摘要:

CommentFredman et al. have compared sevoflurane and propofol either alone or in combination in patients undergoing ambulatory surgery. In most of the parameters measured both drugs were comparable in terms of intraoperative complications, recovery, and postrecovery clinical parameters and times.Induction with sevoflurane took approximately 1 min longer than induction with propofol. In an ambulatory facility that performs 20 cases per day, this could translate into 20 min of operating room (OR) time, or a third of an hr for anesthetist, surgeons, nursing, and OR use. However, two factors could have biased these data toward an elevated induction time with sevoflurane. First, patients were pretreated with fentanyl 1–2 μg/kg IV before induction; narcotics reduce minute ventilation and could thus have prolonged induction with the inhalation anesthetic. Second, the vaporizer used to perform the study had a maximum inspired concentration of only 5%; other investigators using sevoflurane with a vital-capacity

ISSN:0039-6206    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

CommentDuring the past several years, inhalation agents with shorter emergence times have become available in the United States. The newest is sevoflurane, an agent associated with reportedly less airway irritability and better cardiovascular stability than the slightly older desflurane. Nathanson et al. have compared maintenance and recovery profiles of these two drugs in ambulatory surgery. Patients receiving desflurane opened their eyes and were extubated earlier than patients receiving sevoflurane. The longer time to awakening (about 60% longer) with sevoflurane could well reflect it's higher fat solubility. Sevoflurane, however, was associated with a lower heart rate than desflurane (by about 15%). No differences were observed in other recovery parameters, such as intermediate recovery times or postoperative tests for sedation, energy, and confusion. No data concerning nausea and vomiting were reported, and (because sevoflurane at the time of the study had not been marketed in the United States) no pharmacoeconomic analysis was performed.Are the clinical differences between these two drugs relevant for the anesdiesiologist? Sevoflurane is undeniably superior to desflurance for inhalation induction. In patients with coronary artery disease, the lower heart rate and reduced sympatiietic stimulation with sevoflurane could well be desirable. However, in the routine ambulatory surgical patient, the cost of prolonging anesthesia-controlled time in the operating room could well tip the scales in favor of desflurane. The final word on cost effectiveness

ISSN:0039-6206    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

CommentA child presenting with hypovolemia, a full stomach, and airway bleeding posttonsillectomy can be one of the most challenging situations that an anesthesiologist faces. In the continuing search for a safer or more effective postoperative analgesic, Gunter et al. have compared recovery and complications after tonsillectomy in children treated with either ketorolac or morphine. Patients who received ketorolac neither awakened sooner, achieved discharge readiness more quickly, nor had fewer unanticipated admissions than the morphine-treated subjects. Surprisingly, children receiving ketorolac were more likely to require supplemental oxygen to maintain oxygen saturation ≥ 95% after discharge from the postanesthesia-care unit (PACU). Patients receiving ketorolac were also more likely to experience major bleeding and experienced five-fold more episodes in the 24 hr after tonsillectomy. Approximately 6% of patients receiving ketorolac manifested clinical signs suggesting abnormal coagulation; two exhibited petechiae, and one, extensive bruising. Morphine was associated with a higher incidence of nausea and vomiting after discharge from the PACU.The study is well designed and well executed. It includes an excellent discussion of the conclusions drawn from the statistical analyses. In particular, the authors describe an increase in bleeding in the ketorolac group during the first 24 hr postoperatively, in the absence of an overall increase in bleeding, which could have been masked by a Type II error.This study, in which ketorolac is administered postoperatively, complements an earlier demonstration of increases in intraoperative bleeding when ketorolac was administered before tonsillectomy. Both suggest that ketorolac is contraindicated in children undergoing adenotonsillectomy. Although use of ketorolac in children with obstructive sleep apnea might seem tempting, the potentially catastrophic consequences of posttonsillectomy hemorrhage clearly preclude the drug's use in this setting.

ISSN:0039-6206    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0039-6206    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

CommentThis is a very interesting study that supplies direct evidence in a canine model that nitrous oxide (N2O) may provide analgesia via the opioid receptor-endogenous opioid peptide system. No other studies have sampled third ventricular fluid during N2O administration. Met-enkephalin concentrations were markedly elevated during N20 inhalation in all eight dogs. Peptides derived from pre-enkephalin increased, whereas those from the other two precursors did not. Although all the dogs were trained to lie quietly and breathe through a face mask, no mention is made of the duration of N2O inhalation at the time of cerebrospinal fluid sampling. A further study to determine the duration of the elevations of these substances after discontinuing N2O would be interesting. It is noted that three of the eight dogs became agitated and required manual restraint so that they could continue breathing N2O. It is possible that this affected results either directly or indirectly secondary to changes in other variables such as in mean arterial blood pressure and PaCO2. This work offers another clue in the ongoing search for the mechanism of action of general anesthetics.

ISSN:0039-6206    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

CommentHealth care access is changing dramatically as we watch. The concept of a hospital providing cardiac surgery, a highly profitable undertaking, was accepted without question until recently. Often, little attention was paid to the number of cases performed and the outcomes.This important paper continues the work of this group looking at outcomes and variables that are often used to assess the grouping of cardiac cases in regional centers. The work shows plainly, by comparing three differing approaches, that regionalization of resources, which is often denigrated because of the resulting cost containment, is, in fact, highly functional.California, with many small hospitals offering cardiac surgery, compares less favorably in outcome measurements with New York, where regionalization has been implemented, and with three Canadian provinces where it has always existed. Although a much smaller percentage of the population (60%) is within 25 miles of a cardiac center in Canada, the population has the same access and, overall, a better outcome than in California. This exists despite the adverse publicity surrounding waiting lists in Canada.

ISSN:0039-6206    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

CommentMilrinone is a phosphodiesterase inhibitor similar to amrinone. It can improve cardiovascular performance in patients with impaired ventricular function by reducing afterload and increasing contractility. Its pharmacokinetics and pharmacodynamics have not been well studied in the post-cardiopuhnonary bypass setting, and this study represents an early attempt to do so. The patients studied had minimal need for inotropic drug support, raising some question of whether the conclusions regarding the appropriate dose would apply to patients with much worse cardiac function. The authors suggest that this is not likely to be true, given previous experi-

ISSN:0039-6206    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0039-6206    

出版商:OVID    

年代:1996

数据来源: OVID

ISSN:0039-6206    

出版商:OVID    

年代:1996

数据来源: OVID

摘要:

CommentAlthough the authors found a logical result, it is a surprising one. Extracorporeal circulation did not adversely affect renal function. In fact, the functional alterations that occurred preopera-tively and in the prebypass period seem almost to be reversed by the benefits of extracorporeal circulation. Although that may be extrapolating the data a little too far, it is clear from the results obtained that the most hazardous times for renal damage to patients are the prebypass and postbypass periods.

ISSN:0039-6206    

出版商:OVID    

年代:1996

数据来源: OVID