IMPLICATIONS: We describe the anesthetic management of two patients who underwent successful mitral valve repair with use of a robot-assisted cardiac surgical technique. We describe the robot used, as well as the surgical procedure, and highlight aspects of the anesthetic management, in particular the need for one-lung ventilation and the utility of transesophageal echocardiography.
IMPLICATIONS: We compared the performance of a new pulse oximeter with that of a conventional pulse oximeter during hypothermic cardiopulmonary bypass with nonpulsatile flow. The newly developed device displayed accurate SpO2 significantly more frequently and longer than a conventional oximeter. Newly developed pulse oximeters seem to be more useful for monitoring SpO2 during hypoperfusion.
IMPLICATIONS: Coagulation dysfunction after cardiopulmonary bypass may contribute to bleeding. Obtaining coagulation tests and fresh frozen plasma requires time and delays treatment in patients who need fresh frozen plasma. We have devised a technique to provide early estimation of postbypass coagulation status.
IMPLICATIONS: This study demonstrates that it is feasible and generally safe to introduce a miniaturized transesophageal echocardiography probe transnasally in awake cardiac risk patients to monitor cardiac performance during the induction of general anesthesia.
IMPLICATIONS: Acute normovolemic hemodilution may be preoperatively used to minimize the requirement of allogeneic blood products during major surgery. We found that baroreflex function is preserved during mild (hemoglobin concentration, 7-8 g/dL) and profound hemodilution (hemoglobin concentration, 4-5 g/dL) in pentobarbital-anesthetized dogs.
IMPLICATIONS: Remifentanil for intraoperative analgesia in carotid artery surgery is associated with a better stability in perioperative hemodynamics when administered in target-controlled infusion compared with continuous weight-adjusted infusion. This may be related to a smaller requirement of this drug when using target-controlled infusion, as well as a smooth mode of administration.
IMPLICATIONS: Fluid resuscitation to a target mean arterial blood pressure of 60 mm Hg during uncontrolled bleeding resulted in larger oxygen delivery and smaller systemic lactate concentrations when hydroxyethyl starch 6% was used, in comparison to lactated Ringer's solution resuscitation to a target mean arterial blood pressure of 60 or 80 mm Hg.
IMPLICATIONS: This study evaluated oxygen saturation monitors in a canine model of acute blood loss and resuscitation with a blood substitute and found that these may interfere with the monitors' results in a dose-dependent way.
IMPLICATIONS: Thrombelastography and platelet function analysis in routine cardiac surgery demonstrate high negative predictive values for postoperative bleeding, which supports early identification and targeted treatment of surgical bleeding by distinguishing it from a significant coagulopathy. The positive predictive values are small. The best predictors are thrombelastography values obtained after cardiopulmonary bypass.
IMPLICATIONS: Citration and storage of whole blood markedly alter the Thrombelastograph(R) effects of hemodilution on coagulation. The results of hemodilution studies in which citrated blood has been used to study coagulation may not be reliable.
IMPLICATIONS: We report a case illustrating the serious perioperative consequences that can potentially result from failure to provide adequate thyroid hormone therapy for severe hypothyroidism before cardiac surgery.
IMPLICATIONS: A child experienced a spinal cord injury by an accidental dural puncture during thoracic epidural anesthesia. A magnetic resonance image was used for diagnosis and treatment.
IMPLICATIONS: The evidence for nonsteroidal antiinflammatory drugs to increase the risk of bleeding after tonsillectomy is equivocal, and the risk-benefit ratio is not straightforward. There is some evidence for an increased likelihood of reoperation because of bleeding. The agenda must be one of further research rather than of clinical recommendations.
IMPLICATIONS: This open-label, multicenter trial was designed to determine the safety profile and analgesic efficacy of tramadol for the treatment of painful conditions lasting 7-30 days in 7-16-yr-old children. We found that tramadol 1-2 mg/kg per os every 4-6 h (maximal dose = 8 mg {middle dot} kg-1 {middle dot} d-1, not to exceed 400 mg/d) is a safe and effective analgesic in this patient population.
IMPLICATIONS: A new combined ear sensor was tested for accuracy in 20 critically ill children. It provides noninvasive and continuous monitoring of arterial oxygen saturation, arterial carbon dioxide tension, and pulse rate. The sensor proved to be clinically accurate in the tested range.
IMPLICATIONS: Hemodynamic compromise caused by the insertion of the probe for transesophageal echocardiography in a patient with severe stenosis of the main pulmonary artery is reported for the first time. The first symptom of the impending problem was a rapid decrease of end-tidal CO2.
IMPLICATIONS: Postoperative management of sedation and analgesia in pediatric cardiac patients presents many challenges. This case report describes a child who experienced dramatic clinical improvement with the postoperative use of caudal morphine and clonidine after conventional therapy had failed.
IMPLICATIONS: Supplemental 80% oxygen administration during surgery and until 1 h after surgery compared with 30% oxygen administration did not prevent postoperative nausea and vomiting after ambulatory gynecologic laparoscopy.
IMPLICATIONS:In vitro, halothane potentiates glycine's effect on strychnine-sensitive glycine receptors more than isoflurane and isoflurane more than cyclopropane. The present in vivo work indicates that antagonism of the glycine receptor with strychnine increases minimum alveolar anesthetic concentration for halothane more than isoflurane and isoflurane more than cyclopropane. Such results support the notion that glycine receptors may mediate part of the immobility produced by inhaled anesthetics.
IMPLICATIONS: Spinal cord NMDA receptors may mediate a portion of the immobilizing effect of isoflurane. Blockade of NMDA receptors in the cord by MK 801 has a MAC-sparing effect, but MK 801 does not, by itself, produce complete anesthesia.
IMPLICATIONS: Volatile anesthetics reduce the activation of nicotinic acetylcholine receptors by an unknown mechanism. We have demonstrated that although isoflurane and sevoflurane inhibit agonist affinity, the concentrations required are too large to be responsible for the dynamic changes observed.
IMPLICATIONS: When normalized to either their in vivo anesthetic potencies or hydrophobicities, cyclopropane and butane are 1-1.5 orders of magnitude less potent enhancers of agonist action on {alpha}1ß2{gamma}2L GABAA receptors than isoflurane. Additionally, cyclopropane and butane fail to directly activate or inhibit receptors, even at near aqueous saturating concentrations. Thus, it is unlikely that either enhancement or inhibition of the most common GABAA receptor subtype in the brain accounts for the behavioral activities of cyclopropane and butane.
IMPLICATIONS: We investigated the influence of the anesthetic gas xenon on the minimum alveolar anesthetic concentration (MAC) for isoflurane (another anesthetic gas). The study was performed in 10 swine ventilated with fixed xenon and various concentrations of isoflurane. The isoflurane MAC is decreased by inhalation of xenon in a nonlinear relationship.
IMPLICATIONS: The anesthetics isoflurane and halothane attenuate nonadrenergic, noncholinergic depressor responses mediated by calcitonin gene-related peptide in the rat without affecting the release of the peptide.
IMPLICATIONS: We demonstrated that the heart rate response to IV isoproterenol infusion is enhanced during propofol-nitrous oxide anesthesia. This suggests that continuous isoproterenol infusion may be useful when a large dose of atropine is ineffective for restoration of normal heart rate in patients receiving propofol-nitrous oxide anesthesia.
IMPLICATIONS: Clonidine premedication augments the pressor and tachycardiac responses to ephedrine in elderly patients during standard or large doses of propofol anesthesia but does not augment during small doses of propofol anesthesia. Clonidine, age, and propofol could be involved in the augmentation of the pressor and tachycardiac responses to ephedrine.
IMPLICATIONS: We describe the development and evaluation of a simple slide rule that enables the bedside determination of the required infusion rate for a particular target plasma concentration. This pocket-sized target-controlled infusion slide rule combines the advantages of minimal financial and technical cost with reasonable accuracy.
IMPLICATIONS: Ketamine increased dopamine release in the nucleus accumbens, which was inhibited by pentobarbital. The mesolimbic dopamine system may be involved in the psychotomimetic effects of ketamine, and the suppression of ketamine emergence reactions by barbiturates may be because of the inhibition of ketamine-induced dopamine release in the nucleus accumbens.
IMPLICATIONS: Varying conditions for storage of muscle were investigated to extend the viability period of muscle in the malignant hyperthermia (MH) test from 5 to 24 h. Muscles stored for 24 h under tension at room temperature remained viable and correctly diagnosed MH susceptibility in all patients.
IMPLICATIONS: Midazolam, which has spinally mediated analgesic potency, was epidurally administered in dogs, and serum and cerebrospinal fluid concentrations were measured. Epidurally administered midazolam enters the cerebrospinal fluid, but concentrations are only 3% of those in the systemic circulation.
IMPLICATIONS: Propofol is often used in patients with asthma, but it can induce bronchospasm. We report a patient with sick house syndrome (nonspecific complaints of mucosal irritation, headache, nausea, and chest symptoms) who suffered bronchospasm. This case suggests that propofol is not always a safe anesthetic for patients with asthma, especially drug-induced asthma.
IMPLICATIONS: Animal-experimental studies demonstrate desflurane's trigger effect for malignant hyperthermia (MH). In contrast to other anesthetics, the time interval from exposure to the occurrence of symptoms is much longer with desflurane. This case report focuses on MH induced by desflurane alone.
IMPLICATIONS: We report a case of mutism secondary to total IV anesthesia with propofol, as an unusual complication that we have not found in the literature.
IMPLICATIONS: Perioperative hypothermia has deleterious effects on patient recovery. We found in patients having knee surgery that reflective technology was less effective than using two cotton blankets, whereas active surface warming with the forced-air method was most effective in maintaining normothermia.
IMPLICATIONS: Pulse oximetry may produce skin damage after the administration of photosensitizing chemotherapeutic drugs. Surgery must often be performed in near darkness during photodynamic therapy. Limiting the duration of pulse oximetry and rotating sites allowed successful use of pulse oximetry in a long anesthetic during which verteporphin was administered.
IMPLICATIONS: This case history describes the treatment of a patient suffering with persistent pain. He was treated surgically with implantation of a spinal cord stimulator. After surgery, a partial paralysis that could not be explained medically and that was probably related to emotional factors occurred, and cognitive behavioral treatment was begun. This paper discusses the importance of considering social and psychological factors when medical treatment options are considered.
IMPLICATIONS: PercuTwist is a new technique for percutaneous tracheostomy in that stoma dilation is achieved with a unique screwlike dilating device. We describe the technique itself and our first clinical experiences with PercuTwist.
IMPLICATIONS: The implementation of an acute pain service, including pain assessment by a visual analog scale, standard multimodal pain treatment, and continuous quality evaluation, improved postoperative pain relief. Establishing teams of surgeons, anesthesiologists, and nurses is the prerequisite for this improvement.
IMPLICATIONS: Catheter-associated intrathecal masses were detected in three of seven patients receiving long-term intrathecal analgesia. In the two asymptomatic patients, timely clinical intervention was associated with the avoidance of subsequent neurologic injury and spontaneous resolution of one of the occult masses.
IMPLICATIONS: Spinal injection of the {alpha}2-adrenergic agonist clonidine and the cyclooxygenase inhibitor ketorolac results in a synergistic interaction for antinociception in normal animals, suggesting that the combination of these drugs will enhance rather than detract from the analgesia of either alone.
IMPLICATIONS: The cessation of the administration of opioids is associated with hyperalgesia in both humans and other animals. However, antinociceptive dexmedetomidine does not seem to be associated with this type of hyperalgesia syndrome during periods of abstinence.
IMPLICATIONS: With updates from training programs, surgical activity, and other sources, our previously described model estimates a continuing shortfall of 1000-3800 anesthesiologists in 2002 and 500-3900 in 2005, assuming that service demand growth is 1.5% or 2% annually. If service growth >1.5% is likely, entry into the specialty should be encouraged beyond current levels.
IMPLICATIONS: Insertion of an IV cannula is painful. Four-hundred patients were randomly allocated to test the analgesic efficacy, adverse effects, and cost-effectiveness of the needle-free intradermal drug delivery system (J-Tip(R); Jet). Jet with lidocaine is effective, but its application is not painless. Costs to achieve one patient with no more than moderate pain (numerical verbal scale <=3 of 10) on insertion of an IV cannula are $10.
IMPLICATIONS: One-lung ventilation with high tidal volumes and zero positive end-expiratory pressure (PEEP) is injurious in the isolated rabbit lung model. A ventilatory strategy with tidal volumes and PEEP set to avoid lung overdistension and collapse minimizes lung injury during one-lung ventilation in this model.
IMPLICATIONS: Brief isoflurane anesthesia induces ischemic tolerance in the brain. The effect was found to be dose dependent in a rat focal cerebral ischemia model. Ischemic tolerance induced by isoflurane preconditioning is dependent on activation of adenosine triphosphate-regulated potassium channels.
IMPLICATIONS: S(+)-Ketamine combines several anesthetic properties suitable for total IV neuroanesthesia, including minimal effects on neurophysiological monitoring. Recording of neural and myogenic responses after electrical stimulation of the motor cortex indicates that S(+)-ketamine modulates myogenic motor-evoked potentials by a peripheral mechanism at or distal to the spinal {alpha}-motoneuron.
IMPLICATIONS: Complications of IV mannitol administration resulting in compartment syndrome may warrant surgical intervention. Compartment syndrome is difficult to diagnose in the anesthetized patient. Infusing mannitol in an observed IV site permits discontinuation of mannitol before complications ensue. Early recognition and surgical intervention averted potential impairment in our patient.
IMPLICATIONS: We evaluated the risk of neurologic complications in 368 patients undergoing 405 consecutive continuous axillary blocks. New neurologic deficits were reported in four patients. This series suggests that the risk of neurologic complications associated with continuous axillary block is similar to that of single-dose techniques.
IMPLICATIONS: This prospective, randomized, double-blinded study demonstrates that 30 mL of 0.5% levobupivacaine produces an interscalene brachial plexus block of similar onset and quality as the one produced by the same volume of 0.5% ropivacaine. When prolonging the block after surgery, 0.125% levobupivacaine provides adequate pain relief and recovery of motor function after open shoulder surgery, with less volume infused during the first 24 h after surgery than 0.2% ropivacaine.
IMPLICATIONS: Clonidine administered via an interscalene catheter enhanced analgesia compared with systemic administration. Nevertheless, the adverse effect of clonidine at this dose limits its use for routine management for postoperative analgesia.
IMPLICATIONS: The use of blunt instead of sharp needles for ophthalmic local anesthesia techniques has reduced the incidence of injury to intra-orbital structures. This case review of complications from blunt needle sub-Tenon's block suggests that sight-threatening or even life-threatening complications can still occur.
IMPLICATIONS: Abdominal insufflation and changes in table position lead to more frequent movements of the endotracheal tube in obese patients undergoing laparoscopic versus open gastroplasty. The RapiscopeTM identifies all these changes, but not the clinically available variables.
IMPLICATIONS: We compared the latest design of double-lumen tubes Broncho-Cath(R), Univent(R), and Arndt(R) blockers during lung isolation. Our results show that the Arndt(R) blocker takes longer to position and longer to deflate the isolated lung. Once the lung was isolated, the management seemed to be similar for all three devices.
IMPLICATIONS: This report shows that a conical sleeve mounted on the insertion cord of a fiberoptic bronchoscope will facilitate advancing the endotracheal tube into the trachea.
IMPLICATIONS: Lidocaine sprayed down the endotracheal tube suppresses the airway-circulatory reflex responses whereas using the same dose IV lidocaine does not. This effect seems to be from the direct local anesthesia rather than from systemic absorption from the airway.
IMPLICATIONS: We describe a technique of one-lung high-frequency jet ventilation surgery with continuous monitoring of airway pressures that achieves satisfactory operating conditions with less complications than other similar approaches.
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