ISSN:0003-3022    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0003-3022    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0003-3022    

出版商:OVID    

年代:1998

数据来源: OVID

ISSN:0003-3022    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundThe authors hypothesized that shorter‐acting opioid and neuromuscular blocking drugs would be associated with reductions in duration of intubation, length of stay (LOS) in the intensive care unit (ICU) after tracheal extubation, or postoperative (exclusive of ICU) LOS, and that shorter durations of intubation would be associated with reduced ICU LOS after extubation and postoperative (exclusive of ICU) LOS.MethodsOne‐thousand ninety‐four patients undergoing primary coronary artery bypass graft surgery at 40 academic health centers were studied. Multiple patient‐related factors were included in multivariate models for hypothesis testing.ResultsThe duration of tracheal intubation, ICU LOS after extubation, and postoperative (exclusive of ICU) LOS all varied significantly by site. There was no difference between vecuronium and pancuronium in duration of intubation, ICU LOS after extubation, or postoperative (exclusive of ICU) LOS. Use of sufentanil rather than fentanyl was associated with a significant (P = 0.045) reduction of 1.9 h (95% CI, 0.04 to 4.1 h) in duration of tracheal intubation but had no significant effect on ICU LOS after extubation, total ICU LOS, postoperative (exclusive of ICU) LOS, or total postoperative LOS. The authors' best model predicts a complex association between increasing duration of intubation and both ICU LOS after tracheal extubation and postoperative (exclusive of ICU) LOS, which was associated with an increase in those measures when duration of intubation exceeded 7.3 or 3 h, respectively.ConclusionsThe LOS measures varied considerably among the institutions. Use of shorter‐acting opioid and neuromuscular blocking drugs had no association with ICU LOS after tracheal extubation or with postoperative (exclusive of ICU) LOS. Only when the duration of intubation exceeded threshold values was it associated with increased LOS measures.

ISSN:0003-3022    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundEarly tracheal extubation is an important component of the “fast track” cardiac surgery pathway. Factors associated with time to extubation in the Department of Veterans Affairs (DVA) population are unknown. The authors determined associations of preoperative risk and intraoperative clinical process variables with time to extubation in this population.MethodsThree hundred four consecutive patients undergoing coronary artery bypass graft, valve surgery, or both on a fast track clinical pathway between October 1, 1993 and September 30, 1995 at a university‐affiliated DVA medical center were studied retrospectively. After univariate screening of a battery of preoperative risk and intraoperative clinical process variables, stepwise logistic regression was used to determine associations with tracheal extubation <or= to 10 h (early) or >10 h (late) after surgery. Postoperative lengths of stay, complications, and 30‐day and 6‐month mortality rates were compared between the two groups.ResultsOne hundred forty‐six patients (48.3%) were extubated early; one patient required emergent reintubation (0.7%). Of the preoperative risk variables considered, only age (odds ratio, 1.80 per 10‐yr increment) and preoperative intra‐aortic balloon pump (odds ratio, 7.88) were multivariately associated with time to extubation (model R) ("late" association is indicated by an odds ratio >1.00; “early” association is indicated by an odds ratio <1.00). Entry of these risk variables into a second regression model, followed by univariately significant intraoperative clinical process variables, yielded the following associations (model R‐P): age (odds ratio, 1.86 per 10‐yr increment), sufentanil dose (odds ratio, 1.54 per 1‐[micro sign]g/kg increment), major inotrope use (odds ratio, 5.73), platelet transfusion (odds ratio, 10.03), use of an arterial graft (odds ratio, 0.32), and fentanyl dose (odds ratio, 1.45 per 10‐[micro sign]g/kg increment). Time of arrival in the intensive care unit after surgery was also significant (odds ratio, 1.42 per 1‐h increment). Intraoperative clinical process variables added significantly to model performance (P < 0.001 by the likelihood ratio test).ConclusionsIn this population, early tracheal extubation was accomplished in 48% of patients. Intraoperative clinical process variables are important factors to be considered in the timing of postoperative extubation after fast track cardiac surgery.

ISSN:0003-3022    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundThe effects of intravenous anesthetics on airway protective reflexes have not been fully explored. The purpose of the present study was to characterize respiratory and laryngeal responses to laryngeal irritation during increasing doses of fentanyl under propofol anesthesia.MethodsTwenty‐two female patients anesthetized with propofol and breathing through the laryngeal mask airway were randomly allocated to three groups: (1) eight patients who received cumulative total doses of 200 [micro sign]g fentanyl given in the form of two doses of 50 [micro sign]g and one dose of 100 [micro sign]g spaced 6 min under mechanical controlled ventilation while end‐tidal carbon dioxide tension (PCO2) was maintained at 38 mmHg (fentanyl‐controlled ventilation group), (2) eight patients who received cumulative total doses of 200 [micro sign]g fentanyl while breathing spontaneously while end‐tidal PCO2was allowed to increase spontaneously (fentanyl‐spontaneous ventilation group), and (3) six spontaneously breathing patients who were anesthetized with propofol alone (propofol group). The laryngeal mucosa of each patient was stimulated by spraying the cord with distilled water, and the evoked responses were assessed by analyzing the respiratory variables and endoscopic images.ResultsBefore administration of fentanyl, laryngeal stimulation caused vigorous reflex responses, such as expiration reflex spasmodic panting, cough reflex, and apnea with laryngospasm. Increasing doses of fentanyl reduced the incidences of all these responses, except for apnea with laryngospasm, in a dose‐related manner in both the fentanyl‐controlled ventilation and the fentanyl‐spontaneous ventilation groups. Detailed analysis of endoscopic images revealed several characteristics of laryngeal behavior during the airway reflex responses.ConclusionIncremental doses of fentanyl depress airway reflex responses in a dose‐related manner, except for apnea with laryngospasm.

ISSN:0003-3022    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundRemifentanil has not been studied in obstetric patients. This study evaluates the placental transfer of remifentanil and the neonatal effects when administered as an intravenous infusion.MethodsNineteen parturients underwent nonemergent cesarean section with epidural anesthesia and received 0.1 [micro sign]g [middle dot] kg‐1[middle dot] min‐1remifentanil intravenously, which was continued until skin closure. Maternal arterial (MA), umbilical arterial (UA), and umbilical venous (UV) blood samples were obtained at delivery for analysis of drug concentrations of remifentanil, its metabolite, and blood gases. Maternal vital signs were monitored continuously, and pain and sedation levels were assessed intermittently. Apgar scores were obtained at 1, 5, 10, and 20 min, and Neonatal and Adaptive Capacity Scores were noted 30 and 60 min after delivery. Parturients and newborns were observed for at least 24 h after surgery for side effects.ResultsThe means and SDs of UV:MA and UA:UV ratios for remifentanil were 0.88 +/‐ 0.78 and 0.29 +/‐ 0.07, respectively. Mean clearance was 93 ml [middle dot] min‐1[middle dot] kg‐1. The mean UV:MA and UA:MV ratios for remifentanil acid were 0.56 +/‐ 0.29 and 1.23 +/‐ 0.89, respectively. The mean MA (remifentanil acid):MA (remifentanil) ratio was 2.92 +/‐ 3.65. There were no adverse effects on the neonates, but there was a sedative effect and respiratory depressant effect on the mothers.ConclusionsRemifentanil crosses the placenta but appears to be rapidly metabolized, redistributed, or both. Maternal sedation and respiratory changes occur, but without adverse neonatal or maternal effects.

ISSN:0003-3022    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundAngiotensin II may prove useful in treating regional anesthesia‐induced hypotension in obstetric patients, because it causes less uterine vasoconstriction than do other vasoconstrictor drugs (such as phenylephrine). This study compared (1) maternal blood pressure and heart rate and (2) fetal status at delivery in parturients given either prophylactic angiotensin II or ephedrine infusion during spinal anesthesia for elective cesarean delivery.MethodsFifty‐four women were randomized to receive either angiotensin II or ephedrine infusion intravenously during spinal anesthesia for elective cesarean section delivery. Simultaneous with subarachnoid injection, infusion of angiotensin II (2.5 [micro sign]g/ml) or ephedrine (5 mg/ml) was initiated at 10 ng [middle dot] kg‐1[middle dot] min‐1and 50 [micro sign]g [middle dot] kg‐1[middle dot] min‐1, respectively. The rate of each infusion was adjusted to maintain maternal systolic blood pressure at 90–100% of baseline.ResultsCumulative vasopressor doses (mean +/‐ SD) through 10, 20, and 30 min were 150 +/‐ 100, 310 +/‐ 180, and 500 +/‐ 320 ng/kg in the angiotensin group and 480 +/‐ 210, 660 +/‐ 390, and 790 +/‐ 640 [micro sign]g/kg in the ephedrine group. Maternal heart rate was significantly higher (P < 0.001) during vasopressor infusion in the ephedrine group than in the angiotensin group. Umbilical arterial and venous blood pH and base excess were all significantly higher (P < 0.05) in the angiotensin group than in the ephedrine group.ConclusionsAngiotensin II infusion maintained maternal systolic blood pressure during spinal anesthesia without increasing maternal heart rate or causing fetal acidosis.

ISSN:0003-3022    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundThe main disadvantage of the posterior approach to the block of the sciatic nerve in the popliteal fossa (popliteal block [PB]) is the need to place the patient in the prone position. In this study, the authors examined the clinical utility of a recently described lateral approach to PB that is performed with the patient in the supine position, and they compared its ability to provide reliable surgical anesthesia with that of the posterior approach.MethodsFifty patients undergoing surgery of a lower extremity were randomized to receive the PB using either the lateral (n = 25) or the posterior approach (n = 25). With both techniques, 40 ml 1.5% alkalinized mepivacaine with 1:200,000 epinephrine were injected on successful nerve localization using low current output nerve stimulation.ResultsThere were no differences in American Society of Anesthesiologists physical status or demographic data between the groups (ASA status, I‐III; mean age, 50 +/‐ 15 yr; 27 men, 23 women). All patients had good intraoperative analgesia, except one in the lateral group, who reported pain outside the distribution of the sciatic nerve.ConclusionsAlthough blockade using the lateral approach took longer to accomplish, both techniques resulted in clinically acceptable anesthesia in the distribution of the sciatic nerve.

ISSN:0003-3022    

出版商:OVID    

年代:1998

数据来源: OVID