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PubMed1984

Porcine regional brain and myocardial blood flows during halothane-O2 and halothane-nitrous oxide anesthesia: comparisons with equipotent isoflurane anesthesia.

Regional distribution of brain and myocardial blood flow were examined in 9 instrumented isocapnic normothermic swine, using 15-microns diameter radionuclide-labeled microspheres injected into the left atrium. Minimal alveolar concentration (MAC) of halothane required to prevent gross purposeful movement in response to a noxious stimulus in 50% of the pigs was found to be 0.70%. Measurements were made on each animal during nonanesthetized state (control), 1.0 and 1.5 MAC halothane anesthesia, and the equivalent of 1.0 and 1.5 MAC halothane anesthesia, using 50% N2O. The order of anesthetized steps was randomized for each pig. Recovery periods of 60 minutes were interposed between the anesthetic treatments. During halothane + 50% N2O anesthesia, heart rate, cardiac output, mean aortic pressure, and rate-pressure product were higher than comparable levels of halothane-O2 anesthesia. Halothane caused dose-dependent vasodilatation in all regions of the brain. Cerebral, cerebellar, and brain-stem blood flows at 1.5 MAC halothane were 135%, 135%, and 115% of respective control values. Substitution of 50% N2O to maintain same MAC dose markedly exaggerated the increment in porcine cerebral and brainstem blood flows, especially at 1.0 MAC when perfusions in these regions were 204% and 128% of respective control values. At 1.5 MAC anesthesia produced by halothane + 50% N2O, the cerebral, cerebellar, and brain stem perfusions were 153%, 146%, and 129% of control values. Transmural myocardial blood flow decreased from control value with both levels of halothane anesthesia, but with equivalent MAC anesthesia produced by halothane + 50% N2O, myocardial perfusion remained near awake values.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1997

Anesthesia providers' interventions during cataract extraction under monitored anesthesia care.

In 1993 Medicare paid more money to anesthesia providers for cataract surgery than for any other surgical procedure. Patients undergoing cataract surgery often receive monitored anesthesia care (MAC). Thus, cuts in anesthesia payments from Medicare for cataract surgery may be forthcoming. If few interventions were being done after a retrobulbar block was placed, then a registered nurse might be a safe alternative to an anesthesia provider to monitor the patient. The goal of this study was to describe interventions of anesthesia providers during cataract extraction after the placement of a retrobulbar block. Anesthetic records were reviewed for 560 consecutive cases of cataract extraction using MAC at a large tertiary medical center. Anesthesia providers performed interventions (e.g., administration of drugs) on 33% of patients after the retrobulbar block was in place (95% confidence bound, < 36%). In conclusion, insufficient evidence exists for managed care organizations or other groups to justify a change in practice toward a registered nurse monitoring patients undergoing cataract extraction with a retrobulbar block. Furthermore, until a prospective randomized study has been done, such organizations lack justification for decreasing the amount of time that anesthesia providers spend caring for such patients undergoing cataract extraction.

Cataract Extraction↗
PubMed1993

Clinical office anesthesia: the use of propofol for the induction and maintenance of general anesthesia.

Ambulatory surgery has become routine for many plastic surgery procedures. Anesthesia techniques including general anesthesia by inhalation and intravenous infusion and the dissociative technique have all been used successfully for outpatient anesthesia. Propofol (Diprivan), a relatively new agent, has proven to be a safe and effective general anesthesia agent for outpatient surgery. We report on our experience with propofol as an induction agent and continuous drip for general anesthesia maintenance in 100 consecutive outpatient, plastic surgery procedures performed in an office facility. Assessment factors were recovery-room time, nausea and vomiting in the recovery room and at home, hallucinations, patients' recollection of anesthesia experience, and overall patient satisfaction.

Ambulatory Surgical Procedures↗
PubMed2004

Brachial plexus anesthesia compared to general anesthesia when a block room is available.

PURPOSE: Regional anesthesia is often felt to be beneficial to patient care but detrimental to operating room (OR) efficiency. In this report we compare how a block room (BR) affects OR time (ORT) utilization for brachial plexus anesthesia (BPA) in a busy upper limb practice. We also compare how anesthetic technique, BPA or general anesthesia (GA), impacts on the time to recovery and discharge in patients having outpatient upper limb surgery. METHODS: With the Ethics Committee's approval, a prospective study using hospital databases was undertaken. All patients presenting for surgery on the upper limb between November 1999 and April 2000 were eligible for analysis. A comparison was made of the various time intervals that comprise a patient's hospital stay for either GA or BPA. Demographic data (ASA, age, outpatient status), and location of BPA were analyzed. RESULTS: Use of the BR for BPA significantly reduced the pre-procedure anesthesia ORT when compared to BPA done in the OR (11.4 vs 32.9 min, P < 0.05; GA pre-procedure time was 17.8 min). In the ambulatory patient, BPA alone reduced post procedure anesthesia ORT, postanesthetic care unit, surgical day care unit, and total hospital times when compared to those receiving GA. On average those receiving a BPA spent 1.5 hr less in hospital (P < 0.01). Additionally, fewer admissions (2.4 vs 5.4%) occurred in the BPA group. CONCLUSION: The use of a BR reduces the anesthesia ORT associated with BPA. Secondly, BPA improves the recovery time phase of outpatients undergoing surgery on the upper limb.

Adolescent↗
PubMed2006

Cervical epidural anesthesia: a safe alternative to general anesthesia for patients undergoing cancer breast surgery.

BACKGROUND: General anesthesia (GA) is the standard anesthesia for patients undergoing modified radical mastectomy (MRM) for breast cancer. Cervical epidural anesthesia (CEA) is practiced less often because of its reported complications. This prospective study aimed to evaluate the safety and efficacy of CEA as an anesthetic technique for MRM. PATIENTS AND METHODS: Fifty breast cancer patients with ASA (American Society of Anesthesiologists) grade I or II underwent MRM under CEA from September 2004 to January 2006. Anesthesia was induced with 10 ml of 1% lignocaine; adrenaline was administered through an 18-gauge catheter in C(6)-C(7) or C(7)-T(1) epidural space. Postoperative analgesia was maintained with 0.125% bupivacaine through the epidural catheter. RESULTS: In 49 (98%) patients surgery was conducted smoothly under CEA with good analgesia. 44 patients were awake during surgery. Five patients had to be given intravenous sedation with midazolam, and in one case the procedure was terminated after accidental dura puncture. There were no clinically significant variations in perioperative pulse and respiratory rate, and there was no fall in mean arterial blood pressure during the procedure. The mean preoperative anesthesia time and total cost of the procedure was 20.36 + 2.75 minutes and 12.19 + 2.2 pound, respectively. All patients were started on a liquid diet and mobilized 4 hours after surgery. CONCLUSIONS: Cervical epidural anesthesia is a safe alternative to GA and was preferred by our patients because of its lower cost and reduced perioperative morbidity.

Anesthesia, Epidural↗
PubMed2005

Effects of fentanyl on emergence characteristics from anesthesia in adult cervical spine surgery: a comparison of fentanyl-based and sevoflurane-based anesthesia.

PURPOSE: To evaluate the effects of different anesthesia regimens on bucking, awareness, and pain during the emergence from anesthesia, which may affect neck stabilization and neurological assessment immediately after cervical spine surgery. METHODS: Patients scheduled to undergo cervical spine surgery were assigned randomly into one of three groups: maintenance of anesthesia with fentanyl and propofol TCI (group FP, n = 25); maintenance with fentanyl and supplementation with less than 1% sevoflurane (group Fs, n = 25); and maintenance solely with sevoflurane (group S, n = 25). The severity of bucking, extent of awareness during neurological examination, and perception of pain during the emergence phase were assessed using predetermined scoring scales by a nurse blinded to the method of anesthesia. RESULTS: The bucking score and pain score were significantly better in group FP and group Fs than in the group S, whereas there was no significant difference between the data of group FP and group Fs. CONCLUSION: The quality of emergence from anesthesia in patients with cervical spine surgery is improved with fentanyl-based anesthesia, but there is no difference between the use of propofol TCI and less than 1% sevoflurane as a concomitant sedative agent with fentanyl.

Adult↗
PubMed1999

Ropivacaine epidural anesthesia and analgesia versus general anesthesia and intravenous patient-controlled analgesia with morphine in the perioperative management of hip replacement. Ropivacaine Hip Replacement Multicenter Study Group.

UNLABELLED: The aim of our study was to compare epidural anesthesia and analgesia (EDA) with ropivacaine versus general anesthesia followed by IV patient-controlled analgesia with morphine (GA/PCA) after hip replacement regarding pain, side effects, and discharge from the postanesthesia care unit. After ethics committee approval, randomization, and informed consent, 90 patients were enrolled. In Group EDA, epidural anesthesia (ropivacaine 10 mg/mL, 15-25 mL) was followed by an epidural infusion (2 mg/mL, 4-6 mL/h for 24 h, plus top-up doses of 6-10 mL for 48 h). GA/PCA patients received general anesthesia (isoflurane/N2O/fentanyl) followed by IV patient-controlled analgesia with morphine postoperatively. Pain was assessed by using visual analog scales (0-100 mm) at rest and during physiotherapy. Pain at rest was less in the EDA (n = 43) group than in the GA/PCA (n = 45) group (at 10 h: 11.8+/-12.9 vs. 28.4+/-17.1 [P< 0.001]; at 24 h: 14.3+/-11.7 vs. 24.0+/-17 [P<0.01]; in 48 h: 14.3+/-9.3 vs. 21.1+/-17.4 [P = 0.1]). Whereas EDA patients were deemed ready for discharge from the postanesthesia care unit earlier than GA/PCA patients (5.6+/-8.9 vs. 39.7+/-41.5 min), the actual discharge time was comparable. The median time for first passage of flatus was shorter in the EDA group than in the GA/PCA group (26 vs. 47 h). Nausea and vomiting were more common in the GA/PCA group than in the EDA group (16% vs. 28% and 11% vs. 22%, respectively), whereas hypotension (11% vs. 4%) and bradycardia (14% vs. 2%) were less frequent. Under the conditions of the present study, EDA with ropivacaine provided pain control after hip replacement superior to that provided by IV patient-controlled analgesia with morphine, particularly during the first 24 h. Both approaches to pain management were equally safe. IMPLICATIONS: Compared with general anesthesia and postoperative IV patient-controlled analgesia with morphine, epidural anesthesia and analgesia with the new local anesthetic ropivacaine enables patients to be discharged sooner from a postanesthesia care unit and provides superior pain relief during the first 24 h after hip replacement.

Amides↗
PubMed1993

Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Perioperative Ischemia Randomized Anesthesia Trial Study Group.

BACKGROUND: Perioperative morbidity may be modifiable in high risk patients by the anesthesiologist's choice of either regional or general anesthesia. This clinical trial compared outcomes between epidural (EA) and general (GA) anesthesia/analgesia regimens in a group of patients at high risk for cardiac and other morbidity who were undergoing similarly stressful surgical procedures. METHODS: One hundred patients scheduled for elective vascular reconstruction of the lower extremities were randomized to receive either EA for surgery followed by epidural analgesia, or GA for surgery followed by intravenous patient-controlled analgesia. Hemodynamic monitoring, blood pressure, and heart rate limits were determined prior to randomization. Management of anesthesia in the immediate postoperative period was standardized. The data collected included continuous electrocardiographic monitoring from the day before surgery through the third postoperative day, serial electrocardiograms, and cardiac enzymes. Cardiac ischemia, myocardial infarction, unstable angina, and cardiac death were identified by a cardiologist blinded to the type of anesthesia received. Other major morbidity was determined at the time of hospital discharge and at 1 and 6 months after surgery. RESULTS: Eleven patients who received GA required regrafting or an embolectomy during their hospital stay, compared with two patients who received EA. This association of GA with reoperation remained significant after adjustment for baseline differences. Cardiac outcomes were similar in the two groups with respect to perioperative death (1 EA and 1 GA), death within 6 months (4 EA and 3 GA), nonfatal myocardial infarction within 7 days (2 EA and 2 GA), unstable angina (0 EA and 2 GA), and myocardial ischemia following randomization (17 EA and 23 GA). Rates of major infections in the two groups (1 EA and 2 GA), renal failure (3 EA and 3 GA), and pulmonary complications (3 EA and 7 GA) also were similar. CONCLUSIONS: Carefully conducted epidural and general anesthesia appear to be associated with comparable rates of cardiac and most other morbidity in patients undergoing lower extremity vascular surgery. However, compared with general anesthesia, epidural anesthesia is associated with a lower incidence of reoperation for inadequate tissue perfusion and, therefore, may be advantageous for this surgical population.

Aged↗
PubMed1993

Guidelines for Regional Anesthesia in Obstetrics: potential impact on obstetric anesthesia services in rural Alabama.

When the American Society of Anesthesiologists published its Guidelines for Regional Anesthesia in Obstetrics, I did a survey to determine what impact a broadly implemented strict interpretation of those guidelines might have on obstetric anesthesia care in small rural Alabama hospitals. Thirty-six rural Alabama hospitals with fewer than 200 beds were included in the survey, with a response rate of 50%. Data included total deliveries, cesarean section rates, utilization rates of anesthesia services, personnel providing anesthesia care, and identification of physician personnel available during labor and cesarean section. Results showed that anesthesia care is provided for approximately 52% of births in the responding hospitals. Of these, approximately 60% of cesarean sections and 90% of vaginal deliveries are not routinely attended by anesthesiologists. If these data also reflect the nonrespondent hospitals, statewide access could be limited for approximately 6000 parturients annually. The Guidelines should be interpreted with caution. Rather than conform to related policies, interpretation should allow implementation consistent with the capabilities of the individual institutions, while ensuring quality anesthesia care for the parturients.

Alabama↗
PubMed2006

Spinal versus general anesthesia for orthopedic surgery: anesthesia drug and supply costs.

Total hip or knee replacement surgeries are common orthopedic interventions that can be performed with spinal anesthesia (SA) or general anesthesia (GA). No study has investigated the economic aspects associated with the two anesthetic techniques for this common surgery. We randomized 40 patients to receive either SA or GA and analyzed the drug and supply costs for anesthesia und recovery. Anesthesia-related times, hemodynamic variables, and pain scores were also recorded. Total costs per case without personnel costs were almost half in the SA group compared with the GA group; this was a result of less cost for anesthesia (P < 0.01) and for recovery (P < 0.05). This finding was supported by a sensitivity analysis. There were no relevant differences regarding anesthesia-related times. Patients in the GA group were admitted to the postanesthesia care unit with a higher pain score and needed more analgesics than patients in the SA group (both P < 0.01). We conclude that SA is a more cost-effective alternative to GA in patients undergoing hip or knee replacement, as it is associated with lower fixed and variable costs. Moreover, SA seems to be more effective, as patients in the SA group showed lower postoperative pain scores during their stay in the postanesthesia care unit.

Analgesics↗
PubMed2000

[Intra- and postoperative heart rate changes following propofol anesthesia; a comparison with isoflurane anesthesia].

Bradycardia during propofol anesthesia is well known, but bradycardia after propofol anesthesia has not been studied well. We compared perioperative heart rates in patients who had undergone gynecological surgery under lumbar epidural anesthesia supplemented with light general anesthesia using isoflurane and nitrous oxide in oxygen (Group Iso, n = 25) with those who had received lumbar epidural anesthesia supplemented with propofol (Group Prop, n = 25). The heart rates for the Group Prop were significantly lower (P < 0.05) than those for the Group Iso after the induction of anesthesia up to 2 hours after surgery. Two patients in the Group Prop developed bradycardia below 50 bpm 1 and 2 hours after surgery. In one of them intravenous atropine was necessary to treat bradycardia. We conclude that more attention should be paid to postoperative as well as intraoperative bradycardia in patients who receive propofol.

Anesthesia, Epidural↗
PubMed2000

[Comparison between total intravenous anesthesia and inhalation anesthesia in the surgery of acute cholecystitis].

We investigated retrospectively the influence of anesthetic methods on the intraoperative managements and postoperative outcomes in 26 patients receiving emergency or early surgery for acute cholecystitis. Fourteen of the 26 patients received total intravenous anesthesia with propofol, fentanyl, and ketamine (PFK group), while the remainder received nitrous oxide and isoflurane or sevoflurane anesthesia (GO group). There were no significant differences between the groups with respect to demographic data. We found no significant differences between the groups in duration of operation and anesthesia, the incidence of intraoperative hypotension, and the use of ephedrine and dopamine during induction and maintenance of anesthesia. After surgery, the PFK group had significantly earlier bowel function than the GO group, with earlier starting of oral intake (54.0 +/- 25.1 vs 89.3 +/- 31.9 hours after surgery; P = 0.026). These data suggest that total intravenous anesthesia by propofol, fentanyl, and ketamine may provide the earlier recovery of bowel function than inhaled anesthesia after emergency or early surgery for acute cholecystitis.

Acute Disease↗
PubMedDate not supplied

[Surgery of the carotid artery: locoregional anesthesia versus general anesthesia: Review of the literature].

The aim of the study was to compare locoregional and general anesthesia in carotid artery surgery in order to establish whether differences exist in terms of perioperative results, use of intraoperative shunts and costs. Seventeen studies, comprising 14,776 carotid endarterectomies performed with either locoregional or general anesthetic and published over the period from 1990 to March 2000, were reviewed. There were no statistically significant differences in the cardiovascular risk factors of the patients. Neurological morbidity and mortality were similar in the two groups, even if the use of shunts in the locoregional anesthesia group was lower than in the general anesthesia group and in four studies was associated with a significant difference (P < 0.01). No statistical differences in cardiac morbidity or mortality were found between the groups, except in two studies. Additional randomised prospective trials are needed in large numbers of patients. Locoregional anesthesia appears to allow a limited use of intraoperative shunts, but with neurological mortality and stroke rates very similar to those in the general anesthesia group. Routine use of locoregional anesthesia makes it possible to lower the cost of carotid surgery without sacrificing quality.

Anesthesia, Conduction↗
PubMed2003

[The effects of general anesthesia combined with epidural anesthesia on the stress response in thoracic surgery].

OBJECTIVE: To study the effects of general anesthesia combined with epidural anesthesia (GEA) and pure general anesthesia (GA) on the surgical stress response and cytokines in pulmonary surgery. METHODS: Twenty patients submitted to elective pulmonary surgery were randomly divided into 2 groups of 10 patients: GEA group receiving general anesthesia combined with thoracic epidural analgesia and GA group receiving only general anesthesia. Blood samples were taken before induction, at incision, 2 h, 4 h, 6 h following the incision, and in the 1st and 3rd postoperative day. IL-6, ACTH and cortisol were detected with radioimmunoassay. RESULTS: (1). The concentration of ACTH was similar in the 2 groups before operation, was remarkably increased 2 hours postoperatively (P < 0.05), reached the peak values 2 approximately 4 hours after the incision in most patients (P < 0.01), and returned to the preoperative levels one day after operation without a significant difference at every time point between the two groups. (2). The concentration of cortisol decreased transiently during incision in the GEA group (P < 0.05), then increased gradually, was significantly higher than the preoperative level (P < 0.01), and remained at the high level till the morning of the 1st day after operation (P < 0.01). In the GA group the cortisol concentration was higher than that before operation 2 hours after incision (P < 0.01), and remained at the level higher than that before operation 4 h and 6 h after incision (P < 0.01), and returned to the normal level by the morning of the 3rd day. The cortisol concentration 2 hours after incision in GEA group was significantly lower than that in GA group (P < 0.05), however, the peak concentrations of these 2 groups were not significantly different (P > 0.05). In the GA group the IL-6 concentration began to increase after operation, became significantly different from that before operation 4 hours after operation (P < 0.01), reached the peak level in the morning of the first postoperative day (P < 0.05), and returned to the preoperative level in the third day. In the GEA group the IL-6 concentration began to increase 2 hours after operation (P < 0.05), and returned to the preoperative level in the morning of the first postoperative day. The concentration of IL-6 was positively correlated with that of cortisol (r = 0.231). CONCLUSION: Pulmonary surgery performed with two different anesthetic techniques causes inflammatory cytokine responses. The additional epidural anesthesia doesn't influence cytokine production. It incompletely inhibits the stress response in the early phase. IL-6 and cortisol may have some effects on each other.

Adrenocorticotropic Hormone↗
PubMed1991

[Hemodynamic effects of a combination of general and peridural anesthesia during anesthesia induction in geriatric patients].

For major operative procedures in the lower abdomen and many orthopedic procedures such as total hip replacement, a combination of general and epidural anesthesia is used. In order to investigate the hemodynamic effects of such a combination in 14 geriatric patients aged 63-80 years who were undergoing total hip replacement, cardiovascular monitoring was established by an arterial line and a pulmonary artery catheter. The epidural anesthesia was achieved with bupivacaine 0.5% in a dose calculated to obtain a block up to Th 6. General anesthesia was then induced and maintained with midazolam, fentanyl, pancuronium bromide, and a 2:1 nitrous oxide-oxygen mixture. Hemodynamic measurements were established before and 30 min after induction of the epidural anesthesia and 20 min after the induction of general anesthesia. After bupivacaine was injected the loss of sympathetic tone produced a systolic arterial blood pressure decrease from 174 +/- 22 to 136 +/- 28 mmHg (p less than 0.05) and a decrease in heart rate from 73 +/- 12 to 66 +/- 10 min-1 (p less than 0.05). The cardiac index did not change, but the peripheral vascular resistance decreased significantly. Because intravenous fluids were given simultaneously, preload could be maintained. Oxygen delivery and oxygen extraction did not change. During general anesthesia a significant drop in cardiac output was observed from 3.0 +/- 0.6 l/min.m2 to 2.3 +/- 0.4 l/min.m2 (p less than 0.05). The systolic arterial blood pressure decreased to as low as 95 +/- 17 mmHg (p less than 0.05) and oxygen delivery decreased from 500 +/- 125 ml/min.m2 to 323 +/- 84 ml/min.m2 (p less than 0.05).

Aged↗
PubMed1997

Anesthesia-related periodic involuntary movement in an obstetrical patient for cesarean section under epidural anesthesia: a case report.

Anesthesia-related periodic involuntary movements in a patient with regional anesthesia or etomidate anesthesia can be alarming. This case report describes anesthesia-related periodic involuntary movement in a patient undergoing cesarean section with epidural anesthesia. The anesthesia-related periodic involuntary movement occurred postoperatively in the recovery room. The discussion includes a brief review of spinal cord anatomy and physiology, as well as a review of the literature describing similar events.

Anesthesia, Epidural↗
PubMed1998

Effect of additional general anesthesia with propofol, midazolam or sevoflurane on stress hormone levels in hysterectomy patients, receiving epidural anesthesia.

Hormonal responses after surgery are characterized by increased pituitary-adrenal axis hormones. We undertook this study to determine whether the choice of anesthesia influences stress hormone levels. Twenty-three adult females scheduled for hysterectomy for benign disease under general anesthesia were randomly assigned to one of three groups: epidural/propofol anesthesia (Group P), epidural/midazolam anesthesia (Group M), and epidural/sevoflurane anesthesia (Group S). The concentrations of ACTH and cortisol in group P and group M were significantly less than that of group S at 60 min after the incision. The concentrations of beta-endorphin and aldosterone in group P and group M were significantly less than that of group S at 60 min after the incision and after extubation. We conclude that combined epidural and general anesthesia with propofol or midazolam has a greater suppressive effect than sevoflurane on the stress response of the pituitary-adrenal axis during hysterectomy.

Adrenal Cortex Hormones↗
PubMedDate not supplied

General anesthesia for developmentally disabled dental care patients: a comparison of reinforced laryngeal mask airway and endotracheal intubation anesthesia.

Providing dental care for developmentally disabled patients who require general anesthesia is challenging for both and dentists and anesthesiologists. This study aimed to compare the efficacy of two anesthetic methods for dental care. The researchers retrospectively analyzed morbidity data following anesthesia using either a reinforced laryngeal mask airway (LMA) or endotracheal intubation anesthesia for a two-year time period. The subjects were developmentally disabled patients receiving dental care. Statistical analyses were by unpaired student t-tests and chi-square tests. Patients were who anesthetized with a reinforced laryngeal mask airway had a significantly shorter recovery period and lower postanesthetic complication rates when compared to patients undergoing endotracheal intubation anesthesia. Although hypoxemia (SPO2 < 90%) during dental care occurred more frequently when using the reinforced laryngeal mask airway, the difference was not significant. Nausea and vomiting were the major complications in the postanesthetic care unit and after discharge. When complication rates were compared in the two patient groups, nausea and vomiting were significantly higher during postanesthetic care and after discharge in the intubated group. In conclusion, reinforced laryngeal mask airway provides general anesthesia with less risk of side effects for developmentally disabled patients undergoing dental care.

Adolescent↗