 5%. An orogastric tube was inserted to measure both gastric pH using a pHmeter and residual gastric volume (RGV) using the phenol red dilutional technique. Six patients were excluded for surgical reasons. More patients in Group P (6/22) than in Group E (0/22) had RGV > 25 ml and more patients in Group P (17/22) presented with a gastric pH < 2.5 than in Group E (5/22), P < 0.05. Since coma and respiratory depression have been reported recently after midazolam and alfentanil administration in patients having received erythromycin, recovery conditions were assessed and were found to be comparable between groups. In conclusion, the administration of iv erythromycin before outpatient laparoscopy decreased residual gastric volume and increased gastric pH without affecting recovery from general anaesthesia.

Adult↗
PubMed1994

Propofol anaesthesia in paediatric ambulatory patients: a comparison with thiopentone and halothane.

The purpose of this study was to evaluate the haemodynamic changes during induction, as well as the speed and quality of recovery when propofol (vs thiopentone and/or halothane) was used for induction and maintenance of anaesthesia in paediatric outpatients. One hundred unmedicated children, 3-12-yr-old, scheduled for ambulatory surgery were studied. The most common surgical procedures performed were eye muscle surgery (42%), plastic surgery (21%), dental restoration (15%), and urological procedures (15%). The children were randomized to an anaesthetic regimen for induction/maintenance as follows: propofol/propofol infusion; propofol/halothane; thiopentone/halothane; halothane for both induction and maintenance. Succinylcholine 1.5 mg.kg-1 was used to facilitate tracheal intubation and N2O/O2 were used as the carrier gases in each case. All maintenance drugs were titrated according to the clinical response of the patient to prevent movement and/or maintain BP +/- 20% of baseline. Two patients (4%) who received propofol expressed discomfort during injection. The mean propofol dose required to prevent movement was 267 +/- 83 micrograms.kg-1.min-1. The overall pattern of haemodynamic changes, as well as awakening (extubation) times were not different among the four groups. Children who received propofol recovered faster (22 vs 29-36 min) (P < 0.05), were discharged home sooner (101 vs 127-144 min) (P < 0.05), and had less postoperative vomiting (4 vs 24-48%) (P < 0.05) than all others.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Succinylcholine and vecuronium blockade of the diaphragm, laryngeal and limb muscles in the anaesthetized goat.

The purpose of the study was to compare the response of the cricoarytenoideus dorsalis muscle (CD) to neuromuscular blocking drugs with those of the thyroarytenoideus (TA), diaphragm (DI) and ulnaris lateralis (UL) muscles. Evoked electromyographic response to indirect supramaximal stimulation at 1 Hz was monitored in ten adult goats under thiopentone-halothane anaesthesia. The onset time and duration of neuromuscular blockade after intravenous administration of 500 micrograms.kg-1 of succinylcholine or 4 micrograms.kg-1 of vecuronium were determined. Times to 100% paralysis in CD, TA, DI and UL after succinylcholine were (mean +/- SD) 39 +/- 11, 39 +/- 11, 42 +/- 8 and 57 +/- 8 seconds, respectively; the corresponding times for vecuronium were 5.6 +/- 2.3, 4.6 +/- 1.7, 6.0 +/- 1.9 and 9.6 +/- 1.7 min. The order of recovery to 25% spontaneous EMG activity was TA, CD, DI and UL after succinylcholine (durations: 9.7 +/- 3.6, 11.0 +/- 3.0, 15.3 +/- 1.3 and 22.0 +/- 1.2 min, respectively) but DI, CD, TA and UL after vecuronium (durations: 31.9 +/- 18.6, 35.2 +/- 19.5, 47.1 +/- 19.9 and 71.7 +/- 16.1 minutes, respectively). Thus, as in the diaphragm and thyroarytenoideus muscles, onset time and duration of succinylcholine or vecuronium blockade were shorter in the abductor muscle of the glottis, cricoarytenoideus dorsalis, than in the limb muscle.

Action Potentials↗
PubMed1994

End-tidal carbon dioxide measurement in infants and children during and after general anaesthesia.

We have examined the reliability of end-tidal carbon dioxide (PetCO2) monitoring as an estimate of arterial carbon dioxide tension (PaCO2) in spontaneously breathing infants and children. Forty patients were studied in the post-anaesthetic care unit; 20 < 12 kg and 20 > or = 12 kg. The PetCO2 was sampled via a 5 cm 16 gauge catheter taped below an external naris and this measurement was compared with the PaCO2 of a sample drawn from an indwelling arterial line. Twenty additional patients were studied during inhalational anaesthesia. The PetCO2 was measured both from the proximal end of the elbow connector and from a 5 cm cannula inserted through the elbow. An arterial blood gas sample was obtained simultaneously. The arterial to end-tidal (Pa-et) differences were compared between the two sites. Patients studied in the post-anaesthetic care unit showed good correlation between PetCO2 and PaCO2 regardless of weight: Pa-etCO2 of -0.6 +/- 3.6 (< 12 kg) and -1.1 +/- 2.8 mmHg (> or = 12 kg). Patients studied during mask anaesthesia showed better correlation between PetCO2 and PaCO2 when PetCO2 was sampled from the cannula: Pa-etCO2 of 3.5 +/- 4.8 mmHg (cannula), 8.6 +/- 4.5 (elbow) (P < 0.05). These results suggest that end-tidal CO2 monitoring is a useful and reliable method for assessing adequacy of ventilation in spontaneously breathing children weighing between 5.2 and 35 kg.

Anesthesia Recovery Period↗
PubMed1994

Opisthotonos following propofol: a nonepileptic perspective and treatment strategy.

In this report of opisthotonos during recovery from propofol anaesthesia, we relate clinical observations with scientific considerations, and propose a strategy for treatment of this rare side effect. Following a brief operative procedure, a healthy 29-yr-old woman developed recurrent opisthotonos while recovering from anaesthesia with alfentanil, propofol, and nitrous oxide. In contrast to accumulating reports, the patient remained conscious during each episode of back extension and retrocollis. The preservation of consciousness and similarities to strychnine-induced opisthotonos suggest to us that the mechanism may have a brainstem and spinal origin. Recent investigations show that propofol potentiates the inhibitory transmitters glycine and gamma-aminobutyric acid (GABA) which would enhance spinal inhibition during anaesthesia. Postanaesthetic opisthotonos, however, may be due to a propofol-induced tolerance to inhibitory transmitters. This rebound phenomenon would lead to an acute, enduring refractoriness in inhibitory pathways of the brainstem and spinal cord, resulting in increased activity of extensor motoneurons. We recommend a therapeutic strategy that restores inhibition by glycine and GABA at multiple sites; the preferred therapeutic agents would be diazepam and physostigmine. The episodes are usually short-lived, but two of the reviewed 17 patients developed recurrent retrocollis for four and 23 days following antiepileptic drug therapy. Since high doses of phenytoin and carbamazepine can result in opisthotonos, we recommend that anticonvulsants be reserved for postanaesthetic patients with electroencephalographic evidence of seizure activity.

Adult↗
PubMed1994

Delayed awakening from general anaesthesia in a patient with Hunter syndrome.

Hunter syndrome is one of a heterogeneous group of recessively inherited mucopolysaccharide storage diseases (MPS) with similar biochemical defects manifested by impairments in mucopolysaccharide catabolism with variable but progressive clinical courses. Abnormal accumulation and deposition of mucopolysaccharides in the tissue of several organs to numerous anatomical, musculoskeletal and neurological abnormalities which are known to complicate anaesthetic and airway management. Hunter syndrome has a wide variance of clinical phenotypes ranging from mild to severe. We present a patient having physical and neurological features consistent with a severe clinical presentation of Hunter syndrome (MPS, Type II). Following a seemingly uneventful intraoperative anaesthetic course including isoflurane, nitrous oxide and fentanyl (0.93 microgram.kg-1), resumption of spontaneous ventilation and return to consciousness were delayed until intravenous naloxone (200 micrograms) was administered 110 min after the opioid administration. The cause of delayed recovery from anaesthesia in this patient is unknown.

Anesthesia Recovery Period↗
PubMed1993

Propofol anaesthesia reduces early postoperative emesis after paediatric strabismus surgery.

Propofol anaesthesia may reduce postoperative emesis. The purpose of this study was to compare the incidence of emesis after propofol anaesthesia with and without nitrous oxide, compared with thiopentone and halothane anaesthesia, in hospital and up to 24 hr postoperatively, in outpatient paediatric patients after strabismus surgery. Seventy-five ASA class I or II, unpremedicated patients, aged 2-12 yr were randomly assigned to one of three groups: Thiopentone, 6.0 mg.kg-1 i.v. induction followed by halothane and N2O/O2 for maintenance (T/H); propofol for induction, followed by propofol and oxygen for maintenance (P/O2); and propofol for i.v. induction, followed by propofol infusion and N2O/O2 for maintenance (P/N2O). All received vecuronium, controlled ventilation, and acetaminophen pr. Morphine was given as needed for postoperative analgesia. There were no differences in age, weight, number of eye muscles operated upon, duration of anaesthesia or surgery. The P/N2O group (255 +/- 80 micrograms.kg-1 x min-1) received less propofol than the P/O2 group (344 +/- 60 micrograms.kg-1 x min-1) (P < or = 0.0001) and had shorter extubation (P < 0.001) and recovery (P < 0.01) times. Emesis in the hospital, in both the P/N2O (4.0%) and P/O2 group (4.0%) was less than in the T/H group (32%) (P < 0.01). Antiemetics were required in four patients in the T/H group (16.0%). Overall emesis after surgery was not different among the groups: T/H (48%), P/O2 (28%) and P/N2O (42%). The use of propofol anaesthesia with and without N2O decreased only early emesis. This supports the concept of a short-acting, specific antiemetic effect of propofol.

Ambulatory Surgical Procedures↗
PubMed1987

PvO2 changes in cutaneous veins during regression of spinal anaesthesia.

Following transurethral resection of the prostate under spinal anaesthesia, 26 patients were divided into two groups according to the sensory levels measured in the recovery room: Group A: 20 patients with sensory level T10 or above, and Group B: six patients with sensory level T11 or T12. Through an intravenous catheter placed preoperatively in a superficial vein of the foot, serial blood samples were drawn to measure the PvO2. In Group A, the PvO2 increased significantly after spinal anaesthesia compared with preoperative control values, then decreased when the sensory level receded to T11 or T12. In Group B, the changes in PvO2 from control to postspinal and to motor recovery were not significant. The authors postulate that sympathetic denervation induced by spinal anaesthesia increases the PvO2 by the opening of arteriovenous anastomoses in the cutaneous circulation, and the PvO2 decreases with sympathetic recovery. These findings confirm that significant sympathetic denervation of the lower limbs can be expected at a sensory level of T10 or above, and sympathetic recovery begins when the sensory level recedes below T10.

Aged↗
PubMed1995

Post-herniorrhaphy pain in outpatients after pre-incision ilioinguinal-hypogastric nerve block during monitored anaesthesia care.

The objective of this study was to evaluate the effect of an ilioinguinal-hypogastric nerve block (IHNB) with bupivacaine 0.25% on the postoperative analgesic requirement and recovery profile in outpatients undergoing inguinal herniorrhaphy with local anaesthetic infiltration. Thirty consenting healthy men undergoing elective unilateral inguinal herniorrhaphy procedures were randomly assigned to receive an IHNB with either saline or bupivacaine according to a double-blind, IRB-approved protocol. All patients received midazolam, 2 mg iv, and fentanyl 25 microgram iv, prior to injection of 30 ml of either bupivacaine 0.25% or saline through the oblique muscle approximately 1.5 cm medial to the anterior superior iliac spine. Subsequently, the surgeon infiltrated the incision site with a lidocaine 1% solution. Sedation was maintained during the operation with a variable-rate propofol infusion, 25-140 micrograms.kg-1.min-1. No significant differences were noted in the intraoperative doses of lidocaine, propofol and fentanyl in the two treatment groups. However, the pain visual analogue score at 30 min after entering the PACU was lower in the bupivacaine (versus saline) group (P < 0.05). Although the times to ambulation (86 +/- 18 vs 99 +/- 27 min) and being judged "fit for discharge" (112 +/- 49 vs 126 +/- 30 min) were similar in the two groups, the bupivacaine-treated (vs saline) patients required less oral analgesic medication after discharge (46% vs 85%). We concluded that the use of an ilioinguinal-hypogastric nerve block with bupivacaine 0.25% as an adjuvant during inguinal herniorrhaphy under monitored anaesthesia care decreased pain in the PACU and oral analgesic requirements after discharge from the day-surgery unit.

Ambulatory Surgical Procedures↗
PubMed1995

Mivacurium-induced neuromuscular blockade during sevoflurane and halothane anaesthesia in children.

The neuromuscular blocking effects of mivacurium during sevoflurane or halothane anaesthesia was studied in 38 paediatric patients aged 1-12 yr. All received premedication with midazolam, 0.5 mg.kg-1 po and an inhalational induction with up to 3 MAC of either agent in 70% N2O and O2. The ulnar nerve was stimulated at the wrist by a train-of-four stimulus every ten seconds and the force of adduction of the thumb recorded with a Myotrace force transducer. Anaesthesia was maintained with a one MAC end-tidal equivalent of either volatile agent for five minutes before patients received mivacurium (0.2 mg.kg-1) iv. The onset of maximal blockade occurred in 2.4 +/- 1.26 (mean +/- SD) min with halothane and 1.8 +/- 0.54 min with sevoflurane (NS). Four patients failed to achieve 100% block (3 halothane, 1 sevoflurane). The times from injection to 5, 75, and 95% recovery during sevoflurane (9.8 +/- 2.6, 19.5 +/- 4.4, and 24.2 +/- 4.8 min) were greater than during halothane anaesthesia (7.2 +/- 2.2, 15.0 +/- 4.0, 19.2 +/- 4.9 min, respectively (P < 0.005). All patients demonstrated complete spontaneous recovery of neuromuscular function (T1 > 95%, T4/T1 > 75%) during the surgery which lasted 24-63 min. All patients showed clinical signs of full recovery of neuromuscular blockade (i.e., headlift, gag, or cough). Pharmacological reversal was not required. It is concluded that following a single intubating dose of mivacurium, the time to maximum relaxation was not different during halothane and sevoflurane anaesthesia; recovery times to 5, 75 and 95% twitch height were longer during sevoflurane anaesthesia and neuromuscular reversal was not necessary.

Anesthesia Recovery Period↗
PubMed1995

Comparison of tactile and mechanomyographical assessment of response to double burst and train-of-four stimulation during moderate and profound neuromuscular blockade.

It is common clinical practice to estimate the degree of neuromuscular blockade by tactile evaluation of twitch responses. The aim of the present study was to evaluate the use of tactile responses of adductor pollicis to double-burst stimulation (DBS) and train-of-four (TOF) peripheral nerve stimulation for monitoring moderate and profound levels of neuromuscular blockade. The study comprised 44 women scheduled for gynaecological laparotomy and anaesthetised with midazolam, fentanyl, thiopentone, halothane, nitrous oxide and atracurium. The tactile responses of the adductor pollicis were compared with mechanomyographical measurements in the contra lateral arm during recovery from neuromuscular blockade. The observers (anaesthetic nurses) of the tactile responses were blinded with regard to the stimulation pattern and the mechanomyographical measurements. The time from injection of the initial dose of atracurium until tactile reappearance of the first twitch in DBS (D1), was 24.6 (0-39.8) min, median (range). This was more rapid than the time until tactile reappearance of the first twitch in TOF (T1) 32.8 (18.2-43.4) min (P < 0.05). The median time from tactile reappearance of D1 until T1 recovered to 15% of the control twitch height was longer than the median time from tactile reappearance of T1 (14.6 versus 10.5 min) (P < 0.05). One or two responses to DBS or TOF were often felt before any responses had been detected mechanomyographically in the contralateral arm. When three or four responses to TOF were felt, responses were always detected mechanomyographically. It is concluded that tactile evaluation of responses ot DBS stimulation can estimate deeper levels of blockade than tactile evaluation of responses to TOF.

Adolescent↗
PubMed1995

Recovery of train-of-four after mivacurium.

The present study was designed to determine the time-course of recovery of the train-of-four (TOF) ratio during spontaneous recovery from mivacurium-induced block. Fifteen patients, free of neuromuscular disease, undergoing general endotracheal anaesthesia with isoflurane were studied. After anaesthetic induction, patients received a bolus dose of mivacurium 0.15 mg.kg-1. The TOF was then recorded continuously every 12 sec with a mechanogram (adductor pollicis monitor). When the TOF ratio recovered spontaneously to 0.9, an additional 0.05 mg.kg-1 of mivacurium was given. The durations required for recovery from a TOF ratio of 0.3 to 0.7 (DUR0.3-0.7) and from a TOF ratio of 0.3 to 0.9 (DUR0.3-0.9) were determined. The DUR0.3-0.7 averaged 7.0 +/- 2.5 min (range 3.4-12.2 min). The DUR0.3-0.9 averaged 11.8 +/- 3.9 min (range 6.0-20.2 min). There was no evidence of prolongation of recovery times (cumulation) following repeated dosing. The present data indicate that, in patients with normal cholinesterase activity (clinical duration 7-25 min), waiting 20 min beyond the time when fade is no longer apparent by visual or tactile evaluation is sufficient to attain a TOF ratio greater than 0.7-0.9 during spontaneous recovery from mivacurium, and may enable anaesthetists to avoid antagonism of mivacurium-induced block.

Adolescent↗
PubMed1995

Regional anaesthesia for hernia repair in children: local vs caudal anaesthesia.

The purpose of this study was to compare the effect of local anaesthesia (LA) with that of caudal anaesthesia (CA) on postoperative care of children undergoing inguinal hernia repair. This was a randomized, single-blind investigation of 202 children aged 1-13 yr. Anaesthesia was induced with N2O/O2 and halothane or propofol and maintained with N2O/O2/halothane. Local anaesthesia included ilioinguinal and iliohypogastric nerve block plus subcutaneous injection by the surgeon of up to 0.3 ml.kg-1 bupivacaine 0.25% with 5 micrograms.kg-1 adrenaline. The dose for caudal anaesthesia was 1 ml.kg-1 up to 20 ml bupivacaine 0.2% with 5 micrograms.kg-1 adrenaline. Postoperative pain was assessed with mCHEOPS in the anaesthesia recovery room, with postoperative usage of opioid and acetaminophen in the hospital, and with parental assessment of pain with a VAS. Vomiting, time to first ambulation and first urination were recorded. The postoperative pain scores and opioid usage were similar; however, the LA-group required more acetaminophen in the Day Care Surgical Unit. The incidence of vomiting and the times to first ambulation and first urination were similar. The LA-patients had a shorter recovery room stay (40 +/- 9 vs 45 +/- 15 min, P < 0.02). The postoperative stay was prolonged in the CA group (176 +/- 32 vs 165 +/- 26 min, P = 0.02). We conclude that LA and CA have similar effects on postoperative care with only slight differences.

Acetaminophen↗
PubMed1995

Midazolam reduces vomiting after tonsillectomy in children.

The purpose of this study was to assess the effect of midazolam on vomiting after tonsillectomy in children. We compared 215 children aged 1.5-14 yr undergoing tonsillectomy or adenotonsillectomy under general anaesthesia with nitrous oxide and halothane. In a double-blind fashion the subjects were administered either placebo or midazolam 75 micrograms.kg-1 iv after induction of anaesthesia. After the operation, the number of emetic episodes and the length of stay in hospital were recorded. The groups were similar with respect to age, weight, sex, mode of induction, duration of anaesthesia, surgical procedure, opioid administration and length of stay in the PAR and the Day Care Surgical Unit. The 108 midazolam-treated children had a lower incidence (42% vs 57%) of vomiting than the placebo group, P < 0.02. The placebo group had a higher incidence (9% vs 2%) of unscheduled admissions to hospital due to nausea and vomiting, P < 0.05. It is concluded that midazolam administered intravenously to children intraoperatively reduces vomiting after tonsillectomy.

Adenoidectomy↗
PubMed1995

Nondepolarizing neuromuscular blocking drugs and train-of-four fade.

The aim of this study was to examine differences in prejunctional effects of different relaxants by measuring the train-of-four (TOF) fade during the onset and recovery of neuromuscular block. The relaxants studied were atracurium (225 micrograms.kg-1), mivacurium (65 micrograms.kg-1) rocuronium (300 micrograms.kg-1) and vecuronium (40 micrograms.kg-1). The TOF ratios were measured at approximate heights of T1 (first response in the TOF) of 90, 75, 50, and 25%. The TOF fade (as shown by lower TOF ratios) increased with a decrease in the T1 during onset of neuromuscular block. Although there was a slightly greater fade with atracurium and rocuronium during the onset of block, the differences among the relaxants were insignificant. It is concluded that the relative prejunctional effects of these relaxants are similar.

Adult↗
PubMed1995

Nitrous oxide does not increase vomiting in children after myringotomy.

The aim of this study was to establish whether nitrous oxide has a clinically important effect on postoperative vomiting in children after myringotomy. We studied 320 healthy children of ages 0.5-13 yr undergoing elective myringotomy and tube insertion. Induction and maintenance of anaesthesia were randomized to inhalation with either 70% N2O/30% O2/halothane or 100%O2/halothane. Surgical technique and postoperative management were not influenced by this study. Vomiting in the recovery room (PAR) and Day Care Surgical Unit (DCSU) was recorded by nurses unaware of the anaesthetic technique. Parents were contacted 24-48 hr after surgery to ascertain the incidence of vomiting after discharge. The groups were similar with respect to demographic data, except that the anaesthesia time was greater among the 158 patients in the N2O-treated group (11 +/- 4 vs 12 +/- 4 min, mean +/- SD). The incidence of vomiting was 13% in both groups. Most of the 42 patients that had emesis only vomited once or twice. The incidence of vomiting was not altered by sex (13% vs 13%) or duration of anaesthesia. The incidence of vomiting increased with increasing age. The children aged less than 3 yr vomited 4% of the time, those aged 3-5 vomited 11% of the time, those aged 6-8 yr vomited 17% of the time, while the incidence of vomiting among those aged 9-13 yr was 31%. Vomiting prolonged the postoperative hospital stay from 75 to 92 min, P < 0.001, ANOVA. In summary, we have been unable to demonstrate that N2O induces vomiting by children after a brief general anaesthetic for myringotomy.

Adolescent↗